rectocele; proctocele; rectal procidentia

Etiology

• pregnancy & childbirth
• increased pressure on the pelvic floor exacerbated by
  • upright position
  • chronic constipation or straining with bowel movements
  • chronic cough or bronchitis
  • repeated heavy lifting
  • overweight or obesity

Epidemiology

• more common in older women

Pathology

• occurs when the thin wall of fascia that separates the rectum from the vagina weakens, allowing the vaginal wall to bulge
• thus the anterior wall of the rectum bulges through the posterior wall of the vagina

Genetics

• genetic predisposition

Clinical manifestations

• may be asymptomatic
• may create a noticeable bulge of tissue through the vaginal opening
• may be uncomfortable, but rarely painful
• difficulty having a bowel movement
  • need to press your fingers on the vaginal bulge push stool out during a bowel movement ("splinting")
• sensation of rectal pressure or fullness
• sensation of incomplete bowel evacuation
• sexual dysfunction due to concerns or embarrassment

Differential diagnosis

• rectal prolapse
• cystocele (anterior prolapse)
• enterocele (apical prolapse)
• uterine prolapse

Management

• medical management generally sufficient
  • digital "splinting" as needed for defecation
    • vaginal pessary may provide adequate splinting
  • vaginal estrogen or barrier cream if vaginal wall is irritated
  • dietary fiber, stool softeners, suppositories
• surgery
  • generally effective in the short-term
  • long-term success rates lower than short-term results

More general terms

• pelvic organ prolapse

Additional terms

• rectal prolapse; proctoptosis