Rectocele is the prolapse of the pelvic organs with the formation of a diverticuloid-like volumetric protrusion of the rectum wall in the direction of the vagina. The complexity of this disease is not so much a disturbed relationship between perineal structures, but in violation of the basic evacuation function of the rectum in the form of evacuation of intestinal stool.
The intensity of clinical manifestations is correlated with the prolapse of the rectum wall. According to statistical indicators, the incidence rate of rectocele among women has increased significantly and most of the patients are women giving birth. The average of men with this pathology affects only patients who have a constant increase in intra-abdominal pressure, which occurs with certain pathologies of the abdominal cavity.
Reasons for rectocele
The most common etiopathogenetic link in the development of rectocele is the stretching and loosening of the musculoskeletal apparatus of the vagina, which takes place during the period of gestation and at the time of delivery. Multiple pregnancy and repeated episodes of delivery create favorable conditions for the development of rectocele. Among gynecologists, there is an opinion that the use of obstetric manipulations in the form of obstetric forceps and episiotomy inevitably provokes the development of rectocele in the parturient woman even in a remote period. However, not all women in labor suffer from this pathology, and this fact is due to the inherent strength of the muscular apparatus of the pelvis and perineum.
There is also a whole range of pathological conditions, each of which does not cause the development of rectocele, but in aggregate are predisposing factors to its development (rectal dysfunction caused by prolonged episodes of constipation , weakness of the musculoskeletal framework of the pelvis of congenital genesis, dysfunction of the external sphincter, excessive body weight and persistent heavy physical activity).
Symptoms of rectocele
The clinical picture of rectoceles develops very slowly and is not accompanied by the development of symptoms that threaten the life of the patient, so there is a tendency for women to turn to a proctologist for later medical consultation when the effectiveness of the conservative component of treatment is very low. There are a number of clinical criteria, the presence of which allows one to suggest rectocele in a particular patient (propensity to constipation, a sense of the presence of volume formation in the perineal region, pain syndrome in the perianal region, and rectal bleeding).
The initial manifestations of this pathology is a violation of the regularity of the act of defecation and the appearance in the patient of a feeling of incomplete emptying, even after the act of defecation. In this situation, most patients resort to frequent use of medicines that have a laxative effect, thereby aggravating the course of the underlying pathology.
With rectocele 2 degrees, when protrusion of the rectum reaches significant parameters, in order to facilitate the condition, women "press the stool" into the intestine through the back surface of the vagina.
A frequent "companion" of rectocele is the process of development of hemorrhoids, anal fissures and paraproctitis, which, in fact, are complications of the main pathology and significantly worsen its course. In some cases, the third degree of rectocele is accompanied by episodes of vaginal bleeding due to additional irritation of the vaginal mucosa.
Stagnation of fecal masses in the area of protrusion of the rectum provokes the development of inflammatory changes accompanied by a developed clinical symptom complex (fever in a hectic type, pronounced pain syndrome in the perineum, intoxication syndrome).
Degrees of rectocele
Rectocele of the rectum belongs to the category of slowly progressing surgical pathologies, the development of which takes an extended period of time. Depending on the prevalence of these or other pathomorphological changes in the projection of the pelvic organs, several degrees of development of the rectocele are distinguished.
The diagnosis of "rectocele 1 degree" can be established as an accidental finding during a routine examination of the patient, including a visit to the proctologist and a digital rectal examination. This category of patient (s) does not present any complaints about changes in bowel function, and pathomorphological changes in the rectum wall are minimal.
The expanded clinical symptomatology takes place at a rectocele of the 2nd degree, when the majority of patients make specific complaints about the impossibility of complete emptying of the intestine and constant discomfort in the perianal region. With an objective examination of the patient, it is easy enough to detect a significant prolapse of the rectum up to the vestibule, which indicates the progression of pathological disturbances.
3 degree of rectocele is critical, at which the quality of life of patients is significantly reduced. In this situation, women feel constant discomfort in the projection of the small pelvis and the perineal region, and sometimes a pronounced pain syndrome. Visual signs of rectocele consist in the detection of protrusion of the wall not only of the rectum, but also of the vagina below the level of the sexual gap. Depending on which of the walls of the rectum prolates, the anterior or posterior version of the rectocele is prominent.
There is also an anatomical classification of rectocele, in which three types of this pathology are divided. The most favorable is a low rectocele, in which there is a violation of the function of the sphincter of the rectum, which usually arises as a result of severe delivery. In the development of high rectocele, the tension of the ligamentous apparatus of the uterus and the vagina is fundamental, in which there is complete loss of the internal genital organs, and sometimes of the small intestine (enterocele).
In addition, there is a diagnostic classification of rectocele based on the results of radiation imaging methods, according to which protrusion up to 20 mm is regarded as minimal, and the critical value is a size of 40 mm or more.
Treatment of rectocele
Despite the fact that surgical intervention is the most effective treatment for rectocele, conservative methods in some situations allow the patient to be best prepared for the operation. The main goal of the conservative direction of therapy is to improve the motor-evacuation function of the thick intestine, which is also important in the post-operative rehabilitation period.
Preoperative conservative treatment is advisable to be carried out for at least two months prior to the proposed date of the operation and the therapy regimen should include a set of therapeutic measures of drug and non-pharmacological direction. An important factor in correction of rectocele and prevention of further progression of the disease is correction of the patient's eating behavior, which consists in enriching the daily diet with foods containing high fiber concentration, which has a beneficial effect on improving the motility of the thick intestine.
In a situation where the diagnosis is established by the patient at the initial stage of the formation of the rectocele, the performance of a complex of physiotherapy exercises and physiotherapy techniques is good. Exercises for rectocele are aimed at strengthening the muscular skeleton of the pelvic floor, in this connection, conditions are created to prevent further progression of the disease.
The medicamentous component of therapy of rectocele is represented by laxative preparations of osmotic action, eubiotics and prokinetics. Laxative osmotic agents have a number of advantages that allow them to be used for a long period of time as a symptomatic drug (Forlax 1 packet 10 mg in the morning orally), but the main advantage of this category of drugs is the safety of their use during the period of childbirth and lactation. It should be borne in mind that prolonged use of osmotic laxatives can be accompanied by dehydration syndrome, which is an absolute indication for stopping the drug.
Eubiotic drugs should be prescribed at any stage of the rectocele, since these drugs have a positive effect on the process of digestion of food substrate in the intestine, inhibit the processes of fermentation and contribute to the formation of a normal consistency of stool. With rectocele, preference should be given to combined eubiotics, which contain a therapeutic concentration of lacto- and bifidobacteria (Linex 2 capsules three times a day after meals). It is necessary to observe the regime of storage of this category of medicines (ambient temperature 4-7 degrees Celsius), since the components of the preparation are sensitive to the effect of increased temperature.
The stimulating effect on the process of fecal matter movement through the intestines and emptying of the rectum is provided by drugs of the prokinetic group (Motillium 10 mg 3 times per day orally).
Operation with rectoceles
Operative treatment is the only pathogenetically justified method of correction of rectocele, since surgical removal of a defect is not a symptomatic method, but a radical one. All methods of surgical correction should be divided into two main groups: direct elimination of prolapse of the rectum wall and strengthening of the muscular framework between the rectum and the vagina.
Depending on the degree of prolapse of the rectum wall and the localization of swelling, the operative allowance can be performed through the vaginal, rectal and transabdominal access under peridural anesthesia. The surgical intervention is performed by the method of performing sequential manipulations in the form of elimination of the prolapse part of the rectum with subsequent fixation of the rectum behind the front wall, strengthening the rectovaginal muscular skeleton and correcting the external sphincter. Sewing of the walls of the rectum is recommended to be performed together with muscle fibers lifting the anus, thereby strengthening the rectovaginal septum.
In some situations, when there is an extreme degree of rectocele with concomitant surgical complications in the form of prolapse of hemorrhoids, the presence of bleeding from the anal fissures, as well as the signs of the existing pararectal fistula, a one-stage surgical removal of the above defects together with the surgical remocele is recommended.
The most modern and acceptable method of operative correction of rectocele is now the installation of a reticular implant with the endoscopic method, which is considered to be a minimally invasive operation, devoid of postoperative complications. Due to the fact that the implant is made of high-quality material, the patients do not have problems with the survival of foreign tissue and there is no allergic component.
Like any other surgical operation, operative treatment of rectocele has a number of absolute contraindications restricting its use (severe form of any chronic pathology in the patient, which can be accompanied by the development of life threatening conditions for the patient). In this situation, a woman is recommended to wear a pessary constantly, preventing further progression of the disease and loss of internal genital organs from the vagina.