Enterocele and Rectocele

A rectocele occurs when the front wall of the lower rectum bulges into the back wall of the vagina, creating a pocket that can trap stool and prevent complete evacuation. Rectoceles are usually due to thinning of the rectovaginal septum (the tissue between the rectum and vagina).  Although this weakening and the resultant out-pouching of the rectum is fairly common, most women do not experience any symptoms.

What causes a rectocele?
Many factors can contribute to the development of a rectocele, including: birthing trauma during vaginal delivery (e.g., forceps delivery, vacuum delivery, tearing with a vaginal delivery, pelvic nerve injury), history of straining with bowel movements, and history of gynecological or rectal surgeries.  Other pelvic organs can also press into the vagina or the rectum and cause similar problems, including the bladder (cystocele), the small intestines (enterocele) and the colon (sigmoidocele).

What are the symptoms of a rectocele?
When the rectocele is large, it most commonly presents with a noticeable bulge into the vagina.  This leads to difficulty evacuating a bowel movement as stool becomes lodged within the rectocele.  This leads to the feeling of incomplete evacuation, straining, the need to make multiple trips the bathroom before achieving complete emptying and the need to manually assist defecation by pressing on the vagina and/or the space between the rectum and the vagina.  Vaginal symptoms of pain with sexual intercourse (dyspareunia), vaginal bleeding and a sense of fullness in the vagina are also common. 

How is a rectocele diagnosed?
A rectocele can be found incidentally during a physical examination by the doctor. Further evaluation of this incidental finding is warranted only if there are associated symptoms of obstructed defecation. The evaluation of its severity, and potential relation to constipation symptoms, is hard to assess with physical examination alone.  Further testing for a rectocele may include the use of a special X-ray study known as defecography or a dynamic pelvic floor MRI.   These studies evaluate the size of the rectocele and one’s ability to empty it.

How are rectoceles treated?
Rectoceles should only be treated if they are causing symptoms.  Their presence in and of themselves is not an indication for surgical repair.  There are both medical and surgical treatment options for rectoceles.  Surgical intervention is considered when symptoms continue despite the use of medical management and are significant enough that they adversely affect the patient’s quality of life.  There are abdominal, rectal, and vaginal surgeries that can be performed depending on each specific situation.