Rectocele: anatomical defect and functional disorder

Rectocele is a type of prolapse that involves a bulging of the rectum into the posterior wall of the vagina. Patients with rectocele may present with a variety of symptoms. The often report defecatory problems, such as obstructed or incomplete defecation, needing to splint to evacuate the rectum or fecal incontinence. Many also report pain or pressure in the pelvis and sexual dysfunction.

Risk Factors

Rectocele is often present in parous women (women who had children), and vaginal delivery is considered an important risk factor. Other risk factors cited in the literature include: chronic increase in intra-abdominal pressure due to conditions such as asthma, and constipation, obesity, estrogen deficiency, advancing age, smoking, and connective tissue disorders. 

What is Rectocele?

Rectocele is in itself an anatomical disorder, meaning that there is a mechanical failure of pelvic tissues to maintain the anatomical position of the rectum. It has been typically described as a defect of the recto-vaginal wall and its attachments to the levator ani fascia and the perineum. However, there is no consensus yet regarding how to define or quantify it, and most importantly, there are no standardized preoperative tests targeted at identifying the specific anatomical defects involved in a patient’s rectocele. Recent studies are starting to try and further elucidate this problem. Luo et all (2) have used 3D MRI imaging to characterize the deformation of the posterior vaginal wall in women with rectocele during Valsalva. The authors found that folding or “kneeling” of the vagina was a consistent finding, as well as perineal descent and distal vaginal widening.

Despite the fact that rectocele is an anatomical disorder, symptoms are not always tied to anatomy. In most patients with rectocele there are coexisting alterations of pelvic anatomy and function and especially defecatory dysfunctions that can’t be expected to resolve with surgical repair of the defect. 

What is ODS?

Obstructive defecation (ODS) is a symptom found in most patients with rectocele. To further compound the complexity of the relationship between these two disorders, ODS is commonly found in individuals that have experienced chronic strain, often associated with the inability to relax puborectalis or the external anal sphincter muscles as well as slow transit motility. Chronic strain overtime leads to stretch and strain of the posterior compartment, and may be a cause of development of rectocele, rather than a consequence. Herein lies the difficulty of recommending rectocele surgical repair to address ODS symptoms. The American Gastroenterological Association’s clinical management algorithm for ODS, only recommends surgery for patients who have significant structural abnormality and normal pelvic floor relaxation observed during balloon expulsion testing (1).

Regarding the relationship of rectocele with other types of prolapses, both clinical studies and computer simulations have found that anterior, apical and posterior compartment prolapse development are inter-related by the phenomenon of “organ competition”, when one organ “fills” the available genital hiatus space, thereby “blocking” the development of a prolapse on the other wall. Apical, anterior and posterior vaginal wall supports as well as levator ani integrity are key to protect the pelvic space from deformation under increased intra-abdominal pressure.  This is an important cause of recurrent prolapse after surgical repair (3).

Traditionally both gynecologists and colorectal surgeons have repaired rectoceles, approaching the defect from the organ they specialize in and patients are normally referred to the professional more closely associated with their symptoms. In the case of general organ prolapse, urinary incontinence, and sexual dysfunction women are normally referred to the gynecologist. In the case of defecatory dysfunction they would be referred to a proctologist or colorectal surgeon. If we consider a rectocele as a functional disorder, that has a an abundance of symptoms associated to it, then it should be necessary to first address the problem as a whole. A thorough evaluation, including a detailed history, physical examination and imaging studies as appropriate, are all important starting point to determine the associated pelvic disorders involved. Several treatment option should then be provided. Surgical intervention is generally reserved for patients in which the symptoms are severe or conservative treatment options have failed.

Conservative Treatment

Conservative treatment includes dietary recommendations, use of laxatives as necessary, use of a pessary, and pelvic floor physical therapy. At Body Harmony Physical Therapy we conduct a thorough examination and history of the problem to decide the most effective treatment plan for every patient. The following physical therapy techniques will often be part of the treatment:

• Pelvic floor muscle strengthening program
• Core, postural and hip muscle strengthening
• Biofeedback to address defecatory mechanics and improve pelvic floor muscle neuromuscular control: including both EMG and visual real-time ultrasound based biofeedback.
• Hypopressive breathing: to improve core, postural, diaphragmatic, pelvic floor function and alleviate organ descent symptoms.

References:

(1) Mustain WC. Functional Disorders: Rectocele. Clin Colon Rectal Surg. 2017;30(1):63–75. doi:10.1055/s-0036-1593425

(2) Luo J, Larson KA, Fenner DE, Ashton-Miller JA, DeLancey JO. Posterior vaginal prolapse shape and position changes at maximal Valsalva seen in 3-D MRI-based models. Int Urogynecol J. 2012;23(9):1301–1306. doi:10.1007/s00192-012-1760-9

(3) Luo J, Chen L, Fenner DE, Ashton-Miller JA, DeLancey JO. A multi-compartment 3-D finite element model of rectocele and its interaction with cystocele [published correction appears in J Biomech. 2015 Sep 18;48(12):3550]. J Biomech. 2015;48(9):1580–1586. doi:10.1016/j.jbiomech.2015.02.041