Rectocele: what is it?

By Cristiano Antonino On Jun 17, 2023

The term ‘rectocele’ refers to the herniation of the anterior wall of the last tract of the intestine – the rectum, which leads to the anal sphincter – in the posterior wall of the vagina, due to a weakening of the pelvic floor muscles

The pelvic floor is the set of muscles, ligaments and connective tissue that are located in the lower part of the abdominal cavity, in the pelvic area.

This structure is essential for supporting and maintaining organs such as the urethra, bladder, rectum and – in females – the uterus in the correct anatomical position.

If there is a weakening of the pelvic floor – or a tear in it – the pelvic floor can no longer offer its natural support, leading to both physical and, consequently, psychological discomfort.

Rectocele is a condition that can occur in women of any age, although – epidemiologically speaking – those most susceptible to developing this condition are women between 40 and 60 years of age, after childbirth and following menopause.

Depending on the severity, rectocele can be classified as follows

Grade I rectocele – mild: only a small portion of the rectum invades the vaginal space.
Grade II rectocele – moderate: a large portion of the rectum invades the vaginal space.
Grade III rectocele – severe: the rectum protrudes from the vaginal opening due to a complete lack of support from the pelvic floor.

What are the causes and risk factors of rectocele?

As mentioned above, rectocele is a condition mainly caused by weakening of the pelvic floor, but what causes this weakening?

As far as young women are concerned, rectocele can be triggered by childbirth accompanied by various complications: very long labour, the use of forceps, extensive episiotomies, difficulty in expelling the foetus, especially when the foetus is large.

Causes unrelated to childbirth, which can affect any woman regardless of age, include chronic constipation and the resulting difficulty in expelling stools, obesity, and a previous hysterectomy.

All these factors contribute, for various reasons, to a progressive weakening of the pelvis, whose muscles, ligaments and connective tissue are injured and make prolapse of the rectum towards the vaginal canal possible.

In view of this, it can be said that the risk factors for rectocele are

A high number of vaginal deliveries. Each vaginal birth contributes to the progressive weakening – up to and including tearing in the most severe cases – of the pelvic floor. It has therefore been observed that women who have undergone a caesarean section are less likely to develop rectocele than women who have undergone vaginal delivery.
As women age, they produce less oestrogen hormones as they enter a very delicate period in their lives: the menopause. The decrease in oestrogen hormones is a risk factor, as their lack weakens the tone of the pelvic floor, exposing women to an increased risk of developing rectocele.
Surgery, even recurrent surgery, to pelvic organs may impair pelvic floor tone.
The genetic one is a risk factor that should not be underestimated: some women suffer from alterations in the structure of collagen – a group of disorders called collagenopathies – that are congenital. A reduced presence of collagen may lead to greater laxity of the tissues, particularly in those of the pelvis, which will be more prone to alterations and ruptures, favouring the onset of rectocele.

Rectocele: the symptoms

When the rectocele is of mild intensity, that is, when only a small portion of the rectum invades the vaginal space, the pathology is usually asymptomatic: there are no problems or obvious signs that lead the patient to suspect the presence of a rectocele.

When the rectocele is moderate or severe, that is, when a substantial part of the rectum invades the vaginal space, the patient will usually complain of a sensation of encumbrance at the vaginal level and, on objective test, a more or less evident protrusion of the rectum from the vaginal opening will be detectable.

The patient may also complain of difficulty in defecation and a feeling of obstructed bowel, a feeling of pressure in the rectum, pain during sexual intercourse or vaginal bleeding.

Diagnosing rectocele

This type of symptomatology, so intimate and delicate, can delay communication with the specialist, which, on the contrary, should be timely. The patient must feel free to communicate her symptoms and difficulties to him clearly and transparently to prevent the neglected condition from worsening.

Many women tend to neglect the condition, resorting to ‘do-it-yourself cures’ such as the immoderate use of laxatives or enemas to promote difficult evacuation or manual evacuation.

This behaviour must be avoided through a careful campaign to raise awareness and support the patient, who must be able to trust her professional reference.

The diagnosis of rectocele is possible through rectal and vaginal exploration and pelvic test: the specialist will measure the extent of the prolapse to analyse its severity.

However, this is not enough, a specialist test – defecography – will be necessary to investigate the presence of other related pathologies in the bladder, vagina and small intestine.

Another test often required in cases of rectocele is the MRI-defecography.

With the data returned by objective observation and specialist tests, it will be possible to make an appropriate diagnosis and, consequently, provide the patient with the correct course of treatment.

Rectocele: the most appropriate therapy

The appropriate therapy to treat rectocele is formulated according to the severity with which the pathology presents itself and the possible concomitance of other medical conditions affecting surrounding organs, such as cystocele or uterine prolapse.

Mild rectocele – as mentioned – is often asymptomatic and the patient discovers its presence following tests performed for other reasons.

Nevertheless, even if it is mild, it will still be necessary for the gynaecologist to propose certain ‘countermeasures’ to the patient, which are necessary to prevent the clinical situation from worsening: Kegel exercises to strengthen the tone of the pelvic muscles and slimming in the case of obesity or overweight.

In some cases, if the therapy is followed continuously and scrupulously, the problem can be resolved without the need for further surgical or pharmacological intervention.

Medium to severe rectocele, on the other hand, presents with a significant set of symptoms.

In order to avoid surgical treatment, the practitioner can propose two different therapies: the use of pessaries and oestrogen-based hormone therapy.

Oestrogen hormone therapy counteracts the physiological weakening of the pelvic muscles due to the reduction of the oestrogen stimulus produced by the menopause: the pelvic floor muscles will regain some of their lost tone, reducing prolapse of the rectum into the vagina.

The pessary is a rubber or semi-rigid plastic ring that – once inserted horizontally into the vagina – serves to physically block the prolapse through the pelvic muscles.

These therapies, however, are temporary and can be used for a limited period of time while waiting for the patient to reach the ideal physical condition to undergo surgery.

Surgery to resolve the rectocele will permanently eliminate the problem, reducing both vaginal and intestinal symptoms.

The operation consists of returning the rectum to its physiological position, providing it with adequate support so as to avoid the risk of recurrence.

Rectocele: how to prevent its formation

There is no universal ‘method’ for preventing rectocele.

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Gynaecologists recommend annual check-ups and – if age or biological conditions are unfavourable – constant Kegel exercises, preventing chronic constipation, avoiding lifting weights incorrectly, treating any chronic coughing and maintaining a healthy weight.

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