Rectocele and enterocele

Definition

• A rectocele is a form of pelvic organ prolapse in which the rectum herniates through the rectovaginal septum into the posterior vaginal wall.
• It frequently coexists with prolapse of the anterior, apical or posterior compartment, for example an enterocele, in which bowel herniates into the vaginal canal through the pouch of Douglas.

Occurrence & epidemiology

Epidemiology

• Up to two thirds of parous women have some degree of rectocele, most of them without symptoms.
• A rectocele may also develop in about 12% of nulliparous women, attributed to congenital defects.

Aetiopathogenesis

Aetiology and pathogenesis

• Weakening or disruption of the rectovaginal septum allows the anterior rectal wall to herniate into the vagina; the most common defect is a transverse break just above the perineal body.
• Weakening of the levator ani muscles or the surrounding connective tissue also contributes.
• Non-modifiable risk factors are advanced age and genetic susceptibility; further factors are higher parity, vaginal birth, obesity, constipation and chronically raised intra-abdominal pressure.

Clinical features

• Typical are a posterior vaginal bulge that worsens with straining, terminal constipation with obstructed defecation, perineal pressure and vaginal or pelvic discomfort.
• A sense of incomplete bowel emptying is common; some patients insert fingers into the vagina and press on the posterior wall (splinting) to change the rectal angle and defecate.
• In advanced cases the prolapse extends beyond the hymen, and the exposed mucosa may erode, bleed, become infected or ulcerate.

Diagnosis

• Examination includes vaginal and rectal assessment: with the anterior wall retracted, the posterior vaginal wall is observed at rest and on straining, together with a rectovaginal examination.
• In the POP-Q system, the rectocele is assessed using two measurement points on the posterior vaginal wall and then staged.
• Fluoroscopic defecography is usually used for anatomical assessment, and dynamic MR defecography gives more detailed images; ultrasonography, anorectal manometry or colonic transit studies may be added.
• Radiological evidence of rectocele is non-specific, as defecography shows it in up to 93% of healthy, asymptomatic women.

Keep learning in the app

Further reading (selection)

1. StatPearls: Rectocele (NCBI Bookshelf)
2. MSD Manual Professional: Anterior and Posterior Vaginal Wall Prolapse

Cross-references