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Rectocele

Definition :
In women, a wall of tough, fibrous tissue (fascia) separates the rectum from the vagina. A rectocele occurs when this fascia weakens, allowing the front wall of the rectum to bulge into your vagina.

A rectocele usually results from prior damage to the fascia that causes it to weaken, such as during childbirth or from excessive straining. It's most common after menopause, when estrogen — which helps keep your pelvic tissues strong — decreases.

Mild (small) rectoceles may cause no signs or symptoms. More severe (large) rectoceles may cause a noticeable bulge of tissue through the vaginal opening. Though this bulge may be uncomfortable, it's rarely painful.

When treatment of a rectocele is necessary, self-care measures and other nonsurgical options are often effective. In severe cases, you may need surgical repair.

Causes:
Pregnancy and delivery are the most common causes of rectoceles. This is because the muscles and ligaments that hold and support your vagina become stretched and weakened during pregnancy, labor and delivery. As a result, the more pregnancies you have, the greater chance you have of developing a rectocele.
Not everyone who has had a baby develops a rectocele. Some women have very strong supporting muscles and ligaments in the pelvis and may never have a problem. Women who have only Caesarean deliveries are less likely to develop a rectocele.

Other conditions and activities that can put pressure on the pelvic floor and cause a rectocele include :

  • Chronic constipation or straining with bowel movements
  • Chronic cough or bronchitis
  • Repeated heavy lifting
  • Being overweight or obese

Risk Factors:
The following factors may increase your risk of experiencing a rectocele :

  • Genetics. Some women are born with weaker connective tissues in their pelvic area, making them naturally more susceptible to rectoceles. Others are born with stronger connective tissues. Chinese women, for instance, rarely develop rectoceles, even after multiple deliveries.
  • Childbirth. If you have vaginally delivered multiple children, you have a higher risk of rectoceles. If you've had tears in the tissue between the vaginal opening and anus (perineal tears) and incisions that extend the opening of the vagina (episiotomies) during childbirth, you also may be at higher risk.
  • Aging. Your risk of experiencing a rectocele increases as you age because you naturally lose muscle mass, elasticity and nerve function as you grow older, causing muscles to stretch or weaken. This is especially true after menopause, when the hormone estrogen — which helps keep pelvic muscles strong — decreases.
  • Having a hysterectomy. Having your uterus removed may contribute to weakness in the muscles and ligaments surrounding your vagina.

When to seek medical advice :
When a rectocele is small, you don't need medical care. In fact, in mild cases, you may not even know you have a rectocele.

In moderate or severe cases, however, rectoceles can be bothersome, uncomfortable and, rarely, painful. Make an appointment with your doctor if you experience :

  • A soft bulge of tissue in your vagina that protrudes through your vaginal opening
  • Rectal pain or bleeding
  • A feeling of fullness or pressure in your rectum
  • Difficulty emptying your rectum
  • Chronic constipation

Symptoms :
In mild cases — when a rectocele is small — it's possible for you to not even notice the bulge. When signs or symptoms do present themselves, they may include :

  • A soft bulge of tissue in your vagina that may or may not protrude through the vaginal opening
  • Constipation or difficulty having a bowel movement
  • Sensation of rectal pressure or fullness
  • A feeling that the rectum has not completely emptied after a bowel movement
  • Difficulty controlling the passage of stool
  • Low back pain that's relieved when you lie down

Many women with a rectocele also experience related conditions, such as :

  • Cystocele, when the bladder bulges into your vagina
  • Enterocele, when the small intestines push down into your vagina
  • Uterine prolapse, when the uterus descends into your vagina

Diagnosis:
In most cases, your doctor can confirm a diagnosis by physical examination of the vagina and rectum.

During the exam, your doctor may ask you to bear down as if having a bowel movement. This may cause the rectocele to bulge so your doctor can assess its size and location. You may also be instructed to contract the muscles of your pelvis — as if you are stopping the stream of urine — to check the strength of your pelvic muscles.

Treatment:
Treatment depends on the severity of the rectocele. If your case is mild — with few or no obvious symptoms — you may need no treatment or require only simple self-care measures, such as performing exercises called Kegels to strengthen your pelvic area muscles.

When treatment is necessary, your doctor may recommend :

  • Pessary. A vaginal pessary is a plastic or rubber ring that's inserted in the vagina to support the bulging tissues. Several types of pessaries are available, including those that you can remove to clean, and those that your doctor must remove periodically to clean. Because they have a high “hassle factor,” many women choose not to use this method.
  • Estrogen therapy. Your doctor may recommend using estrogen — either orally or in a vaginal cream — if you've already experienced menopause. This is because estrogen, which helps keep pelvic muscles strong, decreases after menopause. This approach may slow progression of a rectocele, but it will usually not cure the problem.

When surgery is necessary
If the rectocele protrudes outside your vagina and remains there, you may need surgical treatment. Your doctor may also recommend surgery if your signs and symptoms — such as constipation, difficulty controlling stool and low back pain — are especially bothersome.

Surgery is more common when a rectocele accompanies another condition, such as a cystocele, an enterocele or uterine prolapse. In these cases, surgical repair for all conditions can be completed at the same time.

Surgery usually consists of repairing the weakness in the fascia between your rectum and vagina. In most cases, this is done by reinforcing the fascia with stitches. More rarely, surgery may involve using a mesh patch to support and strengthen the wall between the rectum and vagina.

Prevention:
You may be able to prevent a rectocele by :

  • Doing special exercises called Kegels that are designed to strengthen your pelvic floor muscles. This is especially important after you have a baby.
  • Treating and preventing constipation. Drinking plenty of fluids and eating high-fiber foods can help.
  • Treating a chronic cough.
  • Not smoking, because many smokers eventually develop a chronic cough.
  • Maintaining a healthy weight. Talk to your doctor to determine your ideal weight.
 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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