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Understanding and Repairing Rectocele

Definition

The thin wall of tissue that separates the vagina and the rectum is known as the rectovaginal fascia. When areas of the wall weaken, the rectum might create a protrusion in the vagina, which is known as a rectocele.

A rectocele can develop during vaginal childbirth, due to harm received from exertion of the pelvic muscles. Even if a rectocele occurs immediately following childbirth, symptoms might not show up for years afterward. Rectoceles usually develop in post–menopausal women who experienced multiple vaginal deliveries. Besides vaginal childbirth, any rigorous and repetitive action that puts extreme pressure on the pelvic floor, such as frequent constipation or cough, and heavy lifting, can contribute to the development of a rectocele.

It is difficult diagnose a minor rectocele, because it does not cause many symptoms. Statistical data differs greatly, with a range of 20 to 80 percent of women affected. A recent U.S. study profiled 125 people diagnosed, the average patient was 60 years of age, had multiple vaginal deliveries, and was menopausal.

Patients also tend to have conditions affecting the bladder and uterus, such as a cystocele or a uterine prolapse. A cystocele is when the bladder protrudes because of weakening of the frontal vaginal wall. A uterine prolapse is when the uterus sags to the vagina, which occurs because of insufficient support of the pelvis.

Symptoms

A minor rectocele, especially one that protrudes one inch or less, typically does not cause problems. However, there are many complications within the rectum and vagina that can arise from a larger rectocele. For example, tissue can protrude through the opening of the vagina. Constipation, bowel movement difficultly, an incomplete sensation following a bowel movement, or difficulty controlling gas or stool passage is common. Discomfort and even pain can occur during sex. Rectal pain, extreme rectal pressure, and lower back pain are also problems that can arise. The pain in the lower back might increase throughout the day, but is relieved upon lying down.

In nearly 25% of rectocele patients, digitations (also known as manual evacuation) are necessary to remove stool from the rectum. To do this, the patient must help remove the stool from the body by pressing on the rectocele during defecation.

Diagnosis

Vaginal lacerations and how many vaginal deliveries a patient has had help diagnose a rectocele. In addition to vaginal and rectal symptoms, urinary difficulties are also reviewed. A rectal and gynecological examination is performed by the doctor to reach a diagnosis. During these exams, the patient might have to push to simulate defecating. This strain will enlarge the rectocele so that the location and size can be identified. Rectal imaging tests can also be conducted for location and size identification.

Duration

Because a rectocele is a lasting condition, which will not heal by itself, even minor rectoceles can worsen and grow larger over time.

Prevention

In the 1980s, physicians believed that performing an episiotomy during childbirth prevented the future development of a rectocele. An episiotomy requires cuts to be made to the tissue dividing the rectum and the vagina in order to increase the vaginal opening during delivery. Today’s research shows that a rectocele can still develop in cases of healed episiotomies. Because of this information, episiotomies are performed with less frequency. In fact, many doctors avoid episiotomies if possible.

While some healthcare practitioners feel that exercises (known as Kegel exercises) help prevent or relieve rectocele symptoms, this has not been proven in clinical studies. These exercises tighten the muscles and tissues surrounding the vagina

Treatment

Surgery is possible to rebuild the weakened rectovaginal fascia. The surgery typically requires stitches within the rectovaginal fascia wall for reinforcement. A more complicated surgery would involve procedures such as the insertion of a patch to support and strengthen the wall. If a uterine prolapse or cystocele is also present, surgical procedures can address these conditions simultaneously.

A non-surgical treatment option is a pessary. The vaginal pessary, a small plastic or silicon medical device that can be shaped as either a plug, a circle, or a block, is inserted in the vagina for support of the vaginal walls. Some pessaries require routine removal and cleaning by the doctor, but others are designed so that the patient can remove it themselves and clean it every day.

Consulting a Doctor

You should consult a doctor immediately if a protrusion is discovered in the vaginal wall, if you are experiencing instense rectal pressure or pain, or if bleeding is present. Those who have frequent constipation, have difficulty passing a stool, or experience discomfort or pain during sex should also seek medical attention.

Prognosis

Most patients that undergo rectocele surgery report an improvement in their symptoms or a relief from them altogether. Surgery is very effective in almost all rectocele cases, with structural weaknesses being repaired in most cases.



     
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OSCAR A. AGUIRRE, MD, FACOG

Dr. Aguirre
Dr. Aguirre is the Director of Aguirre Specialty Care, The Center for Female Pelvic Medicine. Dr. Aguirre is also a member of the Laser Vaginal Rejuvenation Institute of America.
The Laser Vaginal Rejuvenation Institute of America is founded and directed by Dr. David L. Matlock.

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