A rectocele is when the rectum bulges on straining, resulting in failed ecvacuation of stool (fig 1). It is more common in women, and typically the bulge is at the front (anteriorly) into the vagina. It leads to incomplete evacuation of the rectum on straining, and can be a cause of constipation.
Figure 1. Rectocele bulging into vagina.
The main symptom is incomplete evacuation of the rectum on straining. Frequently, this leads to the feeling that one needs to evacuate again soon after the last attempt. This feeling can at times be so overwhelming, that a compulsion to digitally evacuate the rectum is felt.
The diagnosis is based on the presence of classic symptoms, the confirmation of an anterior bulge in the rectum on clinical examination and real time x-ray taken while defecating (defecating proctography), as well as anal physiology tests including manometry that show reduced rectal pressures and increased compliance of the rectum.
MEDICAL MANAGEMENT OF A RECTOCELE
The maitenance of a soft stool consistency is important in preventing constipation and overdistension of an easily distensible rectum. Regular fibre, including a tablespoon of metamucil® twice a day, and 30ml of lactulose (Duphulac®) either once or twice a day may be needed.
SURGICAL MANAGEMENT OF A RECTOCELE
A rectocele repair is occasionally indicated, and is a day stay procedure. It involves raising a flap of mucosa to gain access to the weakned part of the wall of the rectum at the front (anteriorly) and gathering up the muscles in this area with a series of reinforcing sutures, before closing the flap over the repair.
WHAT TO EXPECT PRE AND POST OPERATIVELY FOR RECTOCELE SURGERY
Unless you are also having a colonoscopy, a normal diet without a bowel prep is required the day before surgery. You need to fast from midnight the night before if your surgery is scheduled for the morning, or from 6am if scheduled for the afternoon. You will be admitted as a day-stay procedure. You will receive a fleet® enema 1 hour prior to your rectocele operation.
Following your procedure, you will recover for a hour until the effects of sedatives have worn off. You should not drive yourself home after your procedure and should have someone organised (a friend or relative) to accompany you.
You should remain on regular laxatives and simple analgesics for 1 week. We recommend taking twice daily a tablespoon of natural psyllium husk (Metamucil® or Fibogel®), and 30ml of lactulose (Duphalac®) daily or twice dialy to keep stool consistency soft. For pain we recommend after each meal 400mg of ibuprofen (Brufen®) and 1g of paracetamol. Opioid medications (Codeine and Morphine) should be avoided as they cause constipation.
You should follow up with your colorectal surgeon in 6 weeks to review your wound and discuss further management if indicated.