RECTAL prolapse (rectocele) occurs commonly, and may coexist with disorders of defecation(bowel emptying). Mild rectal prolapse into the lumen of the vagina occurs in parous women, but usually presents few problems. As prolapse progresses, symptoms may develop and worsen, and treatment becomes necessary.
CAUSE
Rectal prolapse into the vaginal lumen or rectocele is defined as the abnormal out pocketing of the anterior rectal and posterior vaginal wall into the vaginal lumen. Normal support for the birth canal (vagina) and adjacent pelvic organs is provided by interaction between pelvic muscle and connective tissue.
Distension and detachment of the supporting tissue occurs, due to overdistension of the vagina associated with vaginal delivery or to atrophic changes associated with menopause
SYMPTOMS
Patients with rectocele may complain of symptoms related to prolapse like sensation of mass descending through the vagina and pressure. They may have constipation, or incomplete rectal emptying. Women may have to apply pressure inside the vagina in order to facilitate defecation. Many women have non-specific symptoms like rectal pain, fecal or gas incontinence or low backache. Most women are asymptomatic. The rectocele may be accompanied by uterine prolapse and/or cystocele (bladder prolapse). In such cases, symptoms related to those conditions such as difficulty in urination, or associated stress incontinence may be present.
INVESTIGATIONS
The doctor will perform a vaginal examination to confirm the diagnosis and to grade the prolapse. Urodynamics is indicated when symptoms of incontinence or voiding problem is present. If urinary leaking occurs with coughing or straining, the surgeon can choose an anti-incontinence procedure along with the rectal prolapse repair.
MANAGEMENT
Non surgical treatments consist of proper bowel training, following an active lifestyle and eating appropriate amount of dietary fibre. These steps are most important when the main complaint is constipation. The only nonsurgical therapy is the use of pessary. This may be used in extremely old frail women. Pessaries have not been very effective when used in patients with isolated rectocele. This is only a temporary solution.
Surgical repair would provide a more lasting solution to the problem. The traditional approach has been to offer a hysterectomy with pelvic floor repair(perineorrhaphy) to such patients. But a systematic examination of the patients would help the doctor repair only that organ which has prolapsed, without removing the uterus i.e., only a rectocele repair. This could be by repairing the supports of the rectum (rectovaginal septum) by simply putting together the detached fascia using sutures(plication) or by the use of mesh to reinforce the tissue supporting the rectum or the use of prolapse kits.
Prolene mesh can be placed over the rectovaginal septum; much like the use of mesh in hernia repair. The reccurence rate of rectocle can be as high as 33% with simple repair.
The use of prolapse kits which simulates the rectal supports and its attachments has been shown to be very effective in reducing the rectocele, with low risk of recurrence of the problem.
These patients would also need lifestyle modifications like not lifting heavy weights, and also pelvic floor exercises to strengthen the pelvic floor muscles.
Dr. Karthik Gunasekaran,Consultant Urogynecologist ,Guna Urogynecology Clinic
Crescent park street, T-Nagar Ph:9884298666 , 32904166.