Rectocele

See Anorectal Physiology Testing for the diagnostic toolkit referenced below and Obstructed Defecation Syndrome (ODS) for rectocele's place within the broader obstructed- defecation workup (dyssynergic defecation, internal prolapse, enterocele/sigmoidocele, and overt rectal prolapse). Content below is from textbook reference chapters (Sabiston Ch52 - Pelvic Floor Disorders & Constipation and ASCRS Ch59 - Treatment of Difficult-Obstructive Defecation), not primary literature except where a specific study is named.

Overview

A bulging of the anterior wall of the rectum into the posterior wall of the vagina. Most common risk factors: advanced age, history of pregnancy and vaginal childbirth, increasing BMI, chronically elevated intraabdominal pressure, and history of hysterectomy. Multifactorial cause — a muscular and/or neurologic defect to the rectovaginal septum (usually from obstetric trauma), plus the effect of chronic straining on the endopelvic fascia and posterior vaginal wall. Can be associated with other pelvic organ prolapses.

Most rectoceles are asymptomatic. When symptomatic, the cardinal symptom is difficulty with rectal emptying and the need to press against the posterior vaginal wall or the perineum to complete emptying (splinting) — a form of obstructed defecation. Other symptoms: sensation of a vaginal bulge, urinary and/or sexual dysfunction, constipation, and — in some cases — fecal incontinence (thought to result from fecal trapping within the rectal pocket allowing post-defecatory leakage, an associated mucosal prolapse impairing anal closure, or overflow incontinence).

Diagnosis

Mainly clinical, based on physical exam. Digital vaginal and rectal exams show a bulge in the posterior vaginal wall and anterior rectal wall during straining, which can be associated with the prolapse of other pelvic organs and with an anterior cystocele. Associated stress urinary incontinence is assessed by having the patient cough or perform a Valsalva maneuver with a full bladder.

On defecography, a rectocele appears as a bulging of the rectal wall toward the vagina, graded small (<2 cm), moderate (2–4 cm), or large (>4 cm). This test also shows possible trapping of contrast within the rectocele during defecation, and possible association with an enterocele or sigmoidocele. Dynamic MRI and MRI defecography are limited by being performed with the patient supine (not the normal upright defecation position), so the degree of anatomic distortion often does not correlate with the degree of functional impairment/symptoms. The balloon expulsion test can identify inability to expel an inflated balloon after 4 minutes sitting on a commode.

Management

Asymptomatic rectoceles need no treatment. Symptomatic rectoceles are initially managed with a bowel regimen and fiber products to improve defecation. Only patients with markedly symptomatic rectoceles unresponsive to medical treatment are candidates for surgery. The goal of surgery is to remove the redundant tissue of the rectocele and strengthen the rectovaginal septum.

• Transvaginal repair (preferred by gynecologists): better visualization/access to the levator muscles. A local anesthetic with epinephrine or vasopressin is injected below the vaginal mucosa to dissect the tissue and for hemostasis. The vaginal epithelium is opened in the posterior midline to the upper level of the defect; the fibromuscular layer is exposed and plicated in the midline with vertically or transversely placed sutures. The puborectalis can be reapproximated. Surplus vaginal epithelium is trimmed and sutured with absorbable sutures. Recurrence is about 7.1%, and a meta-analysis recommends native-tissue transvaginal repair preferentially over mesh-augmented repair.
• Transanal repair (endorectal repair) (performed by colorectal surgeons, patient in prone jackknife position): a local anesthetic with epinephrine or vasopressin is injected in the submucosal plane for dissection/hemostasis. The apex of the rectocele is identified and pulled down; the excess rectal mucosa over the rectocele (and the muscularis layer) is excised and plicated with a running horizontal suture at the base, and the mucosal defect is closed. Results show a 30–90% decrease in symptoms, with recurrence reported around 48 months.
• STARR (stapled transanal rectal resection) has also been extensively studied specifically as a rectocele treatment: under general anesthesia in lithotomy position, two circular staplers excise the rectal wall full-thickness anteriorly and posteriorly, taking care not to draw the vaginal wall into the purse-string suture or staple line. Short-term results are good, but long-term recurrence is reported in about 40% of patients, and complications include bleeding, anastomotic leak, rectovaginal fistula, and rectal pain. STARR use for rectocele is currently on the decline in Europe.
• Transperineal repair: performed via a transverse incision across the bulbocavernosus and transverse perineal muscles, with dissection up to the vaginal apex; the two limbs of the puborectalis muscle are reapproximated (a simple fascial repair from the apex to the perineum). A mesh can be placed to reinforce the plasty, though synthetic mesh use here is controversial. Advantage: does not breach the vaginal mucosa. Especially indicated in patients with associated fecal incontinence, since a concomitant sphincteroplasty or levatorplasty can be performed at the same time.

Most symptomatic rectocele patients also have associated urologic/gynecologic issues that should be addressed at the same time, ideally via a multidisciplinary team approach with urogynecology — see Obstructed Defecation Syndrome (ODS) for the enterocele/sigmoidocele repairs (sacrocolpopexy) frequently performed alongside rectocele repair when both coexist, and Pelvic Organ Prolapse (Anterior & Middle Compartment) for the full urogynecologic evaluation/ staging (POP-Q) and anterior/middle-compartment procedure detail behind that multidisciplinary approach — including its explicit point that correcting a rectocele anatomically does little for constipation/intussusception symptoms specifically, since rectoceles may be a result of obstructed defecation rather than its cause.

Open items / gaps

• ~~No specific recurrence-rate figures given for any of the three repair approaches.~~ Resolved by ASCRS Ch59 - Treatment of Difficult-Obstructive Defecation: transvaginal ~7.1%, transanal/ endorectal recurrence at ~48 months (rate not separately quantified from the 30–90% symptom-decrease figure), and STARR ~40% at long-term follow-up.
• ~~No primary trial data comparing transvaginal, endorectal, and transperineal repair outcomes head-to-head.~~ Partially resolved — Ch59 adds a meta-analysis favoring native-tissue transvaginal repair over mesh-augmented repair, and flags the Grimes 2019 systematic review (Research Priorities.md) as a broader comparative synthesis across posterior-compartment repair approaches; no single head-to-head RCT across all three approaches has been identified yet.