A Rectocele Prolapse is a type of prolapse where the supportive wall of tissue between a woman’s rectum and vaginal wall weakens. Without the support of these pelvic floor muscles and ligaments, the front wall of the rectum sags and bulges into the vagina, and in severe cases, protrudes out of the vaginal opening.
The rectum is at the very end of the digestive system, where feces collects before it is expelled from the body through the anus. It is normally separated from the vagina by a wall of thick, strong muscle. A rectocele prolapse is a type of pelvic organ prolapse, occurring on the back posterior wall of the vagina, where the rectal wall pushes against the vaginal wall, creating a bulge that can eventually tear into the vagina.
Rectocele prolapses are most common in women aged over 60 years old that have had multiple children. This is in part due to the menopause contributing to the weakening of the pelvic floor muscles as the levels of the hormone estrogen fall, and the extra weight pregnancy puts on the pelvic floor muscles causing long-lasting damage.
As with most medical problems, it’s important not to put off treatment. Allowing your prolapse to go untreated for a long period of time leads to weakened pelvic muscles and damage to associated nerves – increasing the risk of it reoccurring. To avoid unnecessary delays and speak to your doctor if you have any concerns.
Stages of Rectocele Prolapse
A rectocele doesn’t always become severe, it may always remain a mild problem. However, it is important to acknowledge when symptoms progress and treat them accordingly:
- Mild rectocele prolapse – A mild rectocele is when you may not notice that you have a rectocele developing as there are no associated symptoms presenting themselves. You may only be diagnosed following a routine examination or procedure such as a smear test.
- Moderate rectocele prolapse – If your rectocele becomes worse, then you may begin to experience some or all of the symptoms listed above. You may also notice that your rectocele becomes more pronounced if you strain during a bowel movement, or cough violently. During these times, you may notice or feel red tissue protruding from the vagina that retracts back when you’ve finished straining or coughing.
- Severe rectocele prolapse – Eventually, your rectocele may become severe and you’ll be experiencing symptoms that get worse throughout the day. In this case, your rectum may be protruding permanently through your vagina.
Causes of Rectocele Prolapse
As with all pelvic organ prolapses in women, one of the major causes of a rectocele prolapse is pregnancy and childbirth. Particularly if you carried a large baby and had a difficult birth with sustained pushing, enhanced further with multiple births. However, if damage to the pelvic floor muscles occurs during this time, you are unlikely to experience prolapse problems straight away.
The following factors can also lead to a rectocele prolapse as they all add extra pressure to the pelvic floor muscles, potentially weakening them:
- Pregnancy – Around 50% of women who have carried a baby to full term will experience some kind of vaginal prolapse. This is in part due to the extra weight that the baby adds to the pelvic area, which can weaken the pelvic floor muscles. It is also thought to be caused by pregnancy hormones allowing vaginal tissues to stretch beyond their rebound limits. Multiple pregnancies will increase your risk.
- Childbirth – Again, around 50% of women who give birth vaginally will experience some level of prolapse. A large baby or a difficult birth where you’ve had to push a lot or forceps were used may increase your risk. More than one birth also increases your risk of experiencing a vaginal prolapse. Mothers who have delivered four babies vaginally are at 12 times greater risk than women who have not given birth vaginally.
- Menopause – The change in hormones you experience during this time of your life, particularly the drop in oestrogen, can cause your pelvic floor muscles to weaken. Effects can be worsened by the loss of muscle tone associated with aging.
- Bodyweight – Being overweight or obese can increase your chances of suffering a pelvic organ prolapse due to the weight on your pelvic area.
- Genetics – If someone else in your family has suffered a vaginal prolapse, then you may be at an increased risk.
- Constipation – Continued straining to pass a stool will put extra pressure on the pelvic floor and could cause it to weaken.
- Persistent coughing – Constant heavy coughing can add pressure to the pelvic floor. If you smoke and have a persistent smoker’s cough or if you have a lung condition that results in a cough, such as asthma or bronchitis, then you could be at a higher risk.
- Heavy lifting – Repetitive heavy lifting, and lifting incorrectly, increases the pressure put on the pelvic floor.
- Strenuous activity – Heavy, high impact exercises such as running or plyometric training (jump training) can cause the pelvic floor muscles to weaken.
- Previous pelvic surgeries – A hysterectomy or previous vaginal prolapse surgery can weaken the pelvic floor muscles, and is likely to be part of the cause of any future pelvic organ prolapses.
- Pelvic conditions – Heavy fibroids or a tumor somewhere in your pelvis can add weight to the area and weaken the pelvic floor muscles.
- Hysterectomy – Up to 40% of women who have had a hysterectomy (the complete removal of the womb and cervix) suffer a vaginal vault prolapse. The uterus provides support for the top of the vagina, if it is no longer there, then the top of the vagina can gradually fall towards the vaginal opening and the vaginal walls weaken, allowing other organs to protrude.
Symptoms of Rectocele Prolapse
A rectocele prolapse is not always accompanied by any obvious symptoms, as the pelvic floor muscles may have weakened over many years. Generally, if the rectum bulges into the vagina to a depth of less than 2cm (1 inch), you may not experience any discomfort. In fact, 40% of women with a rectocele prolapse are only diagnosed by a routine examination or procedure such as a smear test.
Some of the common symptoms that you may experience for a rectocele prolapse include:
- a protrusion or bulge into the vagina that you can feel through everyday movements
- a feeling that something is inside the vagina
- pain or discomfort during sex
- pain in the rectum
- unusual bleeding that isn’t associated with your period
- a feeling of pressure in the rectum
- difficulty passing a bowel movement, as the effects of the bulge become more noticeable
- a feeling that the bowel hasn’t completely emptied after a bowel movement
- finding it hard to hold in a stool or wind
- lower back or pelvic pain that is relieved by lying down
- lower back or pelvic pain that gets progressively worse during the day or whilst standing and is at its worst in the evening
With the number of different prolapse conditions and their close proximity to each other in the body, it can be difficult to know which symptoms point to which condition. Visiting your doctor to get a diagnosis is important and can help you decide which course of treatment is best for you.
Similar symptoms can also be experienced with Irritable Bowel Syndrome (IBS) and as such, a rectocele prolapse can often be misdiagnosed as IBS.
A health care professional may ask about your
- symptoms, such as bulges or lumps in the vagina, pelvic pressure or heaviness, and urinary incontinence
- pregnancy and childbirth history
- current and past medical problems, including surgeries
- family history
- over-the-counter and prescription medicines
- bowel habits
Rectoceles have a broad range of symptoms. Some patients may present as asymptomatic while others may demonstrate a significant impact on the quality of life, including the following symptoms[rx]:
Posterior vaginal bulge
Erosions and bleeding of mucosa if there is tissue exposure to the outside environment
A thorough examination will include a vaginal exam, rectal exam, abdominal exam, and focused neurological exam.
The focused neurological exam consists of levator ani muscle tone and contraction strength.
The vaginal exam can be evaluated using the Baden-Walker or POP-Q exam. The Baden-Walker system utilizes one measurement. The distance of the most distal portion of the prolapse from the hymen while the patient is completing the Valsalva maneuver.[rx]
- A pelvic exam – You may be examined while lying down and possibly while standing up. During the exam, your doctor looks for a tissue bulge in your vagina that indicates pelvic organ prolapse. You’ll likely be asked to bear down as if during a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic floor muscles, you’ll be asked to contact them, as if you’re trying to stop the stream of urine.
- Filling out a questionnaire – You may fill out a form that helps your doctor assess your medical history, the degree of your prolapse, and how much it affects your quality of life. This information also helps guide treatment decisions.
- Bladder and urine tests – If you have significant prolapse, you might be tested to see how well and completely your bladder empties. Your doctor might also run a test on a urine sample to look for signs of a bladder infection if it seems that you’re retaining more urine in your bladder than is normal after urinating.
- Urodynamics – Measures the bladder’s ability to hold and release urine.
- Cystoscopy (cystourethroscopy) – A long tube-like instrument is passed through the urethra to examine the bladder and urinary tract for malformations, blockages, tumors, or stone
- A special test – that can be done to confirm a rectocele is defecography. The patient will have a contrast medium instilled in the vagina, bladder, and rectum. Using a special commode, the patient will be instructed to defecate while the X-ray is taken. This test can be useful to determine the size of the rectocele, larger than 2 cm is considered abnormal.[rx]
- Urodynamic studies – can be helpful in patients with rectocele and complex voiding issues. If a patient is receiving surgery, it may be useful to determine if the patient has urinary incontinence with the prolapse reduced. If there is incontinence with reduction with prolapse, it may be helpful to include a procedure to prevent urinary incontinence in the plan.[rx]
- Pelvic floor strength test – During the pelvic examination, the doctor tests the strength of the pelvic floor, the sphincter muscles, and muscles and ligaments that support the vaginal walls, uterus, rectum, urethra, and bladder. Irregularities in this test can help diagnose vaginal prolapse and determine if kegel exercises would be helpful to the patient.
- Bladder function test – Otherwise known as urodynamics, bladder function tests determine the ability of the bladder to store and eliminate urine. This is measured in two ways. Uroflowmetry measures the volume and force of the urine stream. Cystometrogram is a procedure that fills the bladder with water via a catheter. Measurements of the volume are noted when the patient indicates the urgency of urination.
Another useful diagnostic tool for surgical planning is dynamic MRI (DMRI) which provides visualization of the rectocele and movements of the pelvic floor.[rx] DMRI is a valuable adjunct test when a patient’s symptoms are more significant than the physical examination findings suggest. Its use for preoperative planning has made it more widespread.[rx]
Treatments of Rectocele Prolapse
If you’ve suffered a rectocele prolapse, speak to your doctor about which of the numerous treatments may work best for you. Targeted pelvic floor muscle exercises are a popular choice for seeing a quick and effective improvement in your prolapse.
Surgery is considered as an option only when symptoms are severe and cannot be treated through other means, as success rates are comparatively low and there is a risk of further damage in the case of complications. Effective non-surgical treatments are also preferred when future children are desired, which can reduce the success of previous surgical procedures in the pelvic area:
- Kegel exercises – These are also known as pelvic floor exercises. You can do them quickly and easily, at any time of day as no one will know you’re doing them. They help to strengthen the pelvic floor muscles. You can make them even more effective by using a Kegel8 Ultra 20 Pelvic Toner.
- Maintain your weight – Making sure you stick to a healthy weight will put less pressure on your pelvic floor muscles, giving you more chance of keeping them strong. The National Institute for Health and Care Excellence (NICE) recommends keeping your BMI under 30.
- Avoiding constipation – Eating a high fiber diet of fruits, vegetables, and wholegrain cereals will help your bowels stay regular, as will drinking plenty of water.
- Avoid straining on the toilet – Straining on the toilet puts unnecessary pressure on the pelvic floor muscles. Using a toilet stool when you pass a bowel movement will help avoid straining as it puts your body in the optimum position for fully emptying your bowels.
- Lift heavyweights (and children) safely – Lifting correctly will make all the difference to not only your back but your pelvic area too. The National Health Service (NHS) suggest holding the load close to your waist and avoid bending your back.
- Avoid too much high impact exercise – High impact exercises are great for overall health. But if you’re worried about uterine prolapse, then gentler, lower impact exercise may be better for you.
- Treat that cough – Persistent heavy coughing can cause a weakening in the pelvic floor muscles that may not become apparent straight away. Get medical help for a cough that lasts longer than a week or so.
- Pelvic floor exercises – Regular pelvic floor exercises really can make all the difference and may well be all the treatment you need to keep your rectocele symptoms at bay. Like any muscle, the more you train the pelvic floor, the stronger it will become. Kegels need to be carried out every day and can be made more worthwhile by using the Kegel8 Ultra 20 Electronic Pelvic Toner. Used in conjunction with a biofeedback tool, you can understand how to make the most of pelvic floor exercises.
- Lifestyle changes – Managing your weight, quitting smoking, lifting correctly, and performing low impact exercise can also help. As can doing all you can to avoid constipation, even if that means occasional laxative use. Eating a high fiber diet of 25+ grams a day and drinking in excess of 6 glasses of water are shown to help reduce constipation.
- Hormone replacement therapy (HRT) – HRT can help women manage the symptoms of menopause, plus the extra oestrogen will help keep the pelvic floor muscles strong.
- Wearing a vaginal pessary – A vaginal pessary is a small device, usually made from silicone, that is placed inside the vagina to help support the vaginal wall and prevent other pelvic organs from collapsing further into it. Different shapes and sizes of vaginal pessaries suit different shapes and sizes of women. Your doctor can help you find the right one and help you change the pessary as required, usually every four to six months. This is commonly the favored treatment for those with a severe rectocele prolapse who are unable to undergo surgery due to other medical conditions, or those wishing to have children in the future.
- Surgery – In the circumstance that your rectocele prolapse remains a significant barrier to continuing with your daily routine, regardless of your incorporation of non-surgical treatments into your lifestyle, you may be advised to have surgical intervention. Surgery is a last resort reserved for severe rectoceles. It involves repositioning the rectum back into place and adding stitches to the wall of the vagina to encourage scarring as added strength. The surgery can be performed through the abdomen (open or through keyhole/laparoscopically), vagina, anus, or perineum (the space between your vagina and anus). These can be categorized as transvaginal, transanal, and transperineal repairs. These surgeries reconstruct the vagina and rectal walls, sometimes using synthetic or biological mesh as added support to weakened muscle. The use of synthetic mesh in these surgeries is currently only recommended within the context of research, as current evidence into the safety of the procedure is insufficient. The success of the surgery depends on many factors; including your overall health, the length of time that the prolapse had existed, and your symptoms. There are a number of risks associated with undergoing surgery for a rectocele prolapse; including blood clots in the legs or lungs, infection, and injury to nearby organs. Following the surgery, up to 50% of patients report sexual dysfunction and pain, a feeling of incomplete bowel emptying, and fecal incontinence, and in some patients, these symptoms worsened. There is also a reported 30% chance of developing a future prolapse following pelvic surgery, due to the damage to the vaginal tissue. Overall, following a rectocele repair surgery, improvement is felt in 75-90% of patients initially, falling to 50-60% after two years.
How Long Does it Take to Recover from Rectocele Prolapse Surgery?
You may be required to stay in the hospital for one or two nights following surgery on your rectocele prolapse. During this time you will be encouraged to walk to avoid blood clots and be prescribed pain medication to reduce the cramps, bloating, and lower backache. Recovery time after a rectocele repair surgery can be from three to eight weeks depending on your overall health. During which time you can expect a bright red or pink-colored vaginal discharge for the first six weeks, turning to a brownish or yellow towards the end. It is important to not have sex during this time as it suggests the wound is still healing. It is also important to complete the only light activity, urinate frequently (to avoid discomfort), eat well (to avoid constipation), and not rush to return to work and your daily activities.
Although you may have recovered from the surgery in three to eight weeks, a rectocele is what’s known as a long-term condition. It won’t heal or get better on its own. Kegel / pelvic floor exercises, along with the recommended lifestyle changes, will need to be continued for life in order to keep the pelvic floor muscles strong and prolapses from getting worse or recurring.
If you do opt for surgery, it is important to note that surgery cannot repair your pelvic floor muscles. You will need to perform pelvic floor exercises after you recover from your surgery, to prevent the prolapse from recurring and to support any synthetic or biological mesh from stretching.
What Is the Difference Between a Rectocele Prolapse, a Rectal Prolapse, and a Cystocele Prolapse?
With the number of different prolapse conditions and their close proximity to each other in the body, it can be difficult to know which symptoms point to which condition. See below for how rectocele prolapses differ from rectal and cystocele prolapses.
Whereas during a rectocele the rectum protrudes into the vagina, rectal prolapse is where the walls of the rectum protrude down through the anus. A rectal prolapse of any severity can occur in men and children, as well as in women. In both types of prolapse, when severe the rectum can end up dropping down so far that it protrudes outside of the body; either through the vagina (severe rectocele), or the anus (severe rectal prolapse).
Just like a rectocele is a prolapse of the rectum into the vagina, a cystocele is a prolapse of the bladder into the vagina. A cystocele is known as an anterior wall prolapse as the prolapse bulges into the vagina through its front wall. The cause of both prolapses are the same – a weakness in the pelvic floor muscles that correspond to each organ. Therefore if you have a rectocele you are more prone to developing a cystocele. You must strengthen your pelvic floor with Kegel / pelvic floor exercises to reduce your risk.
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