Rectal Prolapse Expanded Version | ASCRS

This patient education piece is designed to help improve patients’ understanding regarding rectal prolapse, specifically its presentation, evaluation and treatment. This information may also be useful to the friends, families, and caregivers of patients dealing with rectal prolapse.

Treatment of this condition may often require surgery, and this patient education material is intended for patients with rectal prolapse who are considering or have been recommended surgery. It will address why surgery may have been recommended, what the various treatment options are, what it involves and how it may help patients.

WHAT IS RECTAL PROLAPSE?

Rectal prolapse is a condition in which the rectum (the last part of the large intestine before it exits the anus) loses its normal attachments inside the body, allowing it to telescope out through the anus, thereby turning it “inside out”.  While this may be uncomfortable, it rarely results in an emergent medical problem.   However, it can be quite embarrassing and often has a significant negative impact on patients’ quality of life.

Overall, rectal prolapse affects relatively few people (2.5 cases/100,000 people).  This condition affects mostly adults, and women over 50 years of age are six times as likely as men to develop rectal prolapse. Most women with rectal prolapse are in their 60’s, while the few men who develop prolapse are much younger, averaging 40 years of age or less.  In these younger patients, there is higher rate of autism, developmental delay, and psychiatric problems requiring multiple medications.

Although an operation is not always needed, the definitive treatment of rectal prolapse requires surgery.

RISK FACTORS

While a number of factors have been shown to be associated with rectal prolapse development, there is no clear cut “cause” of rectal prolapse.  Chronic constipation (infrequent stools or severe straining) is present in 30-67% of patients, while an additional 15% experience diarrhea.   Some have assumed that the development of rectal prolapse is a consequence of multiple vaginal deliveries; however, up to 35% of patients with rectal prolapse have never had children.

PRESENTATION

Rectal prolapse tends to present gradually.  Initially, the prolapse comes down with a bowel movement (BM) and then returns to its normal position.  Patients may later describe a mass or “something falling out” that they may have to push back in following a BM. Until the prolapsed rectum goes back in, patients may feel like they are “sitting on a ball”.  Rectal prolapse may be confused with significant hemorrhoid disease and can even be confusing at times to physicians not frequently evaluating and treating this problem.

A = Rectal Prolapse                      B = Hemorrhoids

Once a prolapse is apparent, fecal incontinence (inability to control gas, liquid or solid BM) occurs in 50-75% of cases and is likely due to a number of factors.    The anal sphincter is a structure made of a number of muscles that allow one to hold on to their stool when they have the urge to move their bowels.  When the rectum is prolapsed, it has gone past the anal sphincter, and this allows stool and mucus to pass in an uncontrolled fashion.  Pelvic nerve damage (pudendal nerve) has been shown in many patients with prolapse.  The pudendal nerve contributes to the control of the anal sphincter and damage can result from direct trauma (birthing injury), chronic diseases such as diabetes, and from back injury or surgery.  The anal sphincter is constantly stretched by the prolapse itself, adding an additional risk factor for incontinence.

Upwards of 25% to 50% of patients will report constipation.  Constipation associated with prolapse may result from the bunching up of the rectum, creating a blockage that is made worse with straining, generalized coordination problems with the entire pelvic floor, and problems with the ability of the colon to move stool forward at a normal rate.   It is not unusual for some patients to even note both bouts of constipation and incontinence as well.

Over time, prolapsed rectal mucosa may become thickened and ulcerated causing significant bleeding. Rarely, the prolapse becomes stuck or “incarcerated” outside the anus – a situation that could require emergent surgery.

EVALUATION OF PATIENTS WITH PROLAPSE

Before considering surgery, a careful history and physical examination should be done.  As mentioned above, attention should be focused on complaints of constipation, fecal incontinence, and any complaints of urinary incontinence (inability to control urine) or bulging into the vagina.

Direct examination of the anal region is important and often reveals low anal sphincter tone (sphincter feels “loose”).  The patient may be asked to squeeze and relax their anal sphincter while the doctor has their finger in the patient’s bottom. This helps the doctor get a sense of how well the anal sphincter is functioning.   Formal anal manometry (a test that directly measures the anal sphincter pressures) could be recommended, as low sphincter pressures may affect the choice of procedure to repair the rectal prolapse.

While a spontaneous prolapse is obvious, it can be confusing as to whether a patient has significant hemorrhoids or rectal prolapse. To demonstrate a rectal prolapse, the patient may be asked to strain while being observed while squatting, or on a toilet or commode.  While this may be somewhat embarrassing for patients, it is very important to make an accurate diagnosis, as the treatments of hemorrhoids and rectal prolapse are very different.

A colonoscopy will often be necessary to rule out any associated polyps or cancer prior to consideration of treatment for rectal prolapse.  Colonoscopy is a procedure where a long, flexible, tubular instrument called a colonoscope is used to look at the entire inner lining of the colon (large intestine) and the rectum.

Colonoscopy picture from NCI Website

When the diagnosis remains in doubt, defecography may reveal the problem.  This test involves the patient taking an enema containing x-ray contrast and taking x-ray pictures during the process of having a BM.  Occasionally, additional contrast may be given to drink and/or placed into the vagina.  As mentioned, rectal prolapse can occur in the setting of a more generalized pelvic floor problem.  Twenty to 35% of patients with rectal prolapse complain of urinary incontinence, while another 15% of women have a significant prolapse of structures into their vagina (a feeling of something bulging into the vagina). These additional problems may also be demonstrated on defecography and may require surgery, typically involving surgeons from other specialties at the time of surgery for the rectal prolapse.  Importantly, if these additional issues are not addressed at the time of fixing the rectal prolapse, the symptoms related to these other problems may worsen.

As mentioned, many patients will present with rectal prolapse in the setting of lifelong constipation. Depending upon the severity of symptoms, a patient may be asked to undergo a transit study to evaluate their colon’s ability to evacuate stool.  A transit study involves swallowing a capsule containing multiple markers that can be seen on an abdominal x-ray.  Several x-rays are then taken over a five-day period to see how the markers move through the small intestine and colon, referred to as “transit time”.  Patients found to have unusually long transit times may benefit from having some or, less likely all, of their colon removed at the time of the repair of their rectal prolapse.

 

WHAT HAPPENS IF PATIENTS CHOOSE TO DO NOTHING ABOUT THEIR RECTAL PROLAPSE?

If a patient has been seen by a colon & rectal surgeon familiar with the diagnosis and treatment of rectal prolapse and given a diagnosis of rectal prolapse, they could potentially choose to do nothing about it.   Patients choosing to do nothing can likely expect their amount of prolapse to get larger over time and to have the rectum prolapse more easily (may just prolapse with standing).  If a patient chooses to delay treatment for a prolonged period of time, they should know that the longer a patient goes without having their prolapse repaired, the greater the chance of having permanent problems with fecal incontinence, as the anal sphincter is repeatedly stretched out and the chance of nerve damage is increased, too.  The length of time that these changes will occur is widely variable and differs from person to person.  In certain cases, the prolapse is very small or the patient is too sick to undergo an operation.  In these cases, supportive garments can help with keeping the prolapse from coming out all the time.

Untreated, rectal prolapse does not turn into cancer.

SURGERY FOR RECTAL PROLAPSE

There are two general approaches to surgery for rectal prolapse – abdominal operations (through the belly) and perineal operations (through “the bottom”).   Both approaches aim to stop the prolapse from occurring again and usually result in a significant improvement in quality of life.

The choice of surgery type depends on both patient factors and procedural factors.  Patient factors include the patient’s age, sex, bowel function, continence, prior operations, and severity of associated medical problems.  Procedural factors include extent of prolapse, what effect the procedure might have on bowel function and incontinence, complication rates of the procedure, recurrence rates of the procedure and the individual surgeon’s experience.

Most surgeons would agree that if a patient is medically fit for surgery, an abdominal approach may offer the best chance for a long-term successful repair of rectal prolapse.  Perineal approaches are often better choices for very elderly patients or patients with very severe medical conditions in addition to rectal prolapse. Consideration can also be given to a perineal approach in younger males, as there is a small chance (1-2%) of causing sexual dysfunction due to nerve injury during the pelvic dissection that occurs during an abdominal approach.   While this is very unusual, it should be considered when making decisions about the type of surgery to perform.  Young males may even want to consider banking sperm prior to the procedure in the very unlikely event they have sexual problems after the procedure.

Operative procedures for rectal prolapse can be performed under a number of different types of anesthesia. The patient and surgeon can decide what is appropriate for a given patient based on their particular circumstances. Potential options include:

• General anesthesia (completely asleep with a “breathing tube” in place)
• Under a spinal block (similar to an epidural injection during childbirth)
• A combination of intravenous relaxing medications and local anesthesia (numbing medicine) injected around the anus after relaxing medications have been given.  This is called monitored anesthesia with a perianal block.

ABDOMINAL APPROACHES

ABDOMINAL RECTOPEXY WITH POSSIBLE BOWEL RESECTION:

Most abdominal techniques involve making an incision in the lower abdomen and dividing the loose rectal attachments from the pelvic walls all the way to the floor of the pelvis.   A rectopexy is then performed, whereby the rectum is pulled upwards and secured to the sacrum (back wall of the pelvis) in a variety of ways.  Depending on the surgeon’s preference, the rectum may be sutured directly to the sacrum with stitches or a prosthetic material (mesh) may be included.  Regardless of the specific technique used, the intent is to hold the rectum in the appropriate position until such a time as scarring occurs to fix the rectum in place.  Overall, both of these techniques yield very good results, with recurrent rectal prolapse occurring in approximately 2-5% of cases. 

When patients complain of a long history of constipation, removal of a portion of the colon may be included in an attempt to improve bowel function.  The amount of colon removed is determined by the severity of constipation and may involve the use of the previously described colonic transit study. Interestingly, in patients with fecal incontinence prior to surgery, this symptom improves in about 35%, even with removal of part of the colon. This improvement often occurs within 2 to 3 months.

Figure 33-6, page 555

ASCRS Textbook, 2nd Edition

It is important to note that although the prolapse can be fixed, the function (incontinence or constipation) may not always improve. In a small number of cases, a potential complication of abdominal rectopexy is the development of new or worsened constipation. Following abdominal rectopexy, 15% of patients will develop constipation for the first time and at least half of those who were constipated prior to surgery are made worse. It is not clear what is to blame for those findings.  Fiber, fluids, and stool softeners may be needed in the setting of constipation following rectal prolapse repairs of any type. Occasionally, mild laxatives may be needed temporarily after surgery.  Sexual dysfunction may be reported in some patients following the extensive pelvic dissection involved in this surgery.

MINIMALLY INVASIVE RECTOPEXY WITH POSSIBLE BOWEL RESECTION:

Minimally invasive techniques such as laparoscopy or robotically, are used in some centers with equivalent success to traditional abdominal procedures.   Laparoscopy refers to the use of small incisions through which the surgeon may place a camera and surgical instruments, allowing them to perform the same procedures described above for abdominal approaches.

The robotic approach similarly uses smaller incisions with the aid of a robot to perform the abdominal operation.  In each of these instances, the operation that is performed is identical to an open approach, only through smaller incisions and the aid of a camera.  Potential benefits of a laparoscopic approach include less pain, shorter hospital stay, and earlier return to full activity and work.  Complication rates seem to be better than with open procedures and recurrent rectal prolapse appears to be the same as in open procedures (less than 5%).  Not all surgeons have the experience or expertise to perform these operations, and as such, it may not always be available.

PERINEAL APPROACHES

It is generally believed that the perineal approach results in fewer complications and pain, with a reduced length of hospital stay. These advantages have, until recently, been considered to be offset by a higher recurrence rate. Recent data is unclear on this point, however, and a properly executed perineal operation may yield good long-term results.

PERINEAL RECTOSIGMOIDECTOMY:  

The most common perineal approach is often referred to as a perineal rectosigmoidectomy or an “Altemeier procedure”, named after the surgeon who popularized this operation.  This approach to the surgical repair of rectal prolapse is done through the anus, with no abdominal incision.  In the operating room, the rectum is made to intentionally prolapse outside the body and is then divided.  The excess rectum and colon is pulled down and out of the body.  A full-thickness excision is done, with the remaining colon pulled down and sewn or stapled to the anus.  Lack of an abdominal incision, minimal pain, and a shorter hospital stay make this procedure an attractive option in appropriate patients.

Fig 33-3, page 551

ASCRS Textbook, 2nd Edition

Patients undergoing perineal rectosigmoidectomy tend to be older with more serious medical problems than those undergoing an abdominal repair.   Additionally, patients with a small prolapse, or those with incarcerated prolapse (rectum “stuck” on the outside) with concerns for a non-viable (or “dead”) rectum, may need to undergo this approach, even if medically fit for an abdominal approach.  Traditionally, recurrence rates have been reported to be much higher (> 10%) than abdominal approaches (2–5%).  Complication rates have been reported to range from 5-24%, and include bleeding or leak from the new connection sewn or stapled in the pelvis, and pelvic infection.  Fecal incontinence can be a bigger problem following this procedure compared to an abdominal rectopexy, though most patients have had pre-existing incontinence.  The rectum’s job is to serve as a reservoir to hold stool, and this procedure removes the rectum.  This leaves the colon to now do the job of the rectum, and it may not be able to hold the stool as well as the native rectum.  A levatoroplasty may be performed to help combat this problem.  A levatoroplasty is done at the same time as the perineal rectosigmoidectomy and involves “tightening” up the pelvic floor muscles by sewing some of them closer together.   This seems to aid fecal continence in as many as two-thirds of patients.

MUCOSAL SLEEVE RESECTION (DELORME PROCEDURE):

Occasionally, a surgeon may choose to do a perineal procedure slightly less extensive than a perineal rectosigmoidectomy.  A Delorme procedure does not involve a full thickness resection, as described in the perineal rectosigmoidectomy.  Instead, the inner lining of the rectum is stripped away from the muscle and removed.  The muscles of the rectum are then folded and sewn to themselves (plicate) to reduce the prolapse.  This particular procedure may be recommended in the setting of a small prolapse or if the prolapse is full-thickness but limited to partial circumference, where a perineal rectosigmoidectomy may be difficult to accomplish.  Incontinence is improved in 40-50% of patients after this procedure.

Fig 33-4, page 553

ASCRS Textbook, 2nd Edition

Complications are quite wide ranging in various series (0-76%) and most were due to pre-existing medical problems.   Complications specific to the surgery include bleeding, leakage of the sewn connection and stricture development (narrowing of the anal opening).  Rates of recurrent prolapse (6-26%) are generally felt to be higher than with a perineal rectosigmoidectomy.

QUESTIONS TO ASK OF THE SURGEON

1. Do I need surgery?
2. What are my options for surgery?
3. What options do I have for anesthesia with an operative procedure?
4. What can I expect after surgery?
5. How do you plan to address my pain after surgery?
6. What will happen if I don’t want any treatment for my rectal prolapse?

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum, and anus. They have completed advanced surgical training in the treatment of these diseases, as well as full general surgical training. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

DISCLAIMER

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention and management of disorders and diseases of the colon, rectum and anus. These brochures are inclusive but not prescriptive. Their purpose is to provide information on diseases and processes, rather than dictate a specific form of treatment. They are intended for the use of all practitioners, health care workers and patients who desire information about the management of the conditions addressed. It should be recognized that these brochures should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtain the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.  

CITATIONS

Mills, S. Chapter 33, “Rectal Prolapse”. Chapter in Beck, D. E., Roberts, P. L., Saclarides, T. J., Senagore, A. J., Stamos, M. J., Wexner, S. D., Eds. ASCRS Textbook of Colon and Rectal Surgery, 2nd edition. Springer, New York, NY; 2011.

ASCRS website, 2008 Core Subjects; Varma, M. G. “Prolapse, Intussusception, and SRUS”

Varma, M., Rafferty, J., Buie, W. D.; Standards Practice Task Force, American Society of Colon and Rectal Surgeons. Practice Parameters for the Management of Rectal Prolapse. Dis Colon Rectum. 2011;54(11):1339-1346.

SELECTED READINGS

https://medicine.umich.edu/dept/mbcp/patient-resources/rectal-prolapse

ENTEROCELE, RECTOCELE, OR BOTH? —

Little talked about, often overlooked; enterocele is like the distant cousin who is more misunderstood thanthe “popular” first cousin’s cystocele and rectocele. Articles about pelvic organ prolapse are incredibly vague when it comes to enterocele; this POP is sometimes undiagnosed when other types of POP are acknowledged (that was my scenario; a large enterocele was discovered during surgery). Let’s shine a bit of light on the difference between rectocele, intussusception, rectal prolapse, and enterocele.

A rectocele is a bulge in the anterior (front) or posterior (rear) rectal wall. During a bowel movement when a rectocele is present, stool typically remains trapped in the bulge. The most significant symptom of a rectocele is chronic constipation or incomplete bowel movements despite fingers inserted into the vagina to assist evacuation or bridging to assist movement (two fingers shaped like a V pushing up against the labia  and/or perineum during defecation). Bowels may still feel full after a movement. Intercourse may be uncomfortable or painful because of pressure of full bowel. Women who’ve been diagnosed with rectocele will gladly share the difficulties they have navigating constipation-it haunts them daily.

Intussusception is the rectum pushing back inside itself (partially inside out), similar to a glove finger pushed into itself. It may appear as finger-like protrusions that branch off of the rectum. Stool becomes trapped in these pockets. An intussusception can be intra-rectal (inside along the rectum), intra-anal (inside along the anus), or extra anal (outside the anus). With the straining that accompanies constipation, these folds sometimes progress and deepen and or reach downward through the anal canal to form rectal prolapse. Common symptoms are chronic constipation, incomplete emptying, pain with bowel movement, blood loss upon defecation, incontinence of gas or feces, or mucus discharge. Upon hard straining, obstructive sensation may increase. Enemas may be ineffective.

Rectal prolapse is when rectal walls have prolapsed to the degree they protrude through the anus and are visible outside the anal canal. Frequently patients with rectal prolapse have fecal incontinence. The sensation may seem similar to an obstacle preventing defecation.

Enterocele occurs when the intestines (or small bowel) protrude through a fascial defect or weak tissues, typically at the top of the vagina (apex). Women who’ve experienced birth trauma or had prolonged deliveries or forceps deliveries may have a higher risk of enterocele. Patients with previous pelvic surgery may have a predisposition to an enterocele as well; particularly a hysterectomy.

An enterocele can develop in the posterior wall (back side by rectum) or anterior wall (front side by bladder), basically wherever the small bowel (intestines) fall through defects in the vaginal wall. The size and “degree of drop” of enteroceles may vary considerably, from halfway down the vaginal length, down to the perineum (tissues surrounding the urogenital and anal openings), or even protrude out of the anal canal to form rectal prolapse.  An enterocele may be distinguished during pelvic examination as a bulge that occurs during the Valsalva maneuver (deep held breath while bearing down). It may also be necessary for a physician to perform the Valsalva maneuver while you are standing with one foot on a stool.

Symptoms of an enterocele may be sensation of a mass bulging into the vagina or pushing against the perineum or pain with intercourse. They may also include a pulling sensation in the pelvis or low back pain that eases up when you lie down, vaginal discharge, or a feeling of pelvic fullness, pain, or pressure. There may be a rapid return of bowel movement urge shortly after evacuating bowels (gotta go, gotta go again).

There are 4 types of enterocele:

• Pulsion: Caused by continual pressure in abdomen from chronic cough or extreme physical exertion like repetitive heavy lifting.
• Traction: Caused by pregnancy, childbirth and estrogen loss which contribute to weakening and stretching of pelvic tissues.  Additionally other prolapsed organs may put pressure on tissues contributing to enterocele.
• Latorgenic: Cause is not fully known but assumed to be related to hysterectomy or some cystocele repair procedures.
• Congenital: Birth defect.

An additional and more definitive diagnostic tool utilized for enterocele is called DRE or defecography (also called proctography). During this test, the act of defecation is assessed by recording expulsion of barium paste that is the consistency of feces. This test can evaluate pelvic floor and rectal function, how well the rectal sphincter works, and the effectiveness of rectal evacuation. Barium is both swallowed (to highlight the intestines) and injected as a paste into the rectum. The patient is sitting on a test commode to mimic normal body language which enables screening of the function of both rectum and pelvic muscle tissue during the procedure. This test facilitates diagnosis of rectocele, enterocele, intussusception, and function of the anal sphincter.

On a more personal note (how much more personal can it get than discussing our bowel concerns, something we ladies do in the APOPS forum almost daily in our individual quest for answers), I’d like to share a few insights. I pay particularly close attention to my body, the signs, symptoms, flags. When something occurs that is the slightest bit left of normal, the wheels are clicking away in my brain, trying to assess whether it is something I need to be concerned about or share with women navigating POP. I’ve noticed a subtle but palpable loss of sensation front to back over the past several months as well as a feeling of fullness (backdrop for me was transvaginal mesh surgery to address grade 3 cysto/rectocele; a large enterocele was found during surgery and repaired without mesh) and continually go hmmmm, what’s going on in there? Could it be my enterocele is back? Could it be as simple as bloated days related to IBS coupled with scar tissue or adhesions? (I’ve experienced the incredible value of myofascial release therapy and recognize I need to get in to test it again when I can schedule a break from APOPS duties.) We all need to recognize that as time keeps ticking away and we move forward with our lives, we must continually monitor change to enjoy the continuing quality of life-no one gets a “free health pass” automatically-we need to be pro-active.

I try to incorporate tools to address this most recent shift in my body. I recognize a distinct difference in how my bowel acts when I eat a healthy diet with lots of produce and how it acts when I shove 6 pieces of Dove dark chocolate in my face in one sitting or knock back a few gin cocktails-I’m only human! I’ve adopted a new practice I’d recommend women test. Every time women with rectal POP issues have a bowel movement, lock the door to make sure no one can disturb you to make it easier to relax, and “V-brace” the labia and push up on the labia gently with fingers, creating some structural support for the pelvic floor. 

References

1.  Wiersma,Tjeerd. The Radiology Assistant: Rectum-Dynamic Examination. www.radiologyassistant.nl/en/p4412ca5e2e2c21a.
2. Jennings, Claire. Bristol Laparoscopic Surgery. www.bristolsurgery.com/article.aspx?articleid=100798. Dec 31, 2007.
3. Mayo Foundation for Medical Education and Research. www.cgi.cnn.com/HEALTH/library/DS/00765. html. June 5, 2006.
4. Hoyte,  Lennox, MD, MSEECS , Professor, Chief of Female Pelvic Medicine and Reconstructive Surgery U of S. Florida.

April 2013

Resolution of Rectal Prolapse by Vaginal Reconstruction

Background:

Rectal prolapse is a disorder of the pelvic floor in which the layers of the rectal mucosa protrude outward through the anus. Surgical repair is the mainstay of treatment. Options include intra-abdominal procedures such as rectopexy and perineal procedures such as the Delorme and Altemeier perineal rectosigmoidectomy. Rectal and vaginal prolapse can often coexist. However, to our knowledge, there are no reported cases of rectal prolapse resolved by the repair of a compressive enterocele abutting the anterior rectal wall through a vaginal approach alone. We present a novel case of rectal prolapse that resolved by correction of the vaginal defect.

Case:

A 53-year-old female with prior history of abdominal hysterectomy, presented to the urogynecology clinic with complaints of vaginal bulge, urge urinary incontinence, and rectal bulge on straining with no fecal incontinence for several years. On physical examination, she was found to have stage 2 anterior, posterior, and apical vaginal prolapse and reducible rectal prolapse. Colorectal surgery (CRS) evaluation was requested, which revealed minimal anterior mucosal prolapse on Valsalva with no full-thickness prolapse. Magnetic resonance imaging (MRI) defecogram was performed, which demonstrated a large rectocele, enterocele, and small bowel prolapsing between the rectum and vagina during the evacuation phase, with no rectal prolapse. The decision to proceed with vaginal prolapse surgery without concomitant rectal prolapse repair was made, as the patient had no fecal incontinence, and the degree of rectal prolapse was minimal. On the day of surgery, which was 2 months later, she presented with a 2-cm anterior rectal prolapse with no incontinence. Colorectal surgery was consulted again, but unavailable. After counseling, the patient wished to proceed with her planned surgery. It was felt that correcting the anterior rectocele and enterocele, thereby eliminating the descent of the bowel on the anterior rectal wall, might cause resolution of the rectal prolapse. She then underwent a sacrospinous ligament fixation with mesh through an anterior vaginal approach, enterocele repair, Moschcowitz culdoplasty, and posterior colporraphy. She had an uneventful postoperative course and noted resolution of both vaginal and rectal prolapse. At 54 weeks, she continues without any complaints of rectal prolapse, which was confirmed on physical examination.

Conclusions:

Usually, the choice of surgical approach is tailored to each individual based on anatomy, age, comorbidity, and patient factors. Correcting both vaginal and rectal prolapse at the same time with a minimally invasive approach is an advantage to the patient. Restoring the apical, anterior, and posterior vaginal wall anatomy and an enterocele repair through the vaginal route caused resolution of the rectal prolapse. Further research is required as to whether rectal prolapse caused by anterior rectal compression needs an additional procedure or repair of the vaginal prolapse and enterocele alone will suffice.

Rectal Prolapse vs Hemorrhoids? Here’s How to Tell the Difference.

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Rectal Prolapse vs Hemorrhoids?

This article was published on August 7, 2013, and was last updated on May 1st, 2019 in Hemorrhoid Banding.

What’s the Difference Between Rectal Prolapse vs. Hemorrhoids?

Though about 75% of adults in America will have hemorrhoids at some point in their lives, discomfort in the anal region doesn’t always guarantee your doctor will diagnose you with hemorrhoids. A rectal prolapse, though less common, can actually cause symptoms similar to hemorrhoids, including anal pain, an itchy feeling around the anus, and blood in stools. If you’re feeling any of these symptoms, it’s important to understand the signs of a rectal prolapse so that you can seek the appropriate treatment.

A rectal prolapse and the more common prolapsed hemorrhoid have some similarities. In both cases, tissue from within the rectum begins to protrude outside of the anus. When veins within the rectum become dilated, an internal hemorrhoid can form and begin to protrude – causing a bleeding mass of swollen tissue that can become increasingly difficult to push back in. Rectal prolapse however, happens when the rectal wall protrudes through the anus (though there are varying degrees). This protrusion can happen during bowel movements, but is also seen in those individuals with weak pelvic muscle tone and/or weak internal tissue that is easily loosened.

Symptoms that are specific to rectal prolapse and not usually present in hemorrhoid cases include:

• Incontinence or leakage of stool.
• A feeling of fullness in your bowels.
• Prolapsed tissue that has the appearance of concentric circles.

Differences in the Advanced Stages of Rectal Prolapse vs. Hemorrhoids:

While hemorrhoids in the advanced stages will become harder and more painful, a rectal prolapse in its most advanced stage is called a complete prolapse. This occurs when the rectum’s sleeve turns inside out and remains outside the body. Advanced stages of these conditions are very rare but can still be easily treated with surgery.

Still, even mild rectal discomfort can be the sign of any number of conditions, so it’s important to get a professional diagnosis from a physician. Our qualified CRH partner doctors have helped many people just like you find long-lasting relief from all kinds of rectal conditions. Contact a CRH O’Regan doctor near you for more information about hemorrhoids, rectal prolapse, and much more.

Rectocele – Better Health Channel

A rectocele occurs when the rectum pushes the back wall of the vagina forward, causing a prominent bulge into the vagina. Risk factors include difficult childbirth and the use of forceps during delivery, but women who have never had children can also develop rectocele.

The degree of severity varies; for example, in mild cases the rectocele may be felt as a small bulge high inside the vagina while, in severe cases, the bulge may be hanging outside of the vagina. Milder cases can be treated by measures such as management of constipation, Kegel exercises to strengthen the pelvic floor and the insertion of a vaginal pessary to prop up the pelvic organs. Surgery may be needed in severe cases.

Symptoms of rectocele

The symptoms of rectocele may be vaginal, rectal or both, and can include:

• A sensation of pressure within the pelvis
• The feeling that something is falling down or falling out within the pelvis
• Symptoms worsened by standing up and eased by lying down
• Lower-abdominal pain
• Lower-back pain
• A bulging mass felt inside the vagina
• Vaginal bleeding that’s not related to the menstrual cycle
• Painful or impossible vaginal intercourse
• Constipation
• Problems with passing a bowel motion, since the stool becomes caught in the rectocele
• The feeling that the bowel isn’t completely empty after passing a motion
• Faecal incontinence (sometimes).

The rectovaginal septum and rectocele

Our pelvic organs are supported by our pelvic floor muscles. Structures including ligaments and connective tissue help to keep the pelvic organs tethered in place.

In women, the front wall of the rectum is situated behind the rear wall of the vagina. The front wall of the rectum and rear wall of the vagina, and the thin layer of tissue between them, are together called the rectovaginal septum (or wall). This wall can become weak or stretched by pressure such as childbirth, straining while going to the toilet, or ageing. A weak or thinned rectovaginal septum allows the front wall of the rectum to bulge into the vagina.

Causes of rectocele

Some of the events that may weaken or thin the rectovaginal septum and cause a rectocele include:

• Vaginal (normal) childbirth
• Giving birth to multiple babies
• A long and difficult labour
• Assisted delivery during childbirth, including the use of forceps
• Tearing during childbirth, particularly if the tear extended from the vagina to the anus
• Episiotomy (a surgical cut made to enlarge the vaginal opening during childbirth to avoid injury to mother and baby), particularly if the cut extends to the anus
• Hysterectomy
• Pelvic surgery
• Chronic constipation
• Straining to pass bowel motions
• Advancing age, as older women are more prone to rectocele.

A rectocele sometimes occurs by itself. In other cases, the woman may also have other problems including:

• Cystocele – the bladder protrudes into the vagina
• Enterocele – the small intestines push down into the vagina
• Uterine prolapse – the cervix and uterus drop down into the vagina and may protrude out of the vaginal opening
• Vaginal prolapse – in cases of severe uterine prolapse, the vagina may slide out of the body too
• Rectal prolapse – the rectum protrudes through the anus.

Diagnosis of rectocele

A doctor can diagnose rectocele by using a number of tests including:

• Pelvic examination
• Special x-ray (proctogram or defaecagram).

Treatment for rectocele

Generally speaking, a rectocele with no obvious symptoms doesn’t need medical treatment, but it is wise to pay attention to diet and other lifestyle factors that contribute to constipation. Treatment options may include:

• High-fibre diet
• Fibre supplements
• At least six to eight glasses of water per day
• Stool softeners (don’t use laxatives)
• Instruction on how to help yourself to pass a bowel motion; for example, you may be advised to gently press a finger against the rear wall of the vagina while toileting
• Don’t strain on the toilet
• Hormone replacement therapy for postmenopausal women
• Pelvic floor (‘Kegel’) exercises
• Insertion of a pessary – a ring-like device worn high in the vagina that helps to support the pelvic organs.

Surgery for rectocele

Surgery may be needed if the rectocele doesn’t respond to other treatments and is causing symptoms. Depending on individual factors, such as the severity of the rectocele and the presence of other prolapsed structures, the operation can be performed in different ways, including:

• Through the vagina
• Through the anus
• Through the area between the vagina and anus (perineum)
• Through the abdomen
• In some cases, a combination of surgical techniques may be necessary.

The aim of surgery is to repair and strengthen the wall between the vagina and rectum. Procedures for vaginal repair include:

• One or more incisions are made along the back wall of the vagina to expose the underlying structures.
• Weakened pelvic floor muscles around the vagina and rectum are strengthened with absorbable stitches.
• The wall is repaired using absorbable stitches.
• Sometimes, the perineum (area between the vagina and anus) needs to be repaired at the same time, with deep stitches into the muscle.
• If the vagina has been stretched (from childbirth, for example), the excess tissue may be removed.
• The vaginal incisions are stitched closed.
• The vagina is packed with gauze.
• A urinary catheter is inserted to allow urine to drain from the bladder.

After your operation for a rectocele, things you can expect include:

• Hospital staff will observe and note your temperature, pulse, breathing and blood pressure.
• You will have an intravenous fluid line in your arm to replace fluids in your body.
• You will receive pain-relieving medications. Tell your nurse if you need more pain relief.
• You may have a catheter to drain off urine for the next day or so, or until you can empty your bladder by yourself.
• If you have a vaginal pack, this will be taken out later the same day or the day after surgery.
• You may be in hospital for three to six days following surgery.
• You will need to make follow-up appointments with your doctor.

Complications of surgery for a rectocele

Possible complications of surgery include:

• Allergic reaction to the anaesthetic
• Haemorrhage
• Infection
• Injury to nearby nerves or blood vessels
• Damage to other pelvic organs, such as the bladder or rectum
• Death (necrosis) of the rectal wall
• Recurrence of the rectal prolapse.

Taking care of yourself at home after surgery for a rectocele

Be guided by your doctor, but general suggestions include:

• Rest as much as you can.
• Avoid heavy lifting or straining for a few weeks.
• Don’t strain on the toilet.
• Take measures to prevent constipation, such as eating high-fibre foods and drinking plenty of water.
• After rectocele surgery, expect bloody vaginal discharge for about four weeks.
• Contact your doctor if you experience any unusual symptoms, such as difficulties with urination, heavy bleeding, fever, or signs of infection around the wound sites.
• You can expect to return to work around six weeks after surgery.
• Attend follow-up appointments with your surgeon.

Where to get help

• Your doctor
• Gynaecologist
• Colorectal or general surgeon

Things to remember

• Some of the causes of a rectocele include vaginal childbirth, hysterectomy, pelvic surgery and chronic constipation.
• A rectocele may occur by itself or present alongside other pelvic abnormalities, such as a prolapsed bladder (cystocele).
• Surgery may be needed if the rectocele doesn’t respond to simpler treatments.

The Major Types of Pelvic Organ Prolapse and Their Differences

It’s been reported that 23.7% of women experience some form of pelvic floor disorder. Common issues range from urinary incontinence to several kinds of pelvic organ prolapse (POP). A “prolapse” is the slipping down or forward of a part or organ, often as a result of weakened or stretched connective tissue. Prolapses happen for both men and women, but women have several more types of prolapse that may affect the pelvic region of their bodies. This may cause pressure, pain during sex, incontinence, stretching sensations or lower back pain, an odd bulging sensation like sitting on a ball and in severe cases the prolapsed organ may sink so that parts are exposed outside of the body. Taking preventative measures, such as doing pelvic floor exercises, may help prevent these issues in women.

Types of Pelvic Organ Prolapse

These are the major types of pelvic prolapse that affect women.

Cystocele

A prolapsed bladder sinks into the anterior wall of the vagina.

Cystocele (or “dropped bladder”) is the most common type of female prolapse and one of the few types of bladder prolapse that may impact the body. Basically, the bladder’s supportive tissue stretches or detaches and sinks against the front (or anterior) vaginal wall at the top of the vagina. This may result in difficulty passing urine, incontinence, pain while having sex or general discomfort.

Urethrocele

The prolapsed urethra sinks into the anterior wall of the vagina.

This is another prolapse that affects the anterior vaginal wall. This type of prolapse affects only the urethra, which is a tube that takes urine away from the body from the bladder. It may lead to incontinence and frequent or urgent urination.

Cystourethrocele

Both the bladder prolapse (cystocele) and urethra prolapse (urethrocele) occur together.

This bladder prolapse affects both the bladder and the urethra, which sink into the anterior wall of the vagina together.

Uterine Prolapse

The uterus droops into the vaginal space and may even protrude outside of the vagina.

The uterus is a powerful, muscular organ that stretches during childbirth and pregnancy, but a dropped uterus can cause quite a few problems. It may lead to other prolapses on this list, as the weight of this organ puts pressure on other weakened organs, causing them to sink.  A uterine prolapse, if it goes completely unaddressed and untreated, can painfully protrude outside of the vagina in a disorder called procidentia. A prolapsed uterus can feel like you’re sitting on a ball, lead to beading and may lead to pain during sex.

Vaginal Vault Prolapse

The top part of the vaginal wall droops towards the vaginal canal.

This type is common for women who have undergone a hysterectomy. Because the uterus has been removed, nothing is anchoring the top of the vagina or cervix in place, and it may sometimes sink. In very severe cases, the vagina may fall through the opening.

Vaginal Prolapse

The vagina itself droops until it protrudes from the body.

A vaginal prolapse is slightly different than a vaginal vault prolapse. This is where the vagina and the ligaments, muscles and skin around it seem to sink and fall out of normal position. This is typically in combination with other types of prolapse on this list.

Enterocele

The small intestine prolapses into the upper wall of the vagina.

In some cases, the small bowel, or small intestine may sink into the lower pelvic cavity, affecting the top part of the vagina.

Rectocele

The rectum bulges into the posterior vaginal wall.

This type of rectum prolapse only affects women, in which the posterior wall of the vagina (a normally thick band of muscle between the vagina and rectum) is weakened. In severe cases, this bulge may tear into the vagina. Earlier stages may cause rectal pain, constipation, a feeling of pressure in the rectum or the feeling that the bowel hasn’t emptied even after finishing a bowel movement.

Rectal Prolapse

The rectum droops and protrudes through the anus.

Men and women can both experience this type of pelvic organ prolapse. The tissues and muscles around the rectal passage loosen, until the rectum may protrude through the anus. People may experience symptoms such as fecal incontinence, urgent bowel movements, or leaking blood or mucus from the anus.

Descending Perineum Syndrome

The perineum sinks down below its normal place on the pelvis.

Excessive trauma to the area may cause the perineum to sink. The perineum is the space between the vulva and the anus. This pelvic floor prolapse affects the whole region, which bulges down beyond its space, which is normally the bony part of the pelvis.

All these prolapses have a lot of potential causes. Pregnancy, childbirth, menopause, having a hysterectomy, excessive heavy lifting, smoking, weight, long-term health conditions that cause constipation, long-term conditions that cause frequent cough or strain, age and specific conditions (such as Marfan syndrome) all increase the risks of different forms of pelvic organ prolapse.

Many of these types of prolapses can be addressed with preventative measures, such as pelvic floor exercises, weight loss and lifestyle changes. More severe issues may be addressed with a type of surgery called sacrocolpopexy. A doctor also may use a pessary fitting, which are silicone rings inserted into the vagina to help address a prolapse. To talk about getting a diagnosis, prevention and the various procedures available, contact us at (678) 250-8451 or schedule an appointment with us.

Pelvic Organ or Vaginal Prolapse

Overview

Pelvic prolapse or vaginal prolapse is the term used to describe a weakness in one or more sides of the vaginal wall, allowing one or more pelvic organs to fall into the vagina. Vaginal prolapse is a broad term used to describe the following:

• Cystocele or weakness in the front wall of the vagina allowing the bladder to fall into the vagina,
• Rectocele is a weakness in the back wall of the vagina allowing the rectum to fall into the vagina,
• Enterocele is a weakness in the top or roof of the vagina allowing small bowel to fall into the vagina,
• Uterine prolapse is when the uterus and cervix descend from its normal position deep in the pelvis at the top of the vagina, towards the vaginal opening and sometimes  through and outside the vaginal opening. Vaginal vault (or vaginal cuff) prolapse is when the top of the vagina, (after hysterectomy) which is usually deep in the pelvis, descends into the bottom of the vagina or completely outside of the opening of the vagina.

Women often have more than one type of prolapse. The prolapse is staged according to how severe it is, meaning how much the prolapse has descended into the vagina and sometimes outside of the vaginal opening.

Symptoms

Women complain of a bulging or pressure inside the vagina. Some women can see or feel a bulge from the vagina. Women with a rectocele might need to push the prolapse back inside the vagina to defecate (or have a bowel movement) properly. They may also have difficulty emptying their rectum completely and might leak stool after having a bowel movement. Conversely, women with a cystocele might need to push the prolapse back inside to empty their bladder completely. Women with an enterocele might complain of low abdominal or back pain.

Diagnosis

Vaginal prolapse is diagnosed during a vaginal exam by a physician, usually a primary care physician or gynecologist. Some physicians who specialize in treating prolapse and urologic conditions, such as a urologist, or urogynecologist, might recommend a urodynamic test (evaluation of bladder function) or defecography (evaluation of lower bowel function) to determine if there are associated bladder or bowel conditions that need to be addressed concurrent to the prolapse, such as urinary incontinence, constipation.

Treatment

Vaginal prolapse may be treated nonsurgically or surgically. Nonsurgical treatment involves using a pessary.

Surgical treatment involves repairing the vaginal defect that is causing the pelvic organ to prolapse into the vagina. For example, a cystocele is a weakness in the front wall of the vagina, near the bladder. A cystocele repair is repairing this weakness by sewing the fascia, or tough vaginal tissue, back together where it had broken. This repair is usually done through the vagina, however sometimes the break in fascia is in a place that requires the surgeon to repair the break through an abdominal incision. Surgeons will often, but not always, reinforce the repair with a piece of mesh or allograft material to prevent the prolapse from recurring. A rectocele repair is done in a similar way, except the repair is done on the back wall, or posterior wall, or the vagina.

Women who have a vaginal vault prolapse, or a drop in the top, or roof, of the vagina, require a different type of surgery. They may either have a vaginal or abdominal surgery. During the vaginal surgery, the surgeon reattaches the top of the vagina to supportive ligaments or structures in the pelvis;the uterosacral ligaments, sacrospinous ligaments, or ileococcygeous muscle. The abdominal approach is called an abdominal sacrocolpopexy and is done through a low midline abdominal incision or laparoscopically by using instruments through several small incisions. Regardless, the surgeon attaches a piece mesh from the top of the vaginal to the sacrum, which is the bony spine just above the tailbone. Oftentimes, an enterocele is repaired at the same time as a vault suspension surgery because vault prolapse often occur with an enterocele.

If a woman is no longer sexually active, she will be offered a type of vaginal surgery for prolapse that renders the vagina functionally inadequate for intercourse. This surgery, called a colpocleisis, closes the vagina completely. The introitus, or outside of the vagina, will appear quite normal, but the length will be about 1 inch (an average vagina is about 7 inches).

Women whose uterus is prolapsing will be offered a hysterectomy if they have completed childbearing. A gynecologist almost always performs this procedure. If a woman who has uterine prolapse has not completed childbearing, then a hysteropexy can be considered if a trial of pessary use has failed. Hysteropexy involves leaving the uterus in place and anchoring it to supportive ligaments in the pelvis, sometimes synthetic material is used to reinforce the repair. However, these surgeries can be prone to recurrence and are not recommended unless a woman wants to bear more children.

Preoperative Considerations

Any woman with vaginal prolapse that is bothering them (usually high stage) and who has either tried or considered a pessary, is a candidate for the above described procedures.

90,000 Rectocele: symptoms, diagnosis, treatment, surgery

Unfortunately, this historical definition does not quite correctly describe the clinical situation. Yes, indeed, for the most part, a part of the rectum is hidden behind the prolapsed back wall of the vagina. At the same time, in some patients, the loops of the small intestine or the omentum protrude through the posterior wall. In this case, there is already a posterior enterocele. It should also be noted that there is often a combined problem when both the loops of the small intestine and the rectum fall (recto-enterocele).

Symptoms

The symptoms of rectocele depend on the organ that descends with the back of the vagina. In principle, all symptoms can be divided into two groups:

• Symptoms associated with prolapse of the rectum: difficulty in defecation, the need to squeeze out feces from the protrusion of the posterior wall of the vagina, the need to empty the formed “pocket” in the rectum on their own (with a finger through the anus), defecation in portions, incontinence of gases and damage to the sphincter of the rectum).
• Specific symptoms arising from the omission of the loops of the small intestine and the omentum are either completely absent or are expressed in a pulling sensation in the lower abdomen, bloating and flatulence.

Common to both groups is the feeling of a foreign body in the vagina, possible trauma to the prolapsed mucosa when walking, dryness of the vaginal mucosa, discomfort during sexual intercourse. Given the fact that the contents of the hernial protrusion can be heterogeneous, the symptoms are also often mixed.

Reasons

The reasons for rectocele are the same as for other forms of prolapse: childbirth and pregnancy, heavy physical exertion, chronic constipation and of course a hereditary factor.Despite this, it is with this type of vaginal prolapse that childbirth and constipation play a special role.

The first factor is especially important in the case of episiotomy (perineal incision during labor) and perineal tears (large fetus, rapid (very fast) labor, incorrect obstetric aid).

At this moment, the main “defender” of the posterior wall of the vagina – the perineum and the muscles of the pelvic floor – suffers, without them the entire load falls on the thin fascia separating the vagina and rectum.This is why any surgical treatment always includes perineal reconstruction. The second most important factor is chronic constipation.

In the presence of this pathology, the supporting structures of the posterior wall experience constant high loads, as a result of which a rupture of the fascia occurs, through which part of the rectum exits.

Diagnostics

Diagnosis of rectocele consists in collecting complaints from the patient, finding out the anamnesis of the disease and life. This allows you to determine the causes of the disease and to suggest the existing anatomical defects of the pelvic floor. Next, a standard gynecological examination is performed, which gives an idea of ​​the degree of prolapse and the condition of the perineum.In total, four degrees of rectocele are distinguished:

• 1 degree – when there is a slight prolapse, which is determined only during a gynecological examination and does not reach the entrance to the vagina by more than 1 cm;
• 2 degree – when the back wall descends slightly to the entrance to the vagina or falls below it, but not more than 1 cm;
• Grade 3 – in this case, the rectocele falls by more than 1 cm from the entrance to the vagina, but no more than 5-7 cm;
• Grade 4 – complete inversion of the posterior wall of the vagina.

To clarify what exactly comes out along with the back wall of the vagina, a gynecological examination is always complemented by a digital rectal examination – an examination of the rectum with a finger through the anus.

Treatment

Rectocele treatment includes both conservative and surgical methods. The first group includes training of the pelvic floor muscles, aimed at increasing their tone. Exercise can be effective only in the initial stages of prolapse and in patients with preserved muscular apparatus.This type of treatment can show real results in young women, especially in the first year after childbirth. A separate question is the correctness of the exercise (it is not entirely clear what needs to be reduced and whether it is reduced), on which their effectiveness depends.

For control, biofeedback devices (BFB – therapy) have been created, which make it possible to increase the effectiveness of training several times. Another option for non-surgical treatment is pessaries.This is a whole group of devices of various shapes and sizes, made of rubber or silicone. The pessary is inserted into the vagina and blocks the way out for prolapsed organs.

Unfortunately, this device causes chronic inflammation, discomfort and requires regular changes, which means visiting a gynecologist.

Operation

Video lecture for patients and colleagues. Prolapse of the uterus, bladder, rectum: symptoms, diagnosis, treatment, surgery.urologist, MD Dmitry Shkarupa

The main method of treating rectocele is surgical. Moreover, this pathology is dealt with by both gynecologists and proctologists (transanal reconstruction). At the same time, according to international standards, the vaginal route is more preferable as more effective and safer. Surgery for rectocele consists in the restoration of the fascia defect (colporrhaphy) between the rectum and the vagina, as well as reconstruction of damaged structures of the perineum.

It has been proven that the use of synthetic prostheses in this case does not improve the results, but significantly increases the risk of complications.

During the operation, it is very important to correctly collect the damaged fascia and perineum, to excise old scars, otherwise pain may occur, including during sexual intercourse, as well as problems with defecation. Moreover, the cosmetic effect will also largely depend on the experience of the surgeon.

Rectal prolapse

A serious illness with even more serious consequences is rectal prolapse, or rectal prolapse.It is expressed in the fact that the lower part of the intestine is deformed, loses stability and may even bulge outward. The disease does not develop immediately and gradually makes the act of defecation more and more difficult. In the late stage of the disease, going to the toilet turns into a real test, and the intestines begin to fall out when laughing, sneezing and coughing. In the end, the intestine can fall out simply when the patient takes an upright position. In the later stages of the disease, it is impossible to correct it yourself.

The problem also lies in the fact that the prolapsed rectal fragment undergoes pathological changes. It turns red and swells, and in the case of strong squeezing of the sections of the intestine, necrosis, or tissue death, may develop. In addition, prolapse, which in itself is a painful test for the patient, can be complicated by pinching of a fragment of the intestine, and the formation of painful ulcers on its tissues, and the development of peritonitis or acute intestinal obstruction. In order to avoid all these complications, which can ultimately lead to disability and even death, at the first symptoms of the disease, urgently consult a coloproctologist.Our medical center employs experienced doctors who quickly diagnose intestinal prolapse and differentiate it from hemorrhoids, which have some similar symptoms, and also prescribe an effective treatment regimen.

Reasons for rectal prolapse

Most often, rectal prolapse develops against the background of general weakness of the anal sphincter muscles. In 9 out of 10 cases, this happens in women. The reasons that can provoke the onset of the disease include:

• injuries sustained during childbirth;
• neurological diseases affecting the spinal cord;
• too hard feces and frequent constipation – this is what provokes excessive attempts during the act of defecation;
• various neoplasms in the rectum;
• disorder of the function of the pelvic organs.

Also, doctors identify a genetically determined predisposition to the development of this disease. It is characterized by a decrease in sphincter tone with age. In addition, in such patients, the ligaments that hold the rectum in an anatomically natural position are gradually stretched.

In principle, prolapse itself is not dangerous for the patient’s life, but the cause of its development and complications can be deadly. That is why, when the first signs of the disease appear, you should consult a proctologist.ON CLINIC in Ryazan uses an integrated approach to diagnostics, which helps to quickly identify the root cause of rectal prolapse.

Symptoms of rectal prolapse

Patients go to a coloproctologist with a complaint about the exit of a fragment of the rectum outside the anus. This can happen when sneezing, coughing, laughing, or lifting heavy objects. This is the most striking symptom of the disease that cannot be overlooked. Prolapse is also characterized by the following symptoms:

• Difficulty with the act of defecation, even at an early stage of the disease;
• abdominal pain;
• discharge from the anus mixed with blood and mucus;
• frequent false desires that do not turn into an act of defecation;
• bowel incontinence;
• Feeling as if there is a foreign body in the rectum.

This disease can both develop over time and develop rapidly. For example, this happens after childbirth, heavy physical exertion, or as a result of exposure to any other stress factors on the body. Prolapse can be both external and internal.

Diagnosis of rectal prolapse

First of all, the coloproctologist of our medical center collects an anamnesis of the disease in the course of consultation with the patient, analyzes the patient’s lifestyle and performs an initial examination, which includes a finger examination, to study the condition of the muscles involved in the act of defecation, determine the degree of prolapse and assess the ability to correct the fallen out fragment , as well as studying the state of the mucous membrane.In the future, he assigns additional examinations, which may include:

Only a qualified coloproctologist can distinguish rectal prolapse from hemorrhoids, tumors or large polyps, and if the prolapse is internal, from rectocele.

Treatment of the disease in “ON CLINIC in Ryazan”

Only an experienced doctor can identify the factors that led to the development of the disease and prescribe effective treatment. If the disease is still in its initial stage, then it is most reasonable to resort to conservative treatment.With advanced forms of prolapse, a combined surgical intervention is used – resection, fixation, plastic or removal of a fragment of the intestine. Each case is considered individually.

Prevention of rectal prolapse consists in limiting physical activity, especially lifting weights, adjusting the diet towards enriching it with plant fiber, as well as treating other gastrointestinal diseases that can complicate the patient’s condition, and stimulating the muscles of the anus through special gymnastics.

Rectocele

Proctology in our clinic is a solution to a delicate problem!

Faced with certain proctological problems, people in our country are in no hurry to see a doctor for examination. For the majority, as a rule, a visit to a specialist-proctologist is associated with discomfort, fear, and internal prejudices. Meanwhile – while the trip to the hospital is postponed for weeks, months, and maybe years – the disease is steadily progressing.

In our clinic, you can undergo all the necessary examinations related to proctological problems and get advice from experienced specialists – proctologists.

A widespread pathology today is Rectocele (2.5% of the total number of diseases of the female genital organs).

Rectocele is a pathological condition caused by the prolapse of the pelvic organs and manifested by the protrusion of the rectal wall in the vagina…. Rectocele is usually detected in patients who have undergone difficult labor. It can also occur as a result of pelvic floor muscle weakness, excessive physical exertion, congenital anomalies of the pelvic organs, and gynecological diseases.

With age, the likelihood of rectocele increases. Pathology is accompanied by a disorder of the evacuation function of the intestine, while the degree of disorder of the act of defecation directly depends on the severity of the rectocele. In severe cases, bowel movements without additional help (squeezing out fecal masses through the vaginal wall) becomes impossible, other proctological and gynecological diseases develop.

Reasons of rectocele:

Rectocele is a condition in which part of the rectum protrudes towards the vagina and gradually prolapses its wall, forming a sac-like pocket in which fecal masses are retained. The causes of rectocele are various processes that cause a violation of the interposition of the pelvic organs and weakening of the pelvic muscles. The first place in the list of such reasons, according to most experts, is occupied by difficult labor, accompanied by an excessive peak load of the pelvic organs and pelvic floor muscles.

Protrusion of the rectum is the cause of the disorder of the act of defecation and the development of severe constipation. A patient with rectocele has to push harder to empty the bowel. The pressure in the intestine during bowel movements increases more and more, this entails an increase in protrusion and further progression of pathology. Ultimately, rectocele reaches the degree at which the effectiveness of conservative measures is increasingly reduced, the only way to restore normal anatomical relationships between the pelvic organs and to establish an act of defecation is surgery.

Classification of rectocele:

Taking into account the symptoms, proctologists distinguish the following degrees of rectocele:

• 1 degree – no complaints, the act of defecation is not violated. On rectal examination, a small protrusion of the anterior rectal wall is palpated. Due to the absence of complaints, patients do not go to the doctor, rectocele becomes an accidental finding when conducting an examination for other reasons.
• 2 degree – patients with rectocele complain of difficulty during bowel movements and a feeling of incomplete emptying of the intestines.Rectal examination reveals a sac-like pocket extending to the border of the vestibule of the vagina. Sometimes in the protrusion, the remains of fecal masses are found.
• 3 degree – patients with rectocele complain of severe difficulty in defecation and the need for pressure on the vaginal wall for the successful discharge of fecal masses. The anterior wall of the rectum and the posterior wall of the vagina of the patient with rectocele protrude beyond the genital slit. The protrusion contains feces, sometimes fecal stones.Sclerotic changes in the vaginal wall are noted, ulceration is determined in some patients.

Taking into account the level of damage, the following types of rectocele are distinguished: low (accompanied by changes in the sphincter), medium (manifested by the formation of a saccular protrusion above the sphincter), high (accompanied by the formation of a pocket in the upper part of the vagina).

Rectocele symptoms:

The clinical picture of rectocele develops gradually.At first, defecation becomes less regular, there is a tendency to constipation, there is a feeling of incomplete emptying or a foreign body in the rectum. As the symptoms worsen, the patient with rectocele is increasingly forced to take laxatives or use enemas.

Artificial stimulation of the act of defecation contributes to the aggravation of the existing pathology. The rectocele is progressing.

Constipation becomes more and more persistent. Over time, the ability to have a normal bowel movement disappears; in order to achieve the release of feces, a patient rectocele has to press with his hands on the buttocks, perineum, or the back wall of the vagina.Stool stagnation and trauma to the intestinal walls with solid feces cause the development of proctitis or rectosigmoiditis. Due to repeated excessive straining, the rectocele is complicated by hemorrhoids, fissures in the anus, and other diseases of the rectum and the anus. Fecal incontinence sometimes occurs.

Rectocele diagnostics

The diagnosis of rectocele is made taking into account the characteristic symptoms, examination data of the perineum and perianal region, gynecological examination, rectal examination, endoscopy and radiological diagnostic techniques.When examining the anus in patients with rectocele, anal fissures and enlarged hemorrhoids can be detected. With fecal incontinence in the anal area, traces of fecal masses and areas of irritation are visible. When performing a gynecological and rectal examination, a patient with rectocele is asked to strain. When straining, the intestinal wall protrudes into the vagina. The doctor determines the size and location of the protrusion (high, medium, low), notes the presence or absence of rectocele contents (feces, fecal stones), assesses the thickness of the vaginal septum and the condition of the pelvic floor muscles.

In the process of sigmoidoscopy in patients with rectocele, a characteristic pocket is found in the region of the anterior rectal wall. For a more accurate assessment of the severity of the disorder of the act of defecation and the degree of rectocele, defecography (evacuation proctography) is prescribed. A thick barium suspension is injected into the intestine, and then a series of images are taken during the act of defecation. Sometimes radiological examination is replaced by magnetic resonance imaging. Differential diagnosis of rectocele is carried out with hernias of the rectovaginal septum.

Rectocele treatment

Treatment of rectocele 1 degree conservative. At 2 and 3 degrees of the disease, combined techniques are used, including surgical intervention, pre- and postoperative conservative measures aimed at eliminating constipation, restoring intestinal peristalsis and improving the evacuation of contents from the rectum. An obligatory part of the treatment of rectocele is a diet that provides for an increase in the amount of coarse plant fiber (to stimulate the motor function of the intestine) and a sufficient amount of water (to ensure the softness of the fecal masses).

To restore the regularity of the act of defecation, patients with rectocele are prescribed mild osmotic laxatives. Combined probiotics are used to correct the composition of the intestinal microflora. To normalize the motor function of the intestine, prokinetics (domperidone and its analogues) are used. Rectocele drug therapy is supplemented with physiotherapy and special exercise therapy complexes aimed at strengthening the pelvic floor muscles.

Conservative therapy can slow down the progression of the disease, but cannot provide complete recovery.The only radical way to treat rectocele is surgery. All surgical interventions for this pathology can be divided into two groups: aimed at eliminating the pocket formed by the rectum, and aimed at strengthening the septum between the vagina and the rectum. For rectocele correction, access through the vagina, rectum, perineum or anterior abdominal wall is used.

During the operation, the doctor sutures and fixes the anterior intestinal wall, strengthens the rectovaginal septum and takes measures to restore the sphincter.With combined pathology, along with rectocele, which includes hemorrhoids, anal fissure, cystocele or rectal polyps, a combined surgical intervention is performed to eliminate all existing disorders. In the pre- and postoperative period, exercise therapy, physiotherapy, probiotics and prokinetics are prescribed.

Railway Clinical Hospital will help patients in need of diagnosis and full treatment from the best specialists in proctology
in order to protect health and professional longevity!

We are open to all
Information by phone.:
(3952) 638-800, 638-802

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causes, symptoms and treatment in an article by proctologist Golovin A A.

Date of publication March 5, 2018 Updated April 26, 2021

Rectocele (from Latin rectum – rectum + Greek kēlē – bulging, hernia) is a bag-like bulging of the rectal wall.

By shape they distinguish:

• anterior: accounts for most cases, the wall of the rectum through thinning or defects in the rectovaginal fascia (a dense septum of connective tissue that separates the vagina and rectum) protrudes towards the vagina;
• posterior: is a more rare form of the disease.With it, the posterior wall of the rectum protrudes towards the anal-coccygeal ligament, that is, back towards the coccyx. ^[1]

According to the literature, rectocele occurs quite often, in 15-43% of women, ^{[2] [3] [4]} however in some cases it may not be accompanied by a certain stage of development no symptoms and become an accidental finding during examination.

In modern scientific literature, rectocele is considered as an isolated, special case of pelvic floor prolapse syndrome or pelvic prolapse (lat.prolapsus – “prolapse”). The concept of “pelvic floor” combines muscles and connective tissue structures that provide the physiological position of the pelvic organs. The structures of the pelvic floor are involved in fixing the pelvic organs and do not allow them to move.

Pelvic prolapse, in addition to rectocele, includes prolapse of the vaginal walls, cystocele, urethrocele, prolapse and prolapse of the uterus, enterocele, prolapse of the perineum. All these diseases are not accidentally combined into one syndrome: they have common causes and a common mechanism of development. ^[5]

Regarding the reasons for the development of this disease, it is necessary to clarify that it is polyetiological, that is, many different reasons lead to its appearance, and more often their combination.

Each pregnancy increases the risk of rectocele by 31%. ^[6]

The most common cause of the disease is pregnancy and childbirth . This fact is explained by the fact that in the process of gestation and childbirth, stretching and weakening of the structures of the pelvic floor, which hold the organs in the correct, physiological position, occurs.In addition, the risk of developing rectocele is increased by delivering large fetuses, rapid labor, use of forceps or vacuum extraction of the fetus or other obstetric aids.

The same group of causes can be attributed to injuries of the musculo-ligamentous apparatus, ruptures and discrepancies occurring during childbirth.

However, not every woman who has given birth will develop rectocele! In some women, due to genetic reasons, as well as the fitness of the pelvic muscles, which can be developed with the help of special exercises (biofeedback therapy), the pelvic floor support apparatus is sufficiently elastic and at the same time strong.He is little susceptible to various changes and injuries, and rectocele in such women never develops.

It is important to mention that women who have given birth using Caesarean section have a significantly lower risk of rectocele.

Two factors are key in the development of rectocele:

1. incompetence of the musculo-ligamentous apparatus of the pelvis;
2. Chronic, that is, long-term and frequent, increased intra-abdominal pressure (IAP). IAP increases at the time of straining (lifting weights or frequent constipation), when coughing (chronic lung diseases such as bronchial asthma or chronic obstructive pulmonary disease).

The main symptom of rectocele is constipation. The disease begins gradually and increases over time. At first, the stool ceases to be regular, and there is a tendency to episodic constipation. Then feeling of incomplete emptying of the intestine joins the constipation. It provokes frequent, ineffective urge to defecate. The patient gradually needs to take laxatives or use enemas, which further disrupts the bowel function, over time, laxative disease appears, i.e.e. dependence on taking laxatives. The disease progresses, constipation worsens, and the ability to defecate normally disappears. Patients resort to manual manual aid , that is, pressure with hands on the perineum, or the back wall of the vagina. ^{[7] [8] [9]} This is a characteristic sign of the accumulation of feces in the “sac”, rectocele cavity. Prolonged straining causes further stretching of the intestinal wall. A vicious circle is forming.

In addition, damage occurs, trauma to the rectal mucosa, which leads to the attachment of other proctological diseases (chronic anal fissure, chronic hemorrhoids, chronic cryptitis, proctitis, rectosigmoiditis, rectal fistulas, etc.)etc.). A number of patients, on the other hand, develop fecal incontinence .

In addition, with this disease, intimate life can also be significantly disrupted: there is a foreign body sensation in the vagina, which intensifies in a standing position and disappears or decreases lying down, discomfort and pain during intercourse (dyspareunia). ^{[10] [11]}

Over time, the addition of symptoms of prolapse of other pelvic organs : uterus, bladder, urethra is very likely.In this case, stress urinary incontinence, stool and gas incontinence, frequent genitourinary infections, and inflammatory diseases of the female genital organs may occur. The prolapse of the pelvic organs is often accompanied by pulling pains in the lower abdomen. ^{[12] [13]}

The pathogenesis of rectocele is based on changes in the connective tissue structures of the pelvic floor. The production of collagen and elastin fibers, proteoglycans decreases, the spatial structure of protein-carbohydrate complexes of the connective tissue matrix is ​​disrupted.As a result, the musculo-ligamentous apparatus of the pelvic floor, and in particular, the rectovaginal fascia does not provide the normal position of the organs. These changes can occur as a result of congenital connective tissue dysplasia, estrogen deficiency and age-related changes.

Classification of rectocele by severity:

• 1 degree – nothing bothers patients, the act of defecation is not disturbed, and rectocele is diagnosed accidentally when examined by a doctor for another reason.A rectal examination reveals a slight protrusion of the rectal wall.
• 2 degree – there are violations of the act of defecation, patients complain of a foreign body sensation in the vagina, a feeling of incomplete bowel movement. A rectal examination reveals a bag-like pocket, reaching the size of the vestibule of the vagina.
• 3 degree – patients experience severe difficulty in defecation, manual assistance is required. The protrusion of the posterior wall of the vagina along with the rectum extends beyond the genital gap.The pocket contains feces, and sometimes fecal stones can form. The vaginal wall outside the genital gap undergoes sclerotic changes and ulceration.

According to the level of the defect, the following are distinguished:

1. Low rectocele. It is located in the lower part of the vagina and is combined with changes in the sphincter of the rectum;
2. Average . Located in the middle third of the vagina;
3. High. Located at the top of the vagina. ^[14]

In the absence of timely diagnosis of rectocele and qualified treatment, the disease progresses steadily, which can lead to the development of the following conditions:

• inflammatory diseases of female genital organs: colpitis, vaginitis, vulvovaginitis;
• ulceration of the vaginal wall and / or cervix;
• Attachment of other forms of pelvic descent: prolapse and / or prolapse of the uterus, bladder and urethra;
• accession of chronic anal fissure, chronic hemorrhoids, rectovaginal fistulas, proctitis, cryptitis, etc.proctological diseases.

Conservative treatment

With a slight degree of pelvic floor weakness, conservative treatment of rectocele can be quite effective.

One of the important goals of treatment is the restoration of the motor-evacuation function of the intestine. The first step in achieving this goal is choosing a diet and a diet high in fiber and plenty of fluids. Consumption of 25 g.fiber and 1.5 liters of fluid, according to clinical studies, normalizes stool frequency in patients suffering from chronic constipation. ^{[29] [30]}

If it is not possible to normalize bowel function through diet, then laxatives are used to increase the volume of intestinal contents and stimulate motility. It is also necessary to perform specific exercises to strengthen certain muscle groups. There are Atarbekov complexes, Kegel gymnastics.However, performing such exercises on their own, without the supervision of a specialist, often turns out to be ineffective, due to their incorrect execution, the woman’s inability to correctly contract the necessary muscles.

Special hardware techniques help to significantly increase efficiency and obtain excellent results. For example, one of the most high-tech methods of conservative treatment of rectocele is biofeedback therapy (biofeedback therapy, BFB therapy). It is based on the principle of restoring lost neuromuscular connections.The technique allows, with the help of special equipment and software, to convert voluntary contractions of the pelvic floor muscles into visual or acoustic signals and thus makes it possible to “see” and “hear” how the muscles work. During therapy, the patient learns to control muscle contraction, their dyssynergy is eliminated, and the tone is increased.

The use of biofeedback therapy in patients with rectocele allows:

• to increase the tone of the pelvic floor muscles;
• to prevent the progression of the disease;
• eliminate urinary incontinence or significantly reduce its manifestations;
• eliminate or significantly reduce incontinence of stool and gases;
• improve the quality of intimate life;
• to experience orgasms more often;
• prepare for pregnancy and childbirth;
• to restore the functional state in the postpartum period
• to maintain muscle tone in the postmenopausal period.
• Electrostimulation of the pelvic floor muscles is another modern, effective and painless method for increasing the tone of the pelvic floor muscles. Stimulation is carried out with the help of special devices and is also successfully used in the treatment of stress urinary incontinence and fecal incontinence.

The use of local or systemic estrogen-containing preparations is also relevant . Their use is especially important during the period of perimenopause and with estrogen deficiency.Female sex hormones have a significant effect on metabolic processes in the connective tissue, the synthesis of collagen and elastin, the vaginal mucosa, and slow down the aging process.

Vaginal mesotherapy, aimed at correcting age-related changes in the vaginal mucosa, improving metabolic processes, and the quality of intimate life, also has similar effects.

Surgical treatment

Today there are more than 30 methods of surgical treatment of rectocele.However, before performing the operation, the patient must be explained that the anatomical defect is surgically eliminated, the correct interposition of organs is restored, but there is no direct connection between the severity of the anatomical defects and the severity of symptoms. As a rule, in young patients who are sexually active, even minor changes can cause discomfort and pain. On the contrary, in women of a more mature age, a rectocele of considerable size may be practically asymptomatic.Therefore, the age of the patient must be taken into account when choosing the type of surgery. It is important to take into account both the gynecological history and reproductive plans of the patient.

All methods of surgical treatment are aimed at eliminating the protrusion of the rectum, strengthening the rectovaginal fascia and differ from each other by the surgical approach.

1. Vaginal (transvaginal) approach

Surgical intervention involves dissection of the posterior vaginal wall, performing levatoroplasty and restoration of the rectovaginal fascia.Then perform posterior colporrhaphy with excision of excess mucosa.

There are also modifications of this operation using various synthetic and biological meshes and implants.

2. Rectal (transrectal) approach

Longo operation or stapler transanal rectal resection (STARR) is used when rectocele is combined with internal invagination of the rectal mucosa and allows to remove excess mucosa simultaneously with reconstruction of the rectovaginal septum.

3. Trans-perineal (transperineal approach)

Effective in low rectocele, as well as in combination of rectocele with defects of the anal sphincter. During the operation, sphincteroplasty is also performed .

In addition, there are techniques for plastic surgery of the rectovaginal fascia with mesh implants using transperineal access (mesh technology). In particular, this type of intervention includes operation Prolift posterior .However, it should be noted that these surgical interventions can be complicated by vaginal arrosion, and a number of young patients develop severe dyspareunia, therefore, in the modern world, surgeons use techniques using mesh implants and tension plastics less and less.

4. Transabdominal access

These operations are performed both with the help of celiac dissection and the laparoscopic method. Laparoscopic techniques for fixing the pelvic organs to the rigid structures of the pelvis are most effective for severe pelvic descent syndrome and at the same time are devoid of the inherent drawbacks of mesh technologies, therefore they are the best way to correct rectocele rectocele in young patients who are sexually active .Laparoscopic approach has a number of well-known advantages, including reduced recovery time after surgery, less blood loss and surgical trauma, as a result, less pain. These interventions do not prevent further pregnancy and delivery and can be successfully combined with surgical correction of stress and urgent urinary incontinence.

• Rectosacropexy – fixation of the rectum to the promontory of the sacrum with polypropylene tape, allows you to eliminate not only rectocele, but also other manifestations of the syndrome of prolapse of the perineum.However, when performing this intervention, there is a risk of injury to the presacral plexus, hypogastric nerves, ureters and iliac vessels, which can lead to serious complications.

• Colpopectinosuspension – fixation of the posterior wall of the vagina to the comb ligaments and the pubic bone. In addition to eliminating the manifestations of perineal prolapse syndrome, this operation does not lead to complications such as vaginal erosion, dyspareunia, does not interfere with pregnancy and can be used in women who are sexually active.

Despite the high efficiency and fewer complications and undesirable consequences, laparoscopic fixation operations require appropriate equipment and high qualifications of a surgeon, and therefore are performed in a small number of medical institutions.

Often, in order to achieve a high-quality result, combined treatment methods are used that combine different methods of restoring the normal anatomy of the pelvic floor, which allows to achieve the best results in the treatment of pelvic descent syndrome.

Prevention of rectocele is reduced to the elimination of risk factors for its development:

• rational, healthy diet, eating foods rich in fiber;
• stool normalization;
• timely treatment of diseases of the gastrointestinal tract;
• adequate obstetric benefit;
• training of the pelvic floor muscles in preparation for childbirth and in the postpartum period;
• dosed physical activity;
• reduction of excess weight;
• Regular follow-up by a specialist doctor.

The earlier the disease is diagnosed and its therapy is started, the more effective its results and the lower the risk of complications.

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Rectocele.Reasons, symptoms, diagnosis and treatment of rectocele!

1. General information

Rectocele (literally “rectal sac”, synonym “rectal prolapse”) is a pathological condition in which the rectum bulges out, protrudes through the muscular-ligamentous septum towards the coccyx or genitals, forming a diverticulum (hernia).Rectocele is often described as an exclusively female disease; indeed, the anatomy of the pelvic organs in the two sexes differs in such a way that in the overwhelming majority of cases rectocele is diagnosed in women, moreover, predominantly of mature age (giving birth and / or reaching menopause). This pathology, however, also occurs in men – almost always in the form of a posterior, coccygeal rectocele (in contrast to women, in whom the posterior and anterior variants are almost equally probable).

Medical and statistical data on the prevalence of rectal prolapse, sex dependence and other epidemiological features are strangely contradictory, if not directly opposite. In some sources, the disease is defined as rare, in other publications, proctologists speak of it as constantly occurring in clinical practice; you can even find reports that “rectal prolapse” is more inherent in men.Probably, there are discrepancies in diagnostic approaches, but the most likely explanation is that not in all cases a patient with rectocele seeks medical help. So, according to some estimates, more than two-thirds of women suffering from rectocele prefer to endure and “not advertise”, or even do not consider it a disease at all, in any case – curable. It should be noted that such a position is not only deeply erroneous, but also dangerous, since rectocele tends to progress and can not only sharply reduce the quality of life, but also cause more than serious complications.

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2.Reasons

Experts attribute the following to the main, most common causes of rectal prolapse.

• Congenital weakness of the muscles and ligaments of the small pelvis;
• Changes in the ligamentous-muscular apparatus (dystrophy, degeneration) caused by age or any pathological process;
• Long-term predisposition to constipation, anal sphincter dysfunction .;
• The presence of diseases manifested by constant intense cough;
• Physical activity associated with lifting weights;
• Traumatic childbirth.

The last factor deserves special attention: rectocele is often called a disease of many women who have given birth. Thus, difficult childbirth sometimes causes extreme mechanical stress and overstrain, significantly exceeding the elasticity and compensatory capabilities of the muscles and ligaments of the rectovaginal septum. However, this reason, for all its obviousness, is not dominant; however, reliable statistical data on the frequency ratio of etiological factors of rectocele are also lacking.

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3. Symptomatology, diagnostics

In the clinic of rectal prolapse, three significantly different stages can be traced. The first is asymptomatic or does not cause subjective discomfort at all (there is only slight bulging), and is diagnosed mostly by chance, during examinations for some other reason.The second is characterized by the appearance of difficulties with defecation, protrusion up to the vestibule of the vagina and a feeling of incomplete emptying of the intestines. At the third stage, there is a pronounced pain syndrome during bowel movements, frequent false desires and, as a rule, numerous complications: rectal bleeding, anal fissures, hemorrhoids, paraproctitis. In some cases, rectocele is accompanied by diverticular swelling and prolapse of adjacent organs (eg, uterus, bladder), the development of stagnant and inflammatory processes.

Diagnostics includes the collection of complaints and a detailed history, standard proctological examination with palpation, laboratory tests (primarily blood and feces), as well as instrumental methods according to indications (retromanoscopy, irrigoscopy, colonoscopy, ultrasound, MRI of the lower abdomen, dynamic defecoproctography etc.).

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4. Treatment

In the early stages, conservative treatment is possible, which, however, is not so much of a therapeutic nature as an attempt to prevent further progression: first of all, the diet is corrected (it is extremely important to ensure regular free defecation and to eliminate the tendency to constipation) and the exercise regimen is normalized ( lifting weights and excessive tension of the abdominal muscles are contraindicated).In some cases, a temporary positive effect is achieved with physiotherapy and special exercise systems. According to the indications, laxatives, antispasmodic, analgesic, anti-inflammatory drugs are prescribed.

With a more pronounced degree of rectocele, when the symptoms can no longer be stopped by medication and there are a number of serious gynecological, proctological, gastroenterological complications, the only choice is surgical correction. To date, many methods of such intervention have been developed and successfully practiced, including endoscopic technologies, the use of reinforcing implants, etc.As a rule, the operation is of a combined nature and is planned as the elimination of the entire complex of disorders that have developed in connection with rectocele.

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