Rectocele

Rectocele is herniation of the anterior rectal wall into the posterior vaginal wall through a defect in the rectovaginal septum.

• It affects up to 40 to 50 percent of parous women on examination, but only a minority are symptomatic.
• Risk factors: vaginal delivery (instrumental, large baby, prolonged second stage), obstetric tear, chronic straining, obesity, ageing, menopause with oestrogen deficiency, connective tissue disorders, previous hysterectomy and prolapse surgery.
• Size is graded by depth of bulge (small below 2 cm, moderate 2 to 4 cm, large above 4 cm).

Vaginal bulge or pressure, difficulty evacuating stool, need to splint the vagina or perineum to defecate, sense of incomplete emptying, rectal fullness, dyspareunia, backache.

• Retained stool in the rectocele (trapping) gives a feeling of incomplete evacuation and may cause overflow staining.
• Examination: bulge of the posterior vaginal wall during Valsalva, with loss of rectovaginal septum; assess for coexisting cystocele, uterine prolapse and enterocele.
• Differential diagnosis: enterocele, rectal prolapse, vaginal cyst (Gartner, Bartholin), perineal descent, rectal tumour, sigmoidocele, dyssynergic defecation.
• Complications: chronic constipation, faecal impaction, haemorrhoids, ulceration of vaginal skin, sexual dysfunction, urinary symptoms and impaired quality of life.

Clinical pelvic and rectovaginal examination in lithotomy and standing positions.

• Defecography (barium or dynamic MRI) shows size of rectocele, retention of barium after evacuation (trapping), and coexisting intussusception, enterocele or descent.
• Anorectal manometry if dyssynergia is suspected.
• Colonoscopy if alarm features.

Supportive: weight reduction, fibre 25 to 30 g daily, fluids, avoid straining, toileting posture; pelvic floor muscle training under a physiotherapist (three sets of 8 to 12 contractions daily).

Pharmacological

• Macrogol 17 g daily or lactulose 15 to 30 mL twice daily to soften stool.
• Topical vaginal oestrogen in postmenopausal women: oestradiol 10 microgram vaginal tablet daily for 2 weeks then twice weekly, or estriol 0.5 mg cream nightly for 2 weeks then twice weekly.

Procedures

• Vaginal pessary (ring with support or space-filling type) for women declining surgery; replace every 3 to 6 months.
• Surgery for symptomatic large rectocele (above 3 cm) with trapping and failed conservative therapy: posterior colporrhaphy (native tissue repair), transanal repair, or site-specific repair; mesh is avoided because of erosion risk.
• Concurrent repair of enterocele and vault prolapse if present.
• Biofeedback before surgery for coexisting dyssynergia (improves outcome).

Special groups: pregnancy (conservative care only), elderly with comorbidity (pessary), women wishing future pregnancy (delay surgery).

Red flags: rectal bleeding, rectal mass, faecal incontinence, urinary retention, failure to pass stool, suspected malignancy.

Follow-up: pessary check every 3 to 6 months; review 6 weeks after surgery; avoid heavy lifting for 6 weeks.