Rectocele

Rectocele refers to a herniation or bulge of the rectal wall, with the most common type being an anterior rectocele where the bulge is into the posterior vaginal wall in a female patient. Rectoceles can also occur posteriorly or laterally. Rectocele is the term most commonly used by colorectal surgeons, and the same entity is referred to as a posterior vaginal prolapse by urogynaecologists.

Clinical presentation

Typical presenting symptoms include:

• difficult defecation with excessive straining
• perineal and vaginal pressure and bulging
• intermittent fecal soiling
• necessity to digitate to allow the evacuation of stools

The clinical examination may reveal a rectocele and other pelvic organ prolapses such as a cystocele, and these are usually graded using the Pelvic Organ Prolapse Quantification (POP-Q) system ⁸. 

Pathology

Anterior rectocele results from a defect in the integrity of the rectovaginal septum with subsequent herniation of the rectal wall into the vagina and inferiorly into the perineum.

Risk factors

• obstetric trauma
• hysterectomy
• cystopexy
• chronic constipation

Associations

• increasing age
• parturition

Radiographic features

Imaging is used to confirm the diagnosis and evaluate for co-existing pelvic organ prolapse, and to grade the severity of the prolapse(s). Both fluoroscopic and MRI proctography can depict rectoceles, and they can be graded using MRI. Extension beyond the expected position of the normal anterior rectal wall is measured, and the severity of the rectocele graded as ⁷:

• <2 cm: small
• 2-4 cm: medium
• >4 cm: large

See also

• rectal prolapse