Why a rectocele can be a cause
And sometimes a complication
Of constipation

In this article, we explain what a rectocele is, what the typical symptoms are, and why a woman may develop one.

As we have seen in the introductory page of this section, there can be multiple causes of constipation. Some are obvious and can be easily traced: the consumption of opiate medications for instance.

Some are a little more obscure and require precise diagnosis by your doctor. A rectocele belongs to the latter.

Second, we will discuss how a this condition can impact your bowel movements, and trigger constipation crises.

Finally, we will discuss the possible solutions, ranging from a simple and non-invasive approach to a surgical intervention. As we will see, managing constipation to avoid a worsening of the problem will be essential.

What is a rectocele?

It is one particular type of “pelvic organ prolapse”. A pelvic organ prolapse is the abnormal drop or herniation of one of the organs in the pelvis from its normal position.

The organs concerned are the vagina and the rectum. Between those two organs, we have a layer of connective fibrous tissues (also called a fascia). This layer keeps the two organs well separated. When this layer becomes weakened due to causes we will discuss further down, the rectum can develop a bulge that exerts pressure against the back wall of the vagina.

See the two pictures below, the one on top depicting a normal pelvic organ configuration, and the one below showing an abnormal one.

Pelvis - Normal Configuration

Pelvis with Rectocele

The bulge can be of different sizes, and can push at different points (high or low) on the vaginal wall. A low rectocele bulges toward the lower part of the vagina, near the vulva. A high one bulges toward the higher part of the vagina, away from the vulva.

A grading scale is used to denote how large the problem is is. Grade 1 makes reference to a small bulge, and grade 3 being the largest type, with a significant bulge pushing into the vagina’s space. The one shown on the second picture would be more of a type 3.

Possible causes

There are several reasons why the fascia separating the rectum from the vagina becomes weaker.

The direct causes may be:

  • Multiple and/or difficult vaginal births. This is the likeliest cause. The first birth brings its own set of tissue stretching and strains. The next birth will take place in an environment that has already been weakened. The risk increases with each vaginal birth.
  • Perineal tears and episiotomies during childbirth are aggravating factors.
  • Giving birth to a large baby is an aggravating factor.
  • Chronic elevated intra-abdominal pressure, as caused for instance by chronic constipation and overstraining to defecate can contribute. Another cause could be the regular lifting of heavy weights through a demanding job or through exercising. Working as a nurse for instance involves standing for long periods of time and lifting patients.
  • A history of past pelvic surgeries, such as a hysterectomy. Those surgeries weaken some of your pelvic muscles.

The indirect causes may be:

  • An overall inherited weakness of the pelvic muscles and connective tissues that keep all organs in the proper position. Unfortunately we cannot control our genetic makeup.
  • Your age. The younger you are, the lower the risk.
  • Your body-mass index. Being overweight increases the intra-abdominal pressure.
  • lack of estrogen after menopause. Some studies have shown that estrogens are beneficial to muscle strength in women. To me, this makes low levels of estrogens a risk factor(1). However, there does not seem to be a concensus in the scientific community regarding this.

Even though constipation may be a cause of rectocele, it will more likely be an aggravating factor. You may have gone through several vaginal childbirths, which created weaknesses in the fascia and initiated a rectocele, maybe unnoticed at that point. Then, chronic constipation may have made the condition worse, it may have enlarged the bulge.

Symptoms

According to the American Society of Colon & Rectal Surgeons(2), many women suffer from this condition but only a small percentage of women will feel any symptoms.

Those symptoms may be:

  • Constipation. The bulge we see on the second diagram above creates a reservoir that traps a certain quantity of stools that cannot be evacuated. Evacuation is difficult and straining, thus putting more pressure on the rectocele and making the problem worse. Complete evacuation is difficult.
  • The sensation of a bulge in the vagina, sometimes leading to painful sexual intercourse.
  • The vaginal bulge, plus the sensation of incomplete defecation, may create an urge to apply pressure on the vaginal bulge with your fingers, in order to apply pressure on the rectocele and help the stools move in the right direction, toward the anus(3).
  • Hemorrhoids may appear as a result of difficult evacuation of stools and constant straining.

Please note that having some of those symptoms does not necessarily mean you have the condition. You should discuss your particular situation with your doctor.

Your doctor will first do a vaginal and rectal examination. In a second step, he or she may ask you to do a defecography, which will provide details on your bowel evacuation pathways, and will help determine the size and severity of the problem.

Treatments for a small rectocele

For a small grade 1 version, you may have several non-surgical options open to you:

  1. The first priority is to address your constipation and reduce straining and pressure on the rectocele. That is the main purpose of this website, we hope you will find many ways to accomplish this goal. If you have a grade 1, you want to keep it stable and not move to a grade 2 or 3.
  2. The second priority is to provide better support to the vagina and rectum, by strengthening the supporting muscles of that region. Get familiar with the Kegel exercises, which consist of alternatively contracting and relaxing the muscles of the pelvic floor. Practice those exercises as often as possible, while checking emails, watching TV, waiting at the post office, etc. Nobody will ever notice you are doing them.
  3. To strengthen those muscles, you can also try biofeedback. This method will allow you to get control over your pelvic muscles, learn how to isolate them, and how to contract them at will. A study on the efficacy of biofeedback showed major relief in a minority of patients, and partial relief for a majority of patients(4).
  4. To provide artificial support, your doctor may recommend the use of a pessary, which is a small plastic or silicone ring which is inserted into your vagina. Pessaries come in different shapes to ensure a good, comfortable fit.

Treatments for a large rectocele

For a large version, your doctor may suggest surgical intervention. Repair surgery is regarded as safe and its success rate is high. It is an inpatient intervention, and may be done under local or general anesthesia.

Surgery may be performed through the vagina, through the rectum, or through the zone situated in-between (the perineum)(2). A synthetic mesh may be inserted in order to strengthen the weakened zone between the vagina and the rectum.

Both colorectal surgeons and gynecologists are familiar with this type of repair surgery. If your symptoms are mostly vaginal, your gynecologist may be performing the intervention. If your symptoms are more rectal, or if you have other rectal issues to deal with such as hemorrhoids, your colorectal surgeon will perform the intervention.

You may want to seek opinions from both specialties to make sure you have covered all options.

After the surgery, you will have to work on keeping regular and soft bowel movements. This website is of course here to help you achieve that goal.

Recovery time varies from person to person, but overall it should take from 4 to 6 weeks. During recovery, you should rest, avoid lifting heavy objects, refrain from driving and from sexual intercourse, and keep an eye on your diet to avoid constipation.

Conclusion

In this article, we have discussed a condition called rectocele. You may be interested in this condition for three reasons.

First, you may suffer from chronic constipation, and are at a loss trying to find the underlying cause. This article should help you determine whether you fit the profile and symptoms described above. If yes, you should consult with your medical team to reach a diagnosis.

Second, you may have been told that you have a small rectocele. You want to get more familiar with this condition. You have also been told by your doctor that you should avoid constipation to keep it small and stable. This website will definitely allow you to achieve that goal.

Third, you may have been told you have a large one. You want to actively prepare for the post-surgery period, make sure your bowel movements will stay soft and regular, and lower the risk of recurrence in the future. Here again, this website should not fail you.


References

(1) Lowe DA, Baltgalvis KA, Greising SM. "Mechanisms behind estrogen's beneficial effect on muscle strength in females." Exerc Sport Sci Rev. 2010 Apr;38(2):61-7. Review.

(2) American Society of Colon & Rectal Surgeons, rectocele information page.

(3) Beck DE, Allen NL. "Rectocele." Clin Colon Rectal Surg. 2010 Jun;23(2):90-8.

(4) Mimura T, Roy AJ, Storrie JB, Kamm MA. "Treatment of impaired defecation associated with rectocele by behavorial retraining (biofeedback)." Dis Colon Rectum. 2000 Sep;43(9):1267-72.


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