Editing Rectocoele

A bulging of the anterior wall of the rectum into the posterior wall of the vagina

# Cystocoele
# Rectocoele
# Enterocoele

== '''Risk factors''' ==

* Same as for general pelvic     organ prolapse
* Vaginal childbirth
* Old age
* High BMI
* Chronically elevated     intra-abdominal pressure
* Collagen vascular disease
* Hysterectomy

== '''Symptoms''' ==

* Splinting
** The need to place manual      pressure on vagina/rectum/perineum to defecate
** Most specific symptom of      posterior vaginal prolapse, but many women don't have it
* Pelvic pressure sensation
** Frequently described as      'feel like I'm sitting on an egg'
** Usually relieved by lying      down, and less noticeable in the morning
* Constipation
** If they have a rectocoele,      might trap stool within the rectal pocket, leading to a feeling of      incomplete emptying, and possibly soiling
* Sexual dysfunction
* Faecal incontinence
** Thought to be due to fecal      trapping within the rectal pocket, allowing for post-defecatory leakage,      an associated mucosal prolapse that impairs anal closure, or overflow      incontinence
* Defaecatory dysfunction
* Can be asymptomatic in many     women
** Especially if it doesn't      extend beyond hymenal ring
* Urinary incontinence
** Not a symptom of rectocoele,      but often occurs with prolapse, which has many of the same risk factors

== '''Diagnosis''' ==

* Clinical
** Posterior vaginal bulge with      straining and palpation of breaks in rectovaginal fascia
** Examination
*** Best done standing       initially - can miss defects lying down or in lithotomy
*** Confirm prolapse
*** Evaluate perineal body and       posterior vaginal wall
*** Focussed neurological exam
**** Perineal sensation        (discriminate between sharp and dull stimuli on vulva, perineum, inner        thighs)
**** Pelvic floor motor        function (place one or two fingers intra-vaginally and ask the women to        contract and relax the pelvic floor muscles)
**** Sacral nerves 2-4 (assess        bulbocavernosus reflex and anal wink)
*** Evaluate anal sphincter       (tone, squeeze, symmetry, disruption)
* Imaging
** Not routinely required
** Indications:
*** Discordant history and       examination
*** Recurrent posterior vaginal       wall defects
** Interpreting
*** Size of rectocoele       determined by measuring the distance between the line of the anterior       border of the anal canal and the maximal point of the bulge of the       anterior rectal wall into the posterior vaginal wall
**** Small <2cm
**** Moderate 2-4cm
**** Large >4cm
*** Fluoroscopic barium       trapping does not correlate well to patient symptoms
** Defecography
** MRI, especially dynamic

== '''Grading:''' ==

* Stage 1:

* Stage 2: descent of perineal     body

== '''Natural history''' ==

* Mild disease can regress     (regression rate 22%)
* More severe disease likely to     progress

== '''Medical management''' ==

* Only if symptomatic
* Observe with yearly     examination
* Constipation symptoms
** Increased fluid and fibre
** Laxatives
* Pelvic floor exercises
** Slightly unclear role
** One or two visits per week      for 8-12 weeks
** Good for mild prolapse in      engaged patient
* Pessaries
** Supportive (ring)
*** Best if sexually active and       able to manage themselves
** Space-occupying      (cube/Gellhorn)
*** May be more effective for       more advanced disease
** Works about 73% of the time
** May not be as effective with      more distal rectocoeles, short vaginal length, and wide introitus (four      finger breadths)

== '''Surgical intervention''' ==

* 'Usually reserved for highly     selective patients in whom medical management has failed' as per Sabiston
* Goal: to relieve symptoms     related to anatomic support defect
* Indications:
** Hydronephrosis from chronic      ureteral kinking
** Vaginal erosions that do not      resolve with conservative treatment
** Obstructed urination or      defecation
** Severe symptoms
* Posterior colporrhaphy
* Site-specific defect repair
* Graft augmentation
* Endorectal repair
* Perineorrhaphy
* Anal sphincteroplasty
* Ventral mesh rectopexy
** May address symptomatic      rectocoele and internal rectla intussusception
** Mobilise rectum anteriorly,      without division of lateral ligaments
** Pelvic floor musculature and      anterior rectum are suspended using a mesh sling sutured to the sacrum


[[Category:Colorectal]]