A rectocele may be an important cause of obstructive defecation that presents as constipation. A rectocele is a herniation of the anterior wall of the rectum into the lumen of the vagina. A rectovaginal septum weakened by multiple childbirths and the aging process may enable stool to become trapped in this herniation, leading to a sense of incomplete evacuation. Continued straining may further weaken the rectovaginal septum and lead to progressive enlargement of the herniation. Because patients with a rectocele believe that they cannot completely evacuate during a bowel movement, despite a normal urge to do so, digital manipulation, enemas, or suppositories are often used to assist defecation. These patients typically have rectal fullness, bleeding, pain, and soiling. A bimanual examination discloses a defect of the anterior rectal wall above the level of the anal sphincter. Radiographically, a pocket-like protrusion of the rectovaginal septum into the vagina is noted on lateral or oblique views. This is best observed during defecating proctography by retained contrast within the rectocele at the end of defecation (Fig. 3.3).
Rectoceles are a relatively common finding on physical examination, occurring in up to 81% of all women.8 However, only half of these patients report symptoms of constipation or difficulty with defecation. Thus, many women with recto-celes are asymptomatic, and the presence of a rectocele is not an indication for repair. Recto-celes found on defecography that measure less than 2 cm are generally considered to be clinically insignificant, whereas rectoceles larger than 3 cm are usually considered clinically significant.8 Interestingly, the size of a rectocele has been shown not to correlate with the severity of symptoms clinically.911 Furthermore, the size of a rectocele as measured by the amount of
barium trapped radiographically has not been proven to correlate with the success of rectocele repair.9
Controversy exists as to whether rectoceles are the cause or result of excessive straining. Repeated trauma, as in obstetrical injury or repeated vaginal delivery, appears to play a role in weakening the rectovaginal septum. Typically, the sphincter is shortened and the perineal body is thinned. Beven12 has speculated that thinning of the rectovaginal septum and/or pelvic dener-vation seen following hysterectomy may contribute to rectocele formation. Johansson et al13 has noted that some patients have associated paradoxical sphincter contraction and elevated mean resting rectal pressures. Because rectoce-les commonly present in the fourth and fifth decade of life, the postmenopausal hormonal milieu with supporting tissue laxity may play a role in the pathogenesis of rectocele.
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