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.
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.
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.
Herman and Wallace inc. Pelvic Rehabilitation Institute. Pelvic Floor Function, Dysfunction and Treatment.