Posterior Vaginal Prolapse/Rectoceles are common and involve a herniation of the rectum into the posterior vaginal wall that results in a vaginal bulge. Women with rectoceles generally complain of perineal and vaginal pressure, obstructive defecation, constipation, or the need to splint or digitally reduce the vagina to effectuate a bowel movement. Rectoceles are associated with age and parturition and arise from either a tear or stretching of the rectovaginal fascia, and can be repaired via a vaginal, anal, or perineal approach. Although the rate of successful anatomic repair is high, reports of functional outcomes are more variable.
Rectocele is a variety of pelvic organ prolapse (POP) that involves the herniation of the rectum through the rectovaginal septum into the posterior vaginal lumen.
Anatomy
Anatomically, the vagina begins at the hymenal ring and terminates at the cervix. The bladder lies anterior to the vagina, while the rectum lies posterior to the vagina. The vagina has support at three levels. Most superiorly, it is supported by the uterosacral ligament complex. While in the middle, it is supported by the levator ani muscles, and by the endopelvic fascia in the lower segments. The vaginal wall tissue is composed of multiple layers. The innermost tissue layer is a nonkeratinized squamous epithelium, then stroma consisting of collagen and elastic tissue, and the outermost tissue layer is a smooth muscle and collagen layer.[rx]
The rectovaginal septum connects to the endopelvic fascia at the level of the perineal body. The loss of integrity in the rectovaginal fascia would result in a herniation of the rectal tissue into the vaginal lumen, and vice versa, leading to a vaginal bulge along the posterior vaginal wall on examination that would become more pronounced with the Valsalva maneuver.[rx]
These herniations are also associated with enteroceles, or herniation of bowel into the vaginal lumen if there is a separation of the fascia from the vaginal cuff. Many women have an anatomic presence of pelvic organ prolapse. It is present in two-thirds of parous women.[rx] However, not all women who have a rectocele found on the examination will be symptomatic. Over time, as the defect becomes larger, women can become symptomatic. The symptoms include vaginal bulge, obstructive defecation, constipation, and perineal pressure.[rx] As the bulge becomes larger, it can become exteriorized – meaning that the bulge is outside the level of the hymen. The mucosa becomes exposed to the outside environment; it is at risk for erosion and bleeding.[rx]
The management of this condition largely depends on the extent of the prolapse and the severity of the symptoms. Management options include lifestyle changes, medications, pessaries, and surgery.[rx][rx][rx]
Types of Rectoceles
A rectocele is one type of pelvic organ prolapse. In a woman, the rectum bulges into the back wall of the vagina.
Other types of prolapse are:
- anterior vaginal wall prolapse, or cystocele, where the urinary bladder bulges into the front wall of the vagina
- uterine prolapse, when the uterus sags down into the vagina
- vault prolapse, in which the top (vault) of the vagina bulges down after a hysterectomy
Pelvic prolapse can vary in severity. Some people may experience different types of prolapse at the same time, such as both an anterior and posterior vaginal wall prolapse.
Causes of Posterior Vaginal Prolapse
The posterior vaginal wall is supported by uterosacral ligament complex superiorly, levator ani muscles in the middle, and by the endopelvic fascia in the lower segments. The rectovaginal septum is attached to the endopelvic fascia at the level of the perineal body and runs between the vagina and rectum. The loss of integrity in this septum would result in a herniation of the rectal tissue into the vaginal lumen resulting in a vaginal bulge on examination. Many factors play a role in the loss of integrity of the rectovaginal septum, including non-modifiable and modifiable factors.[rx]
Non-modifiable risk factors: e.g., advanced age and genetics.
- Modifiable risk factors – These include greater parity, history of vaginal delivery, history of pelvic surgery, obesity, level of education, constipation, and conditions that increase intra-abdominal pressure chronically such as COPD or a chronic cough.
- Genetics – Some women are born with weaker connective tissues in the pelvic area, making them naturally more likely to develop posterior vaginal prolapse.
- Childbirth – If you have vaginally delivered multiple children, you have a higher risk of developing posterior vaginal prolapse. If you’ve had tears in the tissue between the vaginal opening and anus (perineal tears) or incisions that extend the opening of the vagina (episiotomies) during childbirth, you may also be at higher risk.
- Aging – As you grow older, you naturally lose muscle mass, elasticity and nerve function, causing muscles to stretch or weaken.
- Obesity – Extra body weight places stress on pelvic floor tissues.
Age, BMI, parity, and vaginal delivery are the most well-documented risk factors.[rx][rx]
Symptoms of Posterior Vaginal Prolapse
Most people with a small rectocele do not have symptoms. When the rectocele is large, there is usually a noticeable bulge into the vagina.
Rectal Symptoms
- Difficulty having a complete bowel movement
- Stool getting stuck in the bulge of the rectum
- The need to press against the vagina and/or space between the rectum and the vagina to have a bowel movement
- Straining with bowel movements
- The urge to have multiple bowel movements throughout the day
- Constipation
- Rectal pain
- A soft bulge of tissue in your vagina that might protrude through the vaginal opening
- Difficulty having a bowel movement
- The sensation of rectal pressure or fullness
- A feeling that the rectum has not completely emptied after a bowel movement
- Sexual concerns, such as feeling embarrassed or sensing looseness in the tone of your vaginal tissue
Vaginal Symptoms
- Pain with sexual intercourse (dyspareunia)
- Vaginal bleeding
- A sense of fullness in the vagina
or
A small rectocele may not cause any symptoms, especially if it bulges less than 2 centimeters (less than 1 inch) into the vagina. However, larger rectoceles can trigger a variety of rectal and vaginal complaints, including:
- A bulge of tissue protruding through the vaginal opening
- Constipation
- Difficulty having a bowel movement
- Pain or discomfort during sexual intercourse
- A feeling that the rectum has not emptied completely after a bowel movement
- A sensation of rectal pressure
- Rectal pain
- Difficulty controlling the passage of stool or gas from the rectum
- Low back pain that is relieved by lying down. In many women, this back pain may worsen as the day goes on and is more severe in the evening.
Diagnosis of Posterior Vaginal Prolapse
Medical history
A health care professional may ask about your
- symptoms, such as bulges or lumps in the vagina, pelvic pressure or heaviness, and urinary incontinence
- pregnancy and childbirth history
- current and past medical problems, including surgeries
- family history
- over-the-counter and prescription medicines
- bowel habits
History
Rectoceles have a broad range of symptoms. Some patients may present as asymptomatic while others may demonstrate a significant impact on the quality of life, including the following symptoms[rx]:
-
Pelvic pain/pressure
-
Posterior vaginal bulge
-
Obstructive defecation
-
Incomplete defecation
-
Constipation
-
Dyspareunia
-
Erosions and bleeding of mucosa if there is tissue exposure to the outside environment
Physical Exam
A thorough examination will include a vaginal exam, rectal exam, abdominal exam, and focused neurological exam.
The focused neurological exam consists of levator ani muscle tone and contraction strength.
The vaginal exam can be evaluated using the Baden-Walker or POP-Q exam. The Baden-Walker system utilizes one measurement. The distance of the most distal portion of the prolapse from the hymen while the patient is completing the Valsalva maneuver.[rx] The grades are:
-
Grade 0 – normal position
-
Grade 1 – Descent halfway to the hymen
-
Grade 2 – Descent to the hymen
-
Grade 3 – Descent halfway past the hymen
-
Grade 4 – Descent is as far as possible past the hymen
The POP-Q system involves taking several measurements and is more complex, but it is highly reliable. The posterior points Ap and Bp are the measurements needed to determine the severity of the rectocele.[13]
-
TVL: total vaginal length after reducing the prolapse
-
Gh: Genital hiatus length
-
Pb: perineal body length
-
Ap: A Point on the posterior vaginal wall that is 3 cm proximal to the hymen
-
Bp: A point that is the most distal position of the remaining upper posterior vaginal wall
-
C: Cervical depth
-
D: Posterior fornix depth (only in patients with a uterus)
-
Aa: anterior point analogous to Ap
-
Ba: anterior point analogous to Bp
These points are measured while the patient is performing the Valsalva maneuver. The range of values for the Ap and Bp points, which are important for rectocele measurement, is -3 cm to +3 cm for the Appoint and -3cm to +tvl length in the Bp point. The POP-Q staging criteria are[rx]:
-
Stage 0: Ap, Bp at the leading edge (X) = -3 cm
-
Stage I: X less than -1 cm
-
Stage II: -1 cm less than X less than +1 cm
-
Stage III: +1 cm less than X less than +(TVL-2) cm
-
Stage IV: X greater than +(TVL-2) cm
Evaluation
- A pelvic exam – You may be examined while lying down and possibly while standing up. During the exam, your doctor looks for a tissue bulge in your vagina that indicates pelvic organ prolapse. You’ll likely be asked to bear down as if during a bowel movement to see how much that affects the degree of prolapse. To check the strength of your pelvic floor muscles, you’ll be asked to contact them, as if you’re trying to stop the stream of urine.
- Filling out a questionnaire – You may fill out a form that helps your doctor assess your medical history, the degree of your prolapse, and how much it affects your quality of life. This information also helps guide treatment decisions.
- Bladder and urine tests – If you have significant prolapse, you might be tested to see how well and completely your bladder empties. Your doctor might also run a test on a urine sample to look for signs of a bladder infection if it seems that you’re retaining more urine in your bladder than is normal after urinating.
- Urodynamics – Measures the bladder’s ability to hold and release urine.
- Cystoscopy (cystourethroscopy) – A long tube-like instrument is passed through the urethra to examine the bladder and urinary tract for malformations, blockages, tumors, or stone
- A special test – that can be done to confirm a rectocele is defecography. The patient will have a contrast medium instilled in the vagina, bladder, and rectum. Using a special commode, the patient will be instructed to defecate while the X-ray is taken. This test can be useful to determine the size of the rectocele, larger than 2 cm is considered abnormal.[rx]
- Urodynamic studies – can be helpful in patients with rectocele and complex voiding issues. If a patient is receiving surgery, it may be useful to determine if the patient has urinary incontinence with the prolapse reduced. If there is incontinence with reduction with prolapse, it may be helpful to include a procedure to prevent urinary incontinence in the plan.[rx]
- Pelvic floor strength test – During the pelvic examination, the doctor tests the strength of the pelvic floor, the sphincter muscles, and muscles and ligaments that support the vaginal walls, uterus, rectum, urethra, and bladder. Irregularities in this test can help diagnose vaginal prolapse and determine if kegel exercises would be helpful to the patient.
- Bladder function test – Otherwise known as urodynamics, bladder function tests determine the ability of the bladder to store and eliminate urine. This is measured in two ways. Uroflowmetry measures the volume and force of the urine stream. Cystometrogram is a procedure that fills the bladder with water via a catheter. Measurements of the volume are noted when the patient indicates the urgency of urination.
Another useful diagnostic tool for surgical planning is dynamic MRI (DMRI) which provides visualization of the rectocele and movements of the pelvic floor.[rx] DMRI is a valuable adjunct test when a patient’s symptoms are more significant than the physical examination findings suggest. Its use for preoperative planning has made it more widespread.[rx]
Treatment of Posterior Vaginal Prolapse
Non-surgical
- Eating a high-fiber diet and taking over-the-counter fiber supplements (25-35 grams of fiber/day)
- Drinking more water (typically 6-8 glasses daily)
- Avoiding excessive straining with bowel movements
- Applying pressure to the back of the vagina during bowel movements
- Pelvic floor exercises such as Kegel
- Biofeedback, a special form of pelvic floor physical therapy aimed at improving rectal sensation and pelvic floor muscle contraction
- Pelvic floor exercises, such as Kegel exercises, can strengthen the pelvic floor muscles.
- Drinking plenty of fluids and eating high-fiber foods can reduce constipation.
- Avoiding any type of heavy lifting can also prevent a worsening of symptoms.
- Getting treatment for prolonged coughing can reduce strain on the pelvic floor muscles.
- Stool softeners
- Hormone replacement therapy
Treatment depends on the severity of the problem and may include non-surgical methods such as changes in diet (increase in fiber and water intake), pelvic floor exercises such as Kegel exercises, use of stool softeners, hormone replacement therapy for postmenopausal women, and insertion of a pessary into the vagina. A high fiber diet, consisting of 25–30 grams of fiber daily, as well as increased water intake (typically 6–8 glasses daily), helps to avoid constipation and straining with bowel movements and can relieve symptoms of rectocele.[rx][rx]
The severity of the patient’s symptomatology dictates the management approach to the rectocele.
Conservative medical management of rectoceles begins with behavioral modifications. A high fiber diet and increased water intake to reduce constipation/defecatory symptoms may be enough to improve the patient’s quality of life. The patient should be drinking at least 2 to 3 liters of nonalcoholic, noncaffeinated fluids daily. The patient can also begin performing Kegel exercises and may benefit from the supervision of a pelvic floor physiotherapist.[rx][rx]
When the conservative treatment is unsuccessful, the next step is the use of a vaginal pessary. The vaginal pessaries come in different shapes and sizes. Therefore, fitting the patient with a pessary will come with a little trial and error. The function of this device is to stabilize the defects in the pelvic floor while also managing any other issues, such as cystoceles and prolapse of other organs.[rx] Pessaries have been used to manage pelvic organ prolapse since Hippocrates when he used a halved pomegranate to treat prolapse.[rx] Currently, there are a variety of devices used which differ in shape and size, made of medical-grade silicone. One of the most common shapes is the ring support pessary. Risk factors for pessary failure include large genital hiatus, short vaginal length, and prior pelvic organ prolapse surgery.[rx] If the pessary cannot be manually inserted, then it may be inserted under anesthesia, or it may not be a treatment option for the patient. The most common complications from pessary use include vaginal discharge, vaginal bleeding, and odor.[rx] There is little evidence on how often a pessary cleaning and changing should be performed.[rx] However, teaching the patient how to remove and clean the pessary will increase the patient’s bodily autonomy.[rx]
Surgery
Transvaginal Repair (posterior colporrhaphy)
Posterior colporrhaphy is commonly performed in conjunction with a perineoplasty to address relaxed perineum and widened genital hiatus. Preoperatively, the severity of the rectocele is assessed, as well as the desired final vaginal caliber. Allis clamps are placed on the inner labia minora/hymen remnants bilaterally and then approximated in the midline. The resultant vagina should loosely admit two to three fingers. A triangular (or transverse) incision over the perineal body is made between the Allis clamps [rx]
Transperineal Repairs
For a perineal approach, the patient is placed in the prone jackknife position and a U-shape incision is created [rx]. A high dissection is undertaken to reach the vaginal cupola after which a trapezoid, L-shaped strip of the posterior redundant vaginal wall is resected. Reconstruction is effected by a running suture of 3–0 polyglactin, and the space between the rectal and vaginal walls is closed and a levator plication is then executed by placing two to three single sutures. The skin is then completely closed; combined procedures for hemorrhoidectomies and/or fissures can be undertaken.
Transanal Repair
He felt that the prolapsed anterior rectal mucosa was a source of defecation difficulties that aggravated hemorrhoidal disease despite correction of the posterior vaginal wall and rectovaginal musculofascial layer. His procedure was performed in the lithotomy position. The redundant rectal mucosa was grasped and pulled outward until taut. A two-layer suture closure was performed underlying the rectal mucosa, including hemorrhoid. The anterior rectal mucosa was then removed. The formation of scar at the suture line added to support.
Posterior Colporrhaphy Technique
Posterior colporrhaphy is commonly performed in conjunction with a perineoplasty to address a rectocele or relaxed perineum and widened genital hiatus. Preoperatively, the severity of the rectocele is assessed, as well as the desired final vaginal caliber. Allis clamps are placed on the inner labia minora/hymen remnants bilaterally and then approximated in the midline. The resultant vagina should loosely admit two to three fingers. A triangular incision over the perineal body is made between the Allis clamps, and sharp dissection is then performed to separate the posterior vaginal epithelium from the underlying rectovaginal fascia.
Site-Specific Fascial Defect Repair Technique
Discrete tears or breaks in the rectovaginal fascia or rectovaginal septum have been described and may contribute to the formation of rectoceles.[rx]The intent of the site-specific fascial defect repair of rectoceles is to identify the fascial tears and reapproximate the edges. The surgical dissection is similar to the traditional posterior colporrhaphy whereby the vaginal mucosa is dissected off the underlying rectovaginal fascia to the lateral border of the levator muscles.
Laparoscopic Rectocele Repair Technique
Laparoscopic rectocele repair involves opening the rectovaginal space and dissecting inferiorly to the perineal body. The perineal body is sutured to the rectovaginal septum and rectovaginal fascial defects are identified and closed. The advantages are reported to be better visualization, and more rapid recovery, with decreased pain and hospitalization. Disadvantages include difficulty with laparoscopic suturing, increased operating time/expense, and extended time necessary to master the laparoscopic surgical techniques.[rx]
Transvaginal surgical techniques
PBA technique
The patient is placed in a dorsal lithotomy position. A transverse incision is made at the mucocutaneous junction and thereafter the posterior vaginal wall is opened under the mucosa, transversally, in all the extent of the bulge. The rectal wall and recto-vaginal connective tissue are separated from the vaginal wall by both sharp and blunt dissection, avoiding rectal injury. If an enterocele sac is shown, it is dissected, opened, and closed with a tobacco bag suture. Then the rectovaginal fascia is sutured at the perineal body with separated delayed absorbable stitches. The perineorrhaphy is performed with one or two horizontal sutures. The excess vaginal mucosa is then excised, aiming at a two or three-finger width vaginal caliber, and the vaginal wall is closed with running delayed absorbable sutures [rx].
TDTS technique
The patient is placed in a dorsal lithotomy position. a transverse incision is made at the mucocutaneous junction and thereafter the posterior vaginal wall is incised at the midline. The rectal wall and recto-vaginal connective tissue were separated from the vaginal wall by both sharp and blunt dissection. If an enterocele sac is present, it is repaired as well. At this point, in spite of the previous technique, the Denonvilliers’ recto-vaginal fascia is linked at the midline with interrupted delayed absorbable sutures. Longitudinal suture of the posterior vaginal skin after removing the redundant tissue is performed [rx].
Stapled trans-anal rectal resection procedure (STARR)
It is indicated in patients with outlet obstruction due mostly to rectal intussusception and rectocele. After dilating the anus, the posterior rectal wall is retracted and three purse-string sutures, incorporating the mucosa, submucosa and rectal muscle wall, are placed along the anterior rectal wall, up to the edge of the rectocele. A 33-mm circular stapler is introduced and the rectal mucosa is pulled into the device. The posterior vaginal wall is checked just prior to firing the stapler so as to not include it the resection. 3.0 Vicryl sutures are used to reinforce the staple line or for hemostasis. The same procedure is repeated on the posterior rectal wall. The same procedure can be accomplished through a single circular stapler device.
Posterior Colporrhaphy
Transvaginal plication of the rectovaginal septum is the preferred approach to rectocele repair for most gynecologists and some colorectal surgeons. An incision is made in the vaginal mucosa at the level of the perineal body and extended vertically toward the apex of the vagina. The mucosa is separated from the underlying fibromuscular layer of the vaginal wall by sharp and blunt dissection to a point above the rectocele and laterally to the vaginal sulcus at the medial edge of the puborectalis. Midline plication of the fibromuscular tissue is then performed with absorbable suture, typically in an interrupted fashion. Distal plication of the levators may be performed to normalize the vaginal hiatus.
Transanal Plication
Longstanding rectoceles can lead to a thinning of the anterior rectal wall and the development of redundant rectal mucosa. This observation has been suggested as a potential explanation for the persistence of defecatory symptoms in many women undergoing traditional posterior colporrhaphy.[rx] With the aim of decreasing the size of the rectal vault, resecting redundant mucosa, and reinforcing the anterior rectal wall, several transanal approaches to rectocele repair have been described.
Transanal Resection
Out of the notion that excess tissue in the anterior rectal wall complicates defecation has evolved the concept of transanal rectal resection as a means of treating ODS associated with rectocele and internal intussusception. Originally described using the circular PPH-01 stapler, the stapled transanal rectal resection (STARR procedure) has been met with great enthusiasm in some circles, especially among European surgeons. Numerous modifications of the technique have been described including using a single PPH-01 stapler, two PPH-01 staplers, the semi-circular Contour 30 stapler, a Contour, and a linear stapler, a Contour with two linear staplers, and a Contour with a PPH-01.[rx]
Abdominal Suspension
An alternative approach to direct reinforcement of the rectovaginal septum for rectocele repair is to resuspend the vagina, rectum, and/or perineal body from the sacral promontory. Cundiff et al described a constellation of defects addressed by rectocele repair via sacral colpoperineopexy, which they proposed would correct the common finding of perineal descent, improve constipation symptoms, and avoid damaging stretch on the pudendal nerves.[rx]
Prevention
To reduce your risk of worsening posterior vaginal prolapse, try to:
- Perform Kegel exercises regularly – These exercises can strengthen your pelvic floor muscles — especially important after you have a baby.
- Treat and prevent constipation – Drink plenty of fluids and eat high-fiber foods, such as fruits, vegetables, beans, and whole-grain cereals.
- Avoid heavy lifting and lift correctly – When lifting, use your legs instead of your waist or back.
- Control coughing – Get treatment for a chronic cough or bronchitis, and don’t smoke.
- Avoid weight gain – Talk with your doctor to determine your ideal weight and get advice on weight-loss strategies, if you need them.
References
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