RECTOCELE - BOWEL-HEALTH

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Rectocele

Generality

Rectocele is the sliding of the rectum from its normal anatomical location into the vagina. This event is the result of a weakening of the pelvic floor. The resulting symptoms are numerous: from pelvic pain to difficult defecation. For a correct diagnosis, a pelvic examination is sufficient.
Therapy depends on the severity of the rectocele. Milder cases are treated with simple countermeasures, which avoid a worsening of the disorder. For the most serious patients, on the other hand, specific treatments are provided, sometimes even of a surgical type.

Prevention, as always happens, is essential.

Brief anatomical reference: the pelvic floor

To understand what happens in the rectocele, it is advisable to do a brief anatomical review concerning the pelvic floor.
The pelvic floor is the set of muscles, ligaments and connective tissue located at the base of the abdominal cavity, in the so-called pelvic area. These structures cover a fundamental and indispensable function: they serve to support and maintain the urethra, the bladder, in their positions. the rectum and, in women, the uterus.
If the pelvic floor weakens and no longer offers the same support, ailments of a different nature, both physical and sexual, can appear.

THE POSITION OF THE RECTUM

The rectum is the terminal portion of the intestine. Approximately 13-15 cm long, the rectum connects the colon-sigma intestinal tract with the anus, and is surrounded by several muscles and ligaments of the pelvic floor. These structures are fundamental for the role played by the rectum in the collection and evacuation of faeces.
uterus (anteriorly) and vagina (inferiorly). To separate it from the vagina, there is a band of connective-fibrous tissue, called the recto-vaginal septum.

So is rectocele

Rectocele is the sliding (or prolapse) of a portion of the rectum into the vagina. This sliding occurs due to a weakening, more or less severe, of the pelvic floor: in some cases, the recto-vaginal septum can only loosen; in other cases, however, it can even tear itself apart.

Based on the extent of the damage to the pelvic floor, three forms of rectocele can be distinguished:

1st degree rectocele, or mild. Features: Only a very small portion of the rectum invades the vagina.
2nd degree rectocele, or moderate. Characteristics: the portion of the rectum that invades the vagina is considerable, and almost reaches the vaginal opening.
3rd degree rectocele, or severe. Characteristics: the rectum protrudes from the vagina, due to the complete absence of support from the rectum-vaginal septum.

EPIDEMIOLOGY

Rectocele can occur at any age. However, adult women between the ages of 40 and 60, who have given birth several times or who have gone through menopause, are most affected. The explanation of this phenomenon will be dealt with in the chapter dedicated to the causes.
Unlike uterine prolapse and bladder prolapse (cystocele), which often occur in severe forms, rectocele is usually mild.

Causes of rectocele

Possible causes of a rectocele are as follows:

Vaginal delivery or with complications (for example, long labor)
Large fetus
Constipation
Obesity
Lifting of heavy objects
Chronic constipation
Chronic bronchitis

How do these circumstances lead to a rectocele?

PATHYSIOLOGY

The occurrence of any of the above conditions causes a traumatic strain to damage the pelvic floor. Muscles, ligaments and connective tissue are affected and become weaker.
Usually, a single event is not enough to cause a rectocele; on the other hand, the overlapping of several traumatic episodes, of the same type (for example, several vaginal deliveries) or of a different type (for example, obesity and chronic bronchitis), is decisive.

RISK FACTORS

Several risk factors associated with the onset of rectocele have been identified.

The most important is certainly the high number of vaginal deliveries. According to some statistical data, in fact, women who have given birth several times vaginally are more prone to rectocele. Each birth contributes to gradually weaken the floor. pelvic, up to the laceration of some of its supporting structures. A "further confirmation of the importance of the vaginal parts comes from the comparison with women undergoing caesarean section. The latter" are less affected by rectocele.
The second most important factor is linked to aging. Women, after menopause, produce less estrogen and this causes a weakening of the pelvic floor muscles. Estrogen deficiency also causes cystocele and uterine prolapse.
The third factor is related to previous pelvic organ surgery. If a woman has had such operations in the past, she has a weaker pelvic floor. Among the most favoring pelvic organ interventions, there is the hysterectomy, ie the removal of the uterus.
The last factor is genetic. Although this is a rare circumstance, some women suffer from congenital diseases that alter the structure of collagen (collagenopathies). As a result, the pelvic floor becomes looser and more prone to lacerations.

N.B: collagen is a fundamental protein of connective tissue.

Symptoms, signs and complications

1st degree rectocele (the most common form) is, in many cases, devoid of any noteworthy symptoms and signs. In fact, it may happen that the patient does not even know that she is affected.
However, when the protrusion of the rectum inside the vagina becomes more severe, the characteristic symptoms of rectocele become evident. In similar situations, the patient complains:

Protrusion of a portion, more or less extended, of the rectum from the vaginal opening (the size depends on the severity of the rectal prolapse)
Difficulty with bowel movements (obstructed defecation)
Feeling that the rectum, even after defecation, has not emptied completely
Sensation of pressure in the rectum
Pain during intercourse
Vaginal bleeding

WHEN TO CONTACT A SPECIALIST?

Minor rectoceles do not require a specialist visit or even specific treatment. However, it is good to keep in mind causes and risk factors, to avoid any worsening.
Conversely, a gynecological examination is recommended when the patient experiences difficulty in defecation and pain, such as to affect everyday life. This means, in fact, that the rectocele has degenerated from a mild to a more severe form, and needs due therapeutic attention.

COMPLICATIONS AND ASSOCIATED DISEASES

Figure: the deviation of the rectocele, as can be seen, is the reason why the obstacle to defecation is created. The connection between rectum and anus, in fact, is no longer linear. From the site: proctologia.biz

A rectocele, if underestimated, can get worse. As a result, the symptoms become more and more painful and the first complications emerge. Defecation difficulties, for example, may be such as to require compression of the vaginal area (manual evacuation), to eliminate stool, and constipation takes on the shape of a chronic disorder. Vaginal bleeding is more and more frequent.
Furthermore, rectocele can be accompanied by prolapses of other pelvic organs, such as the bladder and uterus, as the triggering causes are the same. It may therefore occur that the patient suffers simultaneously from cystocele or uterine prolapse.

Diagnosis

For a correct diagnosis of rectocele, a simple pelvic exam is enough. However, it may be useful to investigate some aspects, such as the severity of the disorder or the health of the pelvic floor. An evaluation questionnaire, a nuclear magnetic resonance, an "ultrasound" and defecography serve to enrich the initial diagnosis.

PELVIC EXAMINATION

The pelvic exam is used by the gynecologist to understand whether it is a rectocele or a prolapse of another pelvic organ. This check is more than exhaustive.
The specialist places the patient in a lying position and uses a speculum to examine the vaginal canal. During the examination, the patient is asked to push, as when he goes to the body. With this operation, if it is a rectocele, the exit of the rectum from the vagina should be accentuated. In this way, it is possible to determine the severity of the pathology.
Another important assessment test is the control of the muscle strength of the pelvic floor. In this case, the patient is asked to contract the pelvic muscles, as if to block the flow of urine. If the test fails, the pelvic floor is weak.

EVALUATION QUESTIONNAIRE

Through a questionnaire ad hoc, the gynecologist examines what emerged from the pelvic examination. The questions investigate how the rectocele influences the quality of life of the patients. The information obtained from it helps during the therapeutic process.

INSTRUMENTAL EXAMINATIONS

Ultrasound and nuclear magnetic resonance are two tests that are rarely performed. They serve to enrich the diagnostic picture with further information regarding:

The precise measurement of the portion of the rectum that protrudes from the vagina
The prolapse of other pelvic organs

To evaluate, instead, the efficiency of intestinal emptying, the patient undergoes an X-ray examination, called defecography.

What is defecography?

Defecography provides images, in real time, relating to the defecation of the patient analyzed. It is an X-ray examination performed with a fluoroscope, useful when you come across particular gastrointestinal disorders.
In preparation (about three hours before): a cleansing enema is performed to make what will be observed later more reliable.
The examination involves the rectal injection, via catheter, of a barium-based contrast medium. Then the patient is made to sit on a special toilet and the intestinal contractions, the moment of evacuation and the phase of emptying the rectum are observed. During these projections, the positions taken by the intestine, in its anorectal tract, also emerge. .
Defecography is a comprehensive but also invasive examination.

Therapy

The correct therapy of a rectocele depends on the degree of severity with which it presents and on the possible association with cystocele or uterine prolapse.
As mentioned, mild rectoceles are asymptomatic and do not require special therapeutic treatment. Rectoceles of moderate-severe entity, on the other hand, require specific treatment: initially, the remedies are non-surgical; over time, however, surgery becomes essential.

TREATMENT OF THE 1st DEGREE RECTOCELE

It is very common for a rectocele, in its mildest form, to go unnoticed, due to the absence of specific symptoms. However, even if the gynecologist ascertains its presence, during a routine examination, no specific treatments are provided.
The only recommended countermeasures are:

The constant practice of Kegel exercises, to strengthen the muscle tone of the pelvic floor
The control of obesity, since excessive body weight, due to adipose accumulations, stresses the muscles and ligaments of the pelvic floor
Avoid lifting heavy objects

Sticking to these behaviors is essential to keep the situation stable. In the most fortunate cases, rectocele regression may also occur.

NON-SURGICAL TREATMENT OF THE 2nd AND 3rd DEGREE RECTOCELE

For moderate-severe rectoceles, there are two non-surgical remedies: these are the pessary and estrogen-based hormone therapy.

Non-surgical remedies

What is it and what is it for?

The pessary

It is a rubber or plastic ring that is inserted into the vagina. It serves to block the prolapse of the pelvic organs, which overhang the vagina. The specialist teaches the patient how to clean it and how to apply it. There are pessaries of different sizes, according to needs.

Estrogen

Menopause causes a reduction in estrogen production and their decrease weakens the pelvic muscles. By taking estrogen, the pelvic floor muscles are strengthened, in order to block the prolapse of the pelvic organs.

Pessary and estrogen serve to relieve symptoms, but their use is temporary.

Often, in fact, similar solutions are used for a limited time, pending the ideal conditions for surgery, as these countermeasures have side effects. For example, prolonged use of the pessary causes irritation of the internal cavity of the vagina.
Among the non-surgical remedies, Kegel exercises and weight control continue to provide valid therapeutic support.

THE SURGICAL TREATMENT OF THE RECTOCELE

The reasons why rectocele requires surgery are the following:

Unbearable pain, which negatively affects normal daily life
Obvious leakage of the rectum from the vagina
Obvious difficulty in defecation
Prolapse of other pelvic organs, such as the bladder and uterus

The operation consists of a colorectal surgery. The procedure, which can be carried out via the abdominal or vaginal route, is as follows: the rectum is returned to its original position; then the rectum-vaginal septum is closed and strengthened with a tissue transplant. The support offered by this "patch" helps support the rectum and stop it from protruding inside the vagina.
If rectocele is also accompanied by a cystocele or uterine prolapse, both disorders can be resolved with a single operation.

SURGERY AND PREGNANCY

If a woman with rectocele is still of childbearing age and wishes to have children, it is recommended that the date of surgery be postponed to the end of her pregnancy. In the meantime, she can use the pessary.

Prognosis and prevention

The prognosis of rectocele depends on the degree of severity of the disorder. The milder the rectocele form, the better the prognosis. However, it should not be forgotten that if you do not practice Kegel exercises and neglect your pathological condition, the chances of a worsening of the rectocele increase.
A different speech should be made, however, when the rectocele is severe. In these situations, the containment of symptoms, by means of pessary and estrogen, is a temporary remedy, while the intervention becomes a necessity. However, like any surgical operation, rectocele surgery is not without complications. The recto-vaginal septum, in fact, can rupture again, despite the reconstruction and its reinforcement. The prognosis, therefore, becomes worse.