Rectocoele

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

1. Cystocoele
2. Rectocoele
3. 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