Rectocele

Excerpt

Rectocele is a variety of pelvic organ prolapse (POP) that involves the herniation of the rectum through the rectovaginal septum into the posterior vaginal lumen.

Anatomically, the vagina begins at the hymenal ring and terminates at the cervix. The bladder lies anterior to the vagina, while the rectum lies posterior to the vagina. The vagina has support at three levels. Most superiorly, it is supported by the uterosacral ligament complex. While in the middle, it is supported by the levator ani muscles, and by the endopelvic fascia in the lower segments. The vaginal wall tissue is composed of multiple layers. The innermost tissue layer is a nonkeratinized squamous epithelium, then stroma consisting of collagen and elastic tissue, and the outermost tissue layer is a smooth muscle and collagen layer.

The rectovaginal septum connects to the endopelvic fascia at the level of the perineal body. The loss of integrity in the rectovaginal fascia would result in a herniation of the rectal tissue into the vaginal lumen, and vice versa, leading to a vaginal bulge along the posterior vaginal wall on examination that would become more pronounced with the Valsalva maneuver.

These herniations are also associated with enteroceles, or herniation of bowel into the vaginal lumen if there is a separation of the fascia from the vaginal cuff. Many women have an anatomic presence of pelvic organ prolapse. It is present in two-thirds of parous women. However, not all women who have a rectocele found on the examination will be symptomatic. Over time, as the defect becomes larger, women can become symptomatic. The symptoms include vaginal bulge, obstructive defecation, constipation, and perineal pressure. As the bulge becomes larger, it can become exteriorized - meaning that the bulge is outside the level of the hymen. The mucosa becomes exposed to the outside environment; it is at risk for erosion and bleeding.

The management of this condition largely depends on the extent of the prolapse and the severity of the symptoms. Management options include lifestyle changes, medications, pessaries, and surgery.