Rectocele Pathophysiology and Presentation

Abstract

A rectocele is defi ned as the herniation or bulging of the posterior vaginal wall. The posterior vaginal wall and the anterior rectal wall are in direct apposition, and this bulging may be thought of as the rectum pushing anteriorly into the vagina.Rectoceles may present in isolation but may also often be associated with pelvic organ prolapse (POP). POP describes the herniation of one or more of the pelvic organs including the uterus, the apex of the vagina, the bladder or the rectum from its normal anatomical position into or occasionally beyond the vagina. PrevalencePelvic organ prolapse is common. In the United States, more than 200,000 operations are performed annually for one or more of the different presentations of pelvic organ prolapse, and numbers of women presenting for surgery for prolapse are increasing. The majority of pelvic organ prolapse is mild; however, prolapse beyond the vaginal introitus may occur in up to 5 % of cases. The Women's Health Initiative published in 2002 [ 1 ] suggested that in women aged between 50 and 79 years of age, up to 41 % of patients will present with some degree of POP, 18.3 % with a rectocele. However, the majority of these women are symptom free, and therefore, these prolapses may not be clinically signifi cant. Several larger studies have shown a lifetime risk of symptomatic POP of around 11 % [ 2 , 3 ]. As well as presenting with symptoms of bulge in prolapse, patients with pelvic fl oor disorders may also present with coexisting urinary or anal incontinence, and these symptoms often affect their quality of life, more than the prolapse itself.The prevalence of rectoceles (either with or without POP) depends on whether they are asymptomatic or symptomatic. In a study from the 1980s, radiological rectoceles were seen in 81 % of nulliparous asymptomatic women who were less than 35 years old [ 4 ]. Forty-eight percent of the female patients had rectoceles that were greater than 1 cm in size, and one had one >2 cm. Coexistent intussusception was present in 50 % of women. A Swedish study invited female patients between 20 and 59 years of age for a gynaecological health examination [ 5 ]. 14.4 % of the population had a rectocele.In 1997 the costs of repairing rectoceles in the United States (with or without other prolapse procedures) ran to $75 million [ 6 , 7 ]. It is estimated that with an ever-increasing aging population, the healthcare costs for managing symptomatic rectoceles (along with other POP) will be enormous. The lifetime risk for undergoing a single operation for pelvic fl oor dysfunction is estimated to be 11.1 %, and up to 29 % of patients required reoperation [ 2 ].