By Sigourney Cross, DPT, PHRC Walnut Creek
A rectocele, also known as a posterior wall prolapse, is one of the main types of pelvic organ prolapse (POP). As explained in some of our prior posts, a POP occurs when tissue and muscles can no longer support the pelvic organs and they drop down. For a review of the main types of POP you can click here. A rectocele occurs when the rectum bulges into the vagina. This weakened tissue is usually the result of childbirth, chronic constipation and heavy lifting. In most cases symptoms from a rectocele can be managed with conservative measures including the placement of a pessary and/or skilled pelvic floor physical therapy. Unfortunately, if the rectocele is severe enough surgery may be indicated.
Who is a candidate?
Doctors and physical therapists recommend surgery if the rectocele is large and severe enough and a patient has failed conservative treatment options. When deciding whether or not to have a rectocele repair surgery, the severity of a person’s symptoms are weighed against the potential benefits and relief of symptoms the surgery will provide against the risks and potential complications. Common symptoms include difficulty with bowel movements, a feeling of pelvic pressure and/or fullness, a feeling of incomplete evacuation, bulging pain and discomfort in the vagina, problems inserting tampons and lower back pain. The benefits of getting the surgery include improving bowel control, relieving pain and discomfort with daily activities, relieving pain and discomfort with intercourse, and allowing for more physical activity with less feeling of pressure or fullness. These benefits have to be considered with the potential complications that could arise including a repair failure or rectocele recurrence, injury to the rectum or nearby organs, sexual dysfunction caused by poor healing or vaginal tissue, nerve damage, and other surgical risks related to anesthesia and infection.
The Procedure
Rectocele surgery is a reconstructive procedure that is performed by repairing the damaged or weakened tissue, restoring the rectum to its normal position, and strengthening the wall between the vagina and rectum. This procedure is called a Colporrhaphy and is usually done through the vagina. One or more incisions are made along the back wall of the vagina. Stitches are sewn into tissue around the vaginal wall and rectum that are weakened and/or tissue with any tears. The perineum may also be repaired with deeper stitches. These stitches not only repair any tearing, but can strengthen tissues by encouraging scar tissue formation around the area for added support. If a woman’s own tissues are not strong enough for tissue repair, surgeons may use vaginally placed mesh to get the added support they need. To learn more about mesh you can click here.
Recovery
Many women are discharged after their rectocele repair without clear guidelines as to how to fully recover after surgery and more importantly without instructions on how to prevent repeat prolapse. Recovery time can vary between women depending on the severity of the repair and surgical technique used. In general you should wait six to eight weeks before engaging in higher intensity exercise, lifting, and sexual intercourse. Pain management and managing vaginal discharge are the goal for the first six weeks. Discharge is best managed with use of sanitary pads. You want to avoid tampons and douching. There is no need to worry about stitches as they will dissolve on their own. As you are healing there are measures you can take to ensure the integrity of your repair and prevent a repeat prolapse.
Avoid Straining– As discussed earlier, one of the major causes of rectocele is constipation, more specifically, straining with constipation. It’s easy to get in this bad habit, which will only make the prolapse worse. You’ll also want to avoid straining during urination or when trying to pass gas.
Have good bowel movements- This ties into never straining. There are a few things you can do to ensure good bowel movements. The first is by being in a good posture or position while using the toilet. Some women fall into bad habits such as hovering over the toilet which can tighten the anal sphincter and make it harder for stool to get out. At PHRC we recommend everyone use a squatty potty or stool in front of the toilet to get their knees higher than their hips. This helps relax the puborectalis muscle to allow stool to pass more easily. It’s also important to ensure the use of correct bowel movement technique. There’s a high chance that women who have a history of a rectocele, have formed many different habits or techniques to empty their bowels. Some may use their fingers as a splint inside the vagina or to lift their perineum to empty their bowels. This is because the rectocele causes stool to move into the prolapse instead of out of the rectum. To evacuate your stools without straining you’ll want to start in the position described above. Then try incorporating some diaphragmatic breathing exercises to help relax your pelvic floor allowing you to empty. Lastly, to have good bowel movements you need to have optimal stool consistency. Stool that is either too soft or too hard is more difficult to pass. The ideal stool consistency is type 3-4 on the bristol stool chart. I usually tell my patients to aim for a shape similar to that of a banana. You can achieve this with a well rounded diet, proper water intake, watching what medications you are taking, and use of fiber supplements and stool softeners.
Manage lifestyle factors– Some lifestyle factors can increase the strain and load on the pelvic floor which will make you more susceptible to the repair failing. These include obesity, heavy lifting, and smoking due to chronic coughing. Managing these lifestyle factors will improve surgical outcomes and overall recovery.
Train your pelvic floor muscles– Last but certainly not least, it’s vital to retrain your pelvic floor. Your pelvic floor muscles help support your rectum when you empty your bowels. Working these muscles will assist in providing internal support to the repair so the rectocele doesn’t return, as well as provide the control needed to empty your bowels without straining. The safest and most advantageous way to train your pelvic floor muscles is with the guidance of a pelvic floor physical therapist. Many patients are told to just perform kegels after their surgery. Unfortunately this recommendation is not only insufficient it can actually lead to more harm. This recommendation assumes a person recovering from surgery knows how to perform a kegel properly, which many times isn’t the case. It also doesn’t take into account the overall condition of a person’s pelvic floor muscles. Kegels alone are usually not enough. It’s important to ensure a patient recovering from this procedure has good pelvic floor range of motion and motor control meaning they are able to fully relax and lengthen their pelvic floor muscles in addition to contracting them or performing kegels. A pelvic floor physical therapist can also help train these muscles before a person goes into surgery. As with most surgical procedures, the healthier and more prepared your body is going into the procedure, the better outcome you’ll have coming out of the procedure. Learning how to train your pelvic floor prior to any surgical trauma will assist you in a better overall recovery. An evaluation and treatment plan by a pelvic floor physical therapist before and/or after surgery will help ensure an optimal outcome. It’s important to note that pelvic floor physical therapy isn’t always recommended before or after rectocele repair and it should be! If you or someone you know is undergoing this procedure be sure to be your own advocate and ask your physician and/or surgeon for a referral to a pelvic floor therapist.
References:
Herman and Wallace inc. Pelvic Rehabilitation Institute. Pelvic Floor Function, Dysfunction and Treatment.
https://intermountainhealthcare.org
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.