A rectocele is a common form of pelvic organ prolapse that occurs when the supportive structures of the pelvis weaken. This condition involves the rectum bulging forward into the back wall of the vagina, creating a noticeable protrusion. Although not immediately harmful, the displacement of tissue can interfere with normal bodily functions. Clinicians use a standardized classification system to measure the severity of the descent, which informs the most effective course of treatment.
Understanding Rectocele Formation
A rectocele forms due to a breakdown in the integrity of the rectovaginal septum, the thin layer of tissue that separates the rectum from the vagina. This septum is part of the larger pelvic floor support system, which includes muscles and ligaments designed to hold the pelvic organs in their proper position. When these supporting structures lose their strength, the pressure from the rectum can push through the weakened area and create a sac-like bulge into the vaginal canal.
The weakening of the pelvic floor is often a cumulative process linked to factors that increase downward pressure. Childbirth, particularly multiple vaginal deliveries or those involving prolonged pushing, is a significant contributor to structural damage. Chronic straining from long-term constipation places repeated force on the rectovaginal septum, exacerbating the problem. Additionally, aging and the resulting drop in estrogen after menopause can lead to a loss of muscle tone and tissue elasticity.
The Rectocele Grading System
The severity of a rectocele is classified using clinical systems that measure the degree of tissue descent relative to the vaginal opening, known as the hymen. The most commonly applied method uses a four-point scale to guide clinical decision-making. Grade I, the mildest form, is characterized by a rectocele that protrudes only part of the way into the vagina, descending less than halfway to the hymen. At this stage, the bulge remains contained within the vaginal canal and typically produces no noticeable symptoms.
Progression to Grade II indicates a moderate prolapse where the rectal bulge has descended far enough to reach the plane of the hymen, or the vaginal entrance. This degree of descent is often the point at which women begin to feel a sensation of fullness or pressure in the pelvis. A Grade III rectocele is considered severe, meaning the tissue has descended halfway past the vaginal opening, making the bulge clearly visible outside the body during straining.
The most advanced stage is Grade IV, which describes the maximum possible descent where the entire front wall of the rectum has prolapsed and is fully everted outside the vagina. Classification may also be assessed radiographically, where a rectocele smaller than two centimeters is considered small, and a bulge greater than four centimeters is designated as large. This precise measurement determines whether conservative management or surgical intervention is the appropriate next step.
Clinical Presentation and Visual Indicators
The clinical presentation of a rectocele is closely tied to its grade, ranging from asymptomatic in mild cases to causing significant functional issues in advanced stages. The most common complaint is a feeling of pelvic pressure or the sensation that something is falling out of the vagina. As the bulge grows, it can obstruct the smooth passage of stool, leading to constipation and the feeling of incomplete rectal emptying.
A clear visual indicator is the soft tissue mass that appears at the vaginal opening, becoming more pronounced when the patient strains. For women with Grade II or higher rectoceles, this difficulty during bowel movements often leads to manual splinting. Manual splinting involves applying pressure to the perineum or posterior vaginal wall to physically support the rectal bulge and facilitate stool passage. The visual appearance of the bulge and the reliance on splinting are strong indicators requiring medical attention.
Non-Surgical Management Options
For rectoceles classified as Grade I or mild Grade II, conservative, non-surgical approaches are the preferred initial treatment strategy. Lifestyle modifications focus on preventing the chronic straining that contributes to pelvic floor weakening. This involves adopting a high-fiber diet, ensuring adequate hydration, and using stool softeners to maintain regular, soft bowel movements. Maintaining a healthy body weight and avoiding activities that generate high intra-abdominal pressure, such as heavy lifting, are also recommended.
Pelvic floor physical therapy, including targeted exercises like Kegels, is another foundational non-surgical option. These exercises strengthen the levator ani muscles, which are part of the supportive hammock that helps keep the organs in place. For women requiring mechanical support without surgery, a vaginal pessary may be fitted; this removable device is inserted into the vagina to physically hold the prolapsed rectal tissue in position.