Rectocele

Rectocele is a condition in which the anterior wall of the rectum (the last portion of the large intestine) weakens and bulges into the vagina. This disorder, which is part of pelvic floor disorders, is particularly seen in women who have given birth and are in menopause. Rectocele, which manifests with complaints such as difficulty in defecation, sensation of fullness in the vagina, and effects on sexual life, can be successfully treated with lifestyle changes, physiotherapy, and surgical methods in appropriate cases.

What Is Rectocele?

Rectocele is the protrusion of the anterior wall of the rectum into the vagina as a result of weakening or tearing of the connective tissue between the rectum and vagina, called the rectovaginal septum. This condition is a type of pelvic floor prolapse.

The pelvic floor consists of muscles, ligaments, and fascia structures that support the urinary bladder, uterus, and rectum. Weakening of these support structures may lead to different types of prolapse:

  • Rectocele (rectum bulging)
  • Cystocele (bladder bulging)
  • Uterine prolapse
  • Vaginal vault prolapse

Often, more than one type of prolapse is seen together.

Types of Rectocele

Classified into four stages according to the severity of prolapse:

Stage 1 (Mild)

  • Bulge in the middle upper part of the vagina
  • Usually not noticed by the patient
  • Asymptomatic or mild complaints

Stage 2 (Moderate)

  • Bulge approaches the vaginal entrance level
  • Sensation of fullness begins
  • Difficulty in defecation may develop

Stage 3 (Advanced)

  • Bulge protrudes out of the vagina
  • Significant complaints
  • Affects quality of life

Stage 4 (Complete Prolapse)

  • Bulge is constantly outside the vagina
  • Severe complaints
  • Usually requires surgery

Causes of Rectocele

Rectocele develops as a result of weakening of the pelvic floor support structures.

Main Causes

  • Birth trauma: The most important cause
    • Number of vaginal deliveries
    • Large baby delivery (>4 kg)
    • Prolonged labor
    • Use of forceps or vacuum
    • Wide episiotomy
  • Menopause and estrogen deficiency: Connective tissue weakens
  • Aging: Loss of tissue elasticity
  • Genetic predisposition: Connective tissue weakness

Risk Factors

  • Chronic constipation and straining
  • Excess weight and obesity
  • Chronic cough (COPD, smoking)
  • Heavy lifting
  • Multiple births
  • Previous pelvic surgery
  • History of hysterectomy
  • Pelvic radiotherapy
  • Intense physical activity
  • Connective tissue diseases

Symptoms of Rectocele

Symptoms of rectocele can vary and change according to its severity.

Bowel Complaints

  • Difficulty in defecation (most common symptom)
  • Feeling of incomplete evacuation
  • Need for excessive straining
  • Need for digital manipulation: Defecating by pressing on the vagina or perineum (most typical symptom)
  • Sensation of blockage
  • Difficulty passing gas
  • Stool fragmentation

Vaginal Complaints

  • Sensation of fullness or pressure in the vagina
  • Sensation that something is hanging out of the vagina
  • Seeing a mass from the vagina
  • Back and lower back pain (especially at end of day)
  • Vaginal discharge or irritation

Sexual Life Complaints

  • Discomfort during intercourse
  • Decreased sexual desire
  • Loss of self-confidence
  • Gas passage during intercourse

Other Symptoms

  • Pelvic fullness
  • Discomfort while walking
  • Increased complaints with prolonged standing
  • Sensation of vaginal pressure increasing with movement

Diagnostic Methods

Medical History

Detailed inquiry:

  • Birth history
  • Current complaints and duration
  • Bowel habits
  • Evaluation of sexual life
  • Medical history
  • Previous surgery history
  • Social and psychological effects

Physical Examination

Pelvic examination is the foundation of rectocele diagnosis:

  • Examination in supine position
  • Standing examination (to make the prolapse apparent)
  • Evaluation with straining maneuver
  • Speculum examination
  • Digital rectovaginal examination
  • Evaluation of pelvic floor muscle tone
  • Other accompanying prolapses (cystocele, uterine prolapse)

POP-Q Classification

Pelvic Organ Prolapse Quantification System:

  • Standard evaluation method
  • Objectively determines the degree of prolapse
  • Used in treatment planning

Imaging Methods

Defecography (Defecation MRI)
  • Dynamic imaging during defecation
  • Depth and characteristics of rectocele
  • Evaluation of accompanying problems
  • Important for surgical planning
Pelvic MRI
  • Detailed evaluation of pelvic floor
  • In complex cases
  • Accompanying pathologies
Endoanal Ultrasound
  • Anal sphincter evaluation
  • Pre-surgical planning

Additional Examinations

  • Anorectal manometry (sphincter function)
  • Urodynamic tests (if urinary complaints exist)
  • Colonoscopy (when necessary)

Treatment of Rectocele

The treatment approach is determined according to the stage of prolapse, severity of complaints, the patient's age, general health, and expectations.

Conservative Treatment

Applied in mild and moderate stage rectoceles and in patients who do not prefer surgery.

Lifestyle Changes
  • Weight loss: Reduces load on pelvic floor
  • Smoking cessation: Reduces cough
  • Avoiding heavy lifting
  • Treatment of chronic cough
  • Regular exercise
Nutrition
  • Fiber-rich food consumption: 25-30 g per day
  • Plenty of fluids: 2-2.5 liters per day
  • Prevention of constipation
  • Regular and balanced meals
Bowel Training
  • Regular toilet habits
  • Avoiding excessive straining
  • Correct toilet position (like squatting)
  • Slight elevation of feet (footstool)
  • Not sitting for long periods on the toilet
Pelvic Floor Muscle Exercises (Kegel Exercises)
  • Strengthens pelvic floor muscles
  • Should be done regularly (3-4 sets a day, 10-15 reps)
  • Effective in early and mild cases
  • Guidance from a physiotherapist is recommended
Pelvic Floor Physiotherapy
  • By specialist physiotherapists
  • Biofeedback techniques
  • Electrical stimulation
  • Manual techniques
  • Education and awareness
Pessary (Vaginal Ring)
  • Support device placed in the vagina
  • Temporarily controls prolapse
  • In patients who do not prefer surgery or are not suitable for surgery
  • Requires regular control and cleaning
  • Available in various sizes and shapes
Hormone Replacement Therapy
  • Vaginal estrogen after menopause
  • Strengthens connective tissue
  • In the form of local cream or tablet
  • Can also be applied before surgery

Surgical Treatment

Applied in stage 3-4 rectoceles unresponsive to conservative treatment and cases that severely affect quality of life.

Surgical Approach Routes
Vaginal Approach (Posterior Colporrhaphy)

The most commonly preferred method:

  • Operation through the vaginal route
  • Repair of the rectovaginal septum
  • Strengthening of weakened tissues
  • Less invasive
  • Short hospital stay (1-2 days)
  • Low complications
  • Success rate 80-90%
Transanal (Through Rectum) Approach
  • Repair through the anus
  • Removal of excess rectal tissue
  • May be preferred in some cases
  • Higher recurrence rate
Perineal Approach
  • Performed through the perineum (between vagina and anus)
  • Can be combined with posterior colporrhaphy
Abdominal/Laparoscopic Approach
  • Repair from within the abdomen
  • For repairing all parts of the pelvic floor at once
  • Sacrocolpopexy technique
  • In complex and multiple prolapse cases
  • Robotic support possible
Mesh Use
  • Synthetic or biological materials
  • Reinforces the repair
  • Reduces recurrence rate
  • Attention to mesh-related complications
  • Patient selection is important
Pelvic Floor Reconstruction

In the presence of multiple prolapses:

  • Apical suspension
  • Posterior repair
  • Anterior repair
  • Perineorrhaphy

Patient-specific approach is planned.

Decision for Surgical Treatment

Evaluated when deciding for surgery:

  • Effect of complaints on quality of life
  • Response to conservative treatment
  • Patient's age and health status
  • Desire for sexual activity
  • Other accompanying prolapses
  • Patient's expectations

Post-Operative Process

First Days

  • Hospital stay: 1-3 days
  • Pain control
  • Wound care
  • Soft diet
  • Early mobilization
  • Use of stool softener

First Week

  • Return to light activities
  • Attention to vaginal hygiene
  • Avoiding heavy lifting
  • Bathing according to physician's recommendation

First Month

  • Complete rest period
  • Avoiding sports and heavy exercise
  • Sexual life after 6 weeks
  • Prevention of constipation
  • Regular check-ups

Long Term

  • Continuation of lifestyle changes
  • Pelvic floor exercises
  • Regular follow-up
  • Recurrence-preventing behaviors

Possible Complications

Surgical Complications

  • Bleeding
  • Wound infection
  • Hematoma
  • Difficulty urinating
  • Constipation

Late Complications

  • Recurrence of rectocele (10-30%)
  • Vaginal stenosis (narrowing)
  • Pain during intercourse (dyspareunia)
  • Mesh-related complications (if used)
  • Newly developing prolapses

Prevention of Rectocele

To reduce the risk of developing rectocele:

Postpartum Period

  • Early pelvic floor exercises
  • Avoiding excessive straining
  • Healthy weight control
  • Postpartum physiotherapy

Lifestyle

  • Healthy weight control
  • Regular exercise (supporting pelvic floor)
  • Smoking cessation
  • Treatment of chronic cough
  • Correct lifting techniques

Nutrition

  • Fiber-rich food consumption
  • Plenty of fluid intake
  • Prevention of constipation
  • Healthy weight

Toilet Habits

  • Correct toilet position
  • Avoiding excessive straining
  • Not delaying toilet needs
  • Not sitting for long periods

Pelvic Floor Health

  • Regular Kegel exercises
  • Special attention during menopause
  • Annual gynecological check-ups

FAQ

No. Rectocele is an anatomical disorder and does not resolve on its own. However, in mild cases, complaints can be controlled with lifestyle changes, pelvic floor exercises, and physiotherapy. Surgical treatment may be required in advanced cases.

Yes, rectocele can affect sexual life in various ways. The sensation of swelling and fullness in the vagina may lead to discomfort or pain during intercourse. Sexual life often improves after surgical treatment. However, sexual intercourse is not recommended for the first 6 weeks after surgery.

In early stage and mild rectoceles, Kegel exercises and pelvic floor physiotherapy can significantly reduce complaints. They are effective when done regularly and correctly. However, in advanced stage cases, they are not sufficient alone, and surgery may be required.

With modern surgical techniques, the recurrence rate is between 10-30%. Lifestyle changes, weight control, prevention of constipation, and pelvic floor exercises reduce the risk of recurrence. The recurrence rate is lower in cases where mesh is used.

Although more rare, it can occur. Reasons such as connective tissue weakness, chronic constipation, heavy lifting, obesity, and genetic predisposition can also lead to rectocele in women who have not given birth.