Posterior vaginal prolapse
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Posterior vaginal prolapse, also known as rectocele, occurs when the rectum bulges into the vaginal wall. This is a form of pelvic organ prolapse where the support tissue between the rectum and vagina becomes weakened or rips and can no longer hold them in place.
Posterior vaginal prolapse generally affects women regardless of age. However, it is especially common on people with ages 60 and up. Rectocele results from tears during childbirth, chronic constipation and other activities that impose extra pressure on the pelvic floor tissues.
A small prolapse may not have noticeable symptoms. People with large prolapse will feel a bulge into the vagina. There can be no pain with the bulge, but it can become bothersome. Splinting or using the fingers to support the vaginal wall, can be done by those who are having difficulty to poop due to rectocele.
Both surgical and nonsurgical treatments are available for people with posterior vaginal prolapse. The diagnosis of the doctor will determine the most appropriate treatment for the condition.
Symptoms
Small rectocele may not have symptoms. In moderate or severe cases, common symptoms are:
- A soft bulge of tissue that protrudes through the vagina
- Difficulty having bowel movement
- Rectal fullness or pressure
- Discomfort during intercourse
- Sensation of vaginal looseness
- Requires splinting to help with passing stool
- Feeling the need to pass stool multiple times a day
Surgery may be recommended to treat the rectocele. The doctor will assess possible treatment options and determine potential occurrence of another organ prolapse. Other pelvic organ prolapse, such as uterus or bladder, can occur along with rectocele.
Posterior vaginal prolapse is not painful, however, patients may experience discomfort that can interfere with daily activities. If this happens, visiting a doctor is necessary.
Causes
Rectocele is a result by the weakened or damaged tissue in the pelvis floor. Increased pelvic floor pressure can be caused by:
- Cut or tears during childbirth
- Trauma from operative vaginal deliveries
- Prolonged constipation
- Chronis cough or bronchitis
- Repeated heavy lifting
- Obesity
- Aging
- The tissue in the pelvic floor may be damaged when surgery is undergone on the pelvic organs.
Multiple vaginal childbirth can weaken the pelvic floor muscles. The risk for posterior vaginal prolapse increases with every childbirth, especially with extended labor and large babies. During pregnancy and delivery, the muscles, ligaments, and connective tissue that support the vagina expand. As a result, these tissues are less capable of supporting the pelvic organs.
The occurrence of rectocele is still possible even with cesarean delivery. Although the risk is relatively less to that of vaginal childbirth.
Risk factors
Generally, women are susceptible to posterior vaginal prolapse. However, several factors can contribute to one’s risk, such as:
- Genetics: Although rectocele is an acquired disease rather than congenital, the quality of connective tissues by birth can affect the likelihood that a person will experience posterior vaginal prolapse. Inherently, weak tissues will increase the risk.
- Childbirth: Posterior vaginal prolapse has a higher risk to occur when you vaginally deliver more than one child. Episiotomies, perineal tears, and operative vaginal deliveries, particularly the use of forceps can contribute to one’s risk.
- Age: Tissues in the pelvic area weakens as the person gets older. Normally, a decrease in flexibility, muscle mass and nerve function come with aging.
- Weight: A heavier body or being overweight puts extra strain on the pelvic floor muscles.
Diagnosis
A healthcare provider starts the diagnosis of rectocele with assessing the patient’s medical history and performing a physical exam.
Diagnosis often involves a pelvic exam. The doctor may require the patient to:
- Bear down: Same position with having a bowel movement to show the size and location of the prolapse. The prolapse will become more visible due to the applied pressure.
- Tighten the pelvic muscles: Like stopping a stream of urine. Squeezing and relaxing the pelvic floor muscles will determine how strong it is.
The doctor shall evaluate the extent to which the condition has impacted the well-being of the patient. The treatment decision will be based on this information. In some cases, imaging tests may be required:
- MRI or an X-ray: can provide a good visualization of the size of the rectocele.
- Defecography: is a special X-ray that measures how efficiently the rectum empties. A contrasting agent is used in combination with other tests, like X-ray or MRI. It can reveal the extent of a rectocele.
Treatment
Several treatments are available to fix a rectocele. The doctor shall diagnose the severity of the prolapse to determine the appropriate treatment. It is often composed of:
- Observation: Noninvasive treatments are available to treat a small rectocele with little to no symptoms. The prolapse can be managed by making the pelvic floor muscles stronger, usually in a form of Kegel exercises and bowel training.
- Vaginal Pessary: This is a removable device, made in silicone, that is fitted into the vagina to support the area of a prolapse. Usually, the patient is instructed on how to care, remove, and insert the pessary. This is often recommended for moderate and severe cases of rectocele.
Surgery
A surgical rectocele repair may be recommended in instances that:
- A vaginal pessary and pelvic exercises such as Kegel, did not improve the symptoms of rectocele.
- A secondary prolapse occurred along with rectocele. If the symptoms are uncomfortable, the doctor may need to fix all affected organs to restore quality of life.
During a rectocele repair, the vaginal bulge is removed. The doctor will take out the excess tissue and stabilized the healthy tissues through sutures. In cases where another prolapse is present, a doctor can do multiple repairs in one surgery. For instance, prolapse of uterus may require hysterectomy.
Kegel exercises
Kegel exercises can improve the health of pelvic floor muscles and can also help manage the symptoms of posterior vaginal prolapse.
To do a Kegel:
- Find the right muscles. The pelvic floor muscles are located between the pubic bone in front up to the end of spine at the back, forming a small sling. While peeing, try to stop the flow of urine. If the correct muscles are successfully identified, the patient may start with the exercise. Lying down position is recommended for beginners.
- Correct technique. When performing Kegels, start lifting and holding for three second, then release and relax for three seconds. Visualize sitting on a marble and contract the pelvic muscles as if raising the marble. Patients may gradually add several exercises per set as they improve.
- Maintain focus. Breathe out while performing the exercises, avoid holding breath. Make sure not to press or tighten the muscles in abdomen, back, buttocks, or inner thighs. If these muscles are contracted, the exercise is not executed properly. Focus on squeezing the correct muscles.
- Repeat three sets a day. One set may consist of 10 to 15 repetitions in a row. Patients may reduce or increase this number depending on their strength and endurance.
Some patients may find it hard to do Kegel exercises. A biofeedback training administered by a healthcare professional will help determine if the exercises are done properly. A monitoring device or probe is inserted into the vagina to ensure that the correct muscles are tightened during the session. In time, this will improve the pelvic floor muscles.
