Rectocele

If the bulge is less than one inch into the vagina, the rectocele may not present with any symptoms. However, larger rectoceles can present with both vaginal and rectal symptoms, such as: 

• Bulging of tissue that protrudes through the vaginal opening
• Constipation
• Difficulty in passing stool or gas from the rectum
• Feeling of incomplete emptying even after passing the bowel
• Pain in rectum
• Pain or discomfort while having sex
• Pressure around the rectum 
• Lower back pain which is relieved by lying down and worsened by standing up
• Lower abdomen pain
• Bleeding from the vagina not related to the menstrual cycle
• Faecal incontinence

There are several factors that may result in a rectocele:

• Women who have given vaginal birth with prolonged labour multiple times can suffer from a weakening of the pelvic floor muscles resulting in a weak vagina.
• During menopause, a woman's body undergoes a series of changes which can affect the muscle tone of the pelvic region.
• Chronic constipation or straining while passing stools can weaken pelvic muscles.
• Chronic cough associated with asthma, smoking, bronchitis and respiratory diseases can result in weak pelvic muscles. 
• Repeated heavy lifting can put a strain on the pelvic muscles.

There are some people who are a higher risk of developing rectocele: 

• Genetic factor: Some women are born with weaker connective tissues in the pelvic area. This makes them more prone to developing posterior vaginal prolapse.
• Childbirth: Women who have had multiple vaginal deliveries have a higher risk of developing rectocele. It can also occur to women who have had tears in the tissue between the vaginal opening and anus or had an episiotomy (precise incisions made to open up the vagina during childbirth, either to prevent or reduce the severity of vaginal tears during birth).
• Obesity: People living with obesity may put extra stress on their pelvic floor tissues, thus making them prone to rectocele.
• Older adults: With advancing age, people eventually lose muscle mass, elasticity and nerve function, which makes them prone to vaginal prolapse.

Vaginal prolapse can not be prevented completely but there are certain preventive measures that may help prevent it:

• Practising Kegel exercises: Kegel exercises are extremely important for strengthening the muscles in the pelvic floor, especially after giving birth to a baby.
• Prevent constipation: Consume fibre-rich foods such as fruits, green vegetables, beans and whole-grain cereals and drink lots of water to prevent and treat constipation.
• Avoid straining: Do not strain while passing stool.
• Avoid heavy lifting: Try not to lift heavy objects, or if you need to do it, put pressure on your legs instead of your waist or back.
• Get treatment for cough: Get treated for conditions such as chronic cough, bronchitis and other respiratory conditions. Quit smoking as it can aggravate coughing.
• Exercise regularly: Exercise regularly to lose the extra kilos which can otherwise strain the pelvic muscles.

Usually, women who do not have any symptoms get diagnosed during routine gynaecological examinations. The patient would be asked to give a thorough medical history and other questions such as the number of times they’ve had a vaginal delivery, and other problems such as vaginal tears. The doctors would perform a proper physical examination of the pelvic region in order to diagnose the condition, the exams include:

• Pelvic floor strength test: During the pelvic examination, the doctor tests the strength of the pelvic floor, the sphincter muscles, and the 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: Bladder function tests can help in determining the ability of the bladder to store and eliminate urine. It can be examined with the help of uroflowmetry (a test to measure the volume and force of the urine stream) and cystometrogram (a test to measure the frequency and volume of urine).

Even if it is a small rectocele, it will not heal on its own. Instead, it may become larger with time. In case of a symptomatic patient, the doctor would suggest either a non-surgical or surgical approach depending upon the age, overall health, degree of prolapse and anatomical conditions of the patient.

Women with a less severe bulge, those wish to preserve vaginal function and those with a desire to conceive in future are treated with nonsurgical treatments.

Vaginal pessary is a treatment which is usually given to these women. A pessary is a ring, block or plug shaped device which is inserted into the vagina to support the bulging tissues. Pessaries can either be removed, cleaned and reused daily or there are ones which require periodic doctor’s visit for removal and cleaning. The choice of pessary depends on the degree of prolapse and is decided by the doctor. 

If the conservative approach fails, the doctor would suggest surgery to help fix the problem.

Women who do not benefit from the non-surgical approach or do not wish to conceive in future are given surgical treatments for rectocele.

• Rectocele repair is done to deal with the bulge. The surgery can be done through the vagina, anus, abdomen or sometimes through an area between the vagina and anus called the perineum.
• In the case of severe vaginal prolapse, the woman may have to undergo a hysterectomy, which is a procedure to remove the uterus.
• If the supporting tissues have become weak, the doctor would perform a surgery to repair the weakness in the fascia (tissue wall present between the rectum and the vagina). The repair can be done by various measures such as strengthening the area with the help of stitches or placing a mesh/patch on the fascia to strengthen and support the wall between the rectum and vagina.
• Colporrhaphy is a surgical procedure to repair the walls of the vagina, which, if done on the anterior portion, tightens the front walls of the vagina and if done on the posterior portion tightens the back walls. 
• The doctor would perform laparoscopic surgery to deal with other problems associated with rectoceles such as stress incontinence, hernias at the top of the vagina, and weakness in the vagina after a hysterectomy.

The patients would be provided with antibiotics and pain killers after the surgery. However, the hospital stay is not so extensive as the patient is allowed to go home three to four days after the surgery.