Introduction
Risk factors
Symptoms
Diagnosis
Prevention
Treatment

Introduction
The rectum lies just behind the vagina in a woman. Between the rectum and vagina is a firm fibrous wall of connective and supporting tissue (fascia) separates the rectum from the vagina. This rectal-vaginal wall is made of tissues and muscles that support the rectum and vagina. When a woman has a rectocele, the wall supporting the rectum is weaker than usual.

Rectal-Vaginal Wall: A firm fibrous wall of connective and supporting tissue
separates the anus and rectum from the vagina.

A weakness sometimes develops in the recto-vaginal wall, allowing a portion of the rectum to bulge into the vagina. This bulge is called a rectocele. It is usually the result of damage to the recto-vaginal wall from the pressure and stretching generated during a vaginal delivery.

Rectocele: a portion of the rectum bulges into the vagina.

There are tree types of rectoceles: high, mid, and low. The high rectoceles are usually due to a laxity or disruption of the upper third of the vaginal wall tissue and uterosacral ligaments. Mid level rectoceles are the most common and are associated with loss of pelvic floor support. Low rectoceles are usually caused by obstetric trauma.

Risk Factors
Risk factors for developing a rectocele include:
· Multiple vaginal deliveries
· Episiotomy performed with vaginal delivery
· Menopause
· Chronic constipation
· Chronic cough
· Repetitive heavy lifting, or any activity in which pressure is applied to the pelvic floor over time

Symptoms
A small rectocele is often asymptomatic (without symptoms), especially if it bulges less than 1 inch into the vagina. However, a larger rectocele can produce a variety of rectal and vaginal complaints, including:

· Digitation. About 25-percent of the time, the patient must use a technique called "manual evacuation" or "digitation" to help empty the rectum. In this technique, the patient presses on the rectocele with her fingers inside the vagina, while defecating to facilitate the passage of stool.
· Low back pain that is relieved by lying down. In many women, this back pain worsens as the day progresses and is most severe in the evening.
· A feeling that the rectum has not emptied completely after a bowel movement.
· Difficulty in controlling the passage of stool or gas from the rectum.
· A bulge of tissue protruding through the vaginal opening.
· Pain or discomfort during sexual intercourse.
· Difficulty in having a bowel movement.
· A sensation of rectal pressure.
· Constipation
· Rectal pain.

Diagnosis
Your doctor can confirm that you have a rectocele by performing a gynecologic and a rectal examination. A simple straining maneuver should cause the rectocele to bulge, allowing the doctor to see the size and shape of the rectocele inside your vagina. However, it may be difficult to assess the size and location of the rectocele, and defecagram may be needed. A defecagram is an x-ray study that shows how large the rectocele is and if the rectum empties completely with evacuation.

Prevention
Some health experts believe that Kegel exercises can either help to prevent a rectocele or relieve some of its symptoms. Kegel exercises are muscle-strengthening maneuvers aimed at tightening the tissues around the vagina.

Treatment
Rectoceles that are not causing symptoms do not need to be treated surgically, unless of course other anorectal surgery is being contemplated. Non surgical treatment with diet, stool softeners, a pessary, HRT, and exercises may be prescribed. Eating a high fiber diet and drinking plenty of fluids generally helps one to avoid constipation. Stool softeners may be used to keep the stools soft. Excessive straining during bowel movements or when heavy lifting should be avoided. A pessary is a circular ring device that is fitted into the vagina to hold the rectum in place. Hormone replacement therapy (HRT) may be used for postmenopausal women to help strengthen the muscles around the vagina and rectum. Kegel exercises may also be used to strengthen the muscles supporting the rectum and vagina. Pelvic floor muscles are just like other muscles, exercising these muscles for just 10-minutes every other day can make them grow stronger.

According to Block, Rectocele is a condition that can be repaired transrectally with an obliterative suture technique. The obliterate suture is essentially a tightly drawn continuous lock-stitch suture that strangulates the tissues contained in the suture line, and causes them to slough, yet approximates the tissues at the base of the suture line, the submucosa, and muscularis layers and allows them to heal rapidly. This technique is bloodless, easy to perform, and effective as far as cure and relief of symptoms. The time required for repair of the rectocele is approximately 6 minutes. The presence of a rectocele should be sought for routinely in every proctologic examination in the female. If anorectal surgery is to be performed, the rectocele should be repaired coincidentally, even if the rectocele is asymptomatic. If the rectocele is symptomatic, it should be repaired even if no other anorectal procedure is contemplated. The transrectal obliterative suture technique appears to have advantages over the vaginal or other transrectal techniques and is the method of choice for the repair of rectocele.

Reference
Block IR. Transrectal repair of rectocele using obliterative suture. Dis Colon Rectum 1986 Nov;29(11):707-11,

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