Pelvic organ prolapse (POP) encompasses a range of conditions where pelvic organs, such as the bladder, uterus, or rectum, descend from their normal positions due to weakened pelvic support structures. Among these, rectal prolapse or rectocele which occurs when the rectum bulges into the vaginal wall causing pain and discomfort while also interfering with emptying of stool. In this article, we will delve into what rectal prolapse is, explore its causes and symptoms, discuss available treatment options, and provide guidance on when to seek professional help.

What Is a Rectocele?

Rectocele, also known as a posterior vaginal wall prolapse, occurs when the rectum bulges into the back wall of the vagina due to weakened pelvic support structures. This condition results in a bulge or protrusion that can be felt or seen through the vaginal opening. Unlike other types of pelvic organ prolapse (POP), which involve different pelvic organs such as the bladder or uterus, a rectocele specifically affects the rectal wall and its interaction with the vaginal cavity.

Causes and Risk Factors

• Childbirth: Vaginal delivery, especially multiple or traumatic births, can weaken the pelvic floor and the connective tissues between the rectum and vagina, increasing the risk of a rectocele.
• Chronic Straining: Frequent straining during bowel movements, often due to chronic constipation, can put excessive pressure on the pelvic tissues and lead to the formation of a rectocele.
• Aging: As women age, the tissues and muscles supporting the rectum and vaginal wall can lose strength and elasticity, making the development of a rectocele more likely.
• Obesity: Excess body weight adds pressure to the pelvic region, which can contribute to the development or worsening of a rectocele.
• Pelvic Floor Disorders: Conditions that weaken the pelvic floor, such as previous pelvic surgery or hormonal changes, can also increase the risk of rectocele.

Symptoms of Rectocele

Rectocele presents with a range of symptoms that can vary in intensity depending on the severity of the condition. Recognizing these symptoms is essential for timely diagnosis and effective management.

Common Symptoms

• Vaginal Bulging: One of the most noticeable symptoms of a rectocele is a bulge or protrusion in the vaginal area. This bulge may become more prominent during physical activities such as lifting or during bowel movements. In some cases, the bulge may be visible even when at rest.
• Pelvic Pressure or Discomfort: Women with a rectocele often experience a feeling of pressure or discomfort in the pelvic region. This pressure can be persistent or intermittent and may worsen with prolonged standing or physical exertion.
• Difficulty with Bowel Movements: A rectocele can interfere with normal bowel function, leading to symptoms such as difficulty passing stools, the sensation of incomplete bowel emptying, or a need to manually assist in bowel movements.
• Urinary Symptoms: Although less common, some women may experience urinary symptoms, such as increased frequency or urgency. These symptoms occur because the rectocele can put pressure on the bladder, affecting its function.
• Sexual Discomfort: The presence of a rectocele can cause discomfort or pain during sexual intercourse. The bulge may interfere with normal vaginal anatomy, leading to painful or uncomfortable sensations during sexual activity.

Impact on Daily Life

• Physical Discomfort: The symptoms of a rectocele can lead to significant physical discomfort, affecting daily activities and overall quality of life. Persistent pelvic pressure and bowel difficulties can make routine tasks and physical activities challenging.
• Emotional and Social Effects: The visible bulge and associated discomfort can impact self-esteem and social interactions. Women may feel embarrassed or anxious about their condition, which can affect their emotional well-being and social engagement.
• Functional Limitations: Difficulty with bowel movements and pelvic discomfort can limit participation in activities and reduce overall functionality.

Management of Rectocele

Initial management of a rectocele focuses on alleviating symptoms and addressing contributing factors to prevent the condition from worsening. The first steps often include lifestyle modifications and conservative treatments.

1. High-Fiber Diet: Incorporate plenty of fruits, vegetables, whole grains, and legumes into your diet. A high-fiber diet helps to soften stools and reduce the need for straining during bowel movements, which can alleviate pressure on the rectum and minimize rectocele symptoms.
2. Adequate Hydration: Drink plenty of water throughout the day to support digestive health and maintain regular bowel movements. Proper hydration helps prevent constipation and promotes healthy bowel function.
3. Regular Exercise: Engage in low-impact physical activities such as walking or swimming to maintain overall fitness and support pelvic floor strength. However, avoid high-impact exercises and heavy lifting that can increase abdominal pressure and exacerbate prolapse symptoms.
4. Pelvic Floor Exercises: Perform pelvic floor exercises, such as Kegel exercises, to strengthen the muscles that support the rectum and vagina. Regularly practicing these exercises can help improve muscle tone and support the pelvic floor.
5. Avoid Straining: Practice techniques to avoid straining during bowel movements, such as using a stool softener if needed and adopting a proper sitting posture. Straining can worsen rectocele symptoms and increase pressure on the pelvic organs.
6. Weight Management: Maintain a healthy weight to reduce the pressure on the pelvic floor. Excess body weight can contribute to the development and progression of rectocele, so achieving and maintaining a healthy weight through diet and exercise is beneficial.
7. Modify Daily Activities: Avoid activities that involve heavy lifting or significant physical exertion, which can increase abdominal pressure and aggravate rectocele symptoms. Use proper techniques and seek assistance when lifting or carrying heavy objects.
8. Manage Chronic Conditions: Address any underlying conditions that may contribute to rectocele symptoms, such as chronic constipation or coughing. Managing these conditions effectively can help reduce the strain on the pelvic floor.

Kegel Exercises for Rectal Prolapse

Kegel exercises are a fundamental component in managing a rectocele, as they focus on strengthening the pelvic floor muscles that support the rectum and vagina. By performing these exercises regularly, individuals can enhance muscle tone and support, which helps alleviate symptoms associated with rectocele. Consistent practice of Kegel exercises can reduce pelvic pressure, improve control over bowel movements, and potentially minimize the bulging associated with rectocele. Integrating these exercises into a daily routine can offer significant relief and contribute to overall pelvic health, complementing other lifestyle modifications and treatments. 

Using Supportive Devices for Rectocele

Using supportive devices for rectocele can provide effective relief and help manage the symptoms of this condition. One common device is the pessary, a removable, flexible device inserted into the vagina to support the rectal wall and alleviate the bulging associated with rectocele. By providing physical support, a pessary helps to hold the rectum in place, reducing pressure on the pelvic floor and improving comfort during daily activities. Pessaries come in various shapes and sizes, so it's essential to work with a healthcare provider to select the appropriate type and ensure proper fitting. Regular follow-ups are necessary to adjust or replace the pessary as needed.

Rectal support garments may also be used to provide additional external support and reduce symptoms. These devices can be particularly beneficial for individuals who need temporary relief or are waiting for surgical options

FemiCushion

An at home treatment option for rectocele is FemiCushion. It is an prolapse support device that uses a soft silicone cushion to provide targeted support to the prolapse. The cushion is placed against the vaginal opening to support and strengthen pelvic muscles. Women are able to us FemiCushion to relieve prolapse symptoms without undergoing surgery or using a pessary.

A study from Showa University Northern Yokohama Hospital, published in The Journal of Obstetrics and Gynecology Research, investigated the efficacy of FemiCushion in treating pelvic organ prolapse (POP) using magnetic resonance imaging (MRI). The research included twelve participants aged 56 to 84, all with severe stages 3 or 4 of POP.

Key findings of the study are:

• Effectiveness: FemiCushion demonstrated significant success in repositioning prolapsed pelvic organs.
• Comparison to Pessaries: The device achieved results similar to those of a pessary but with fewer risks, such as vaginal erosion and bleeding.
• Support and Relief: FemiCushion not only lifted the prolapsed organs but also supported the perineal body and closed the hiatuses.
• Significant Improvement: Participants with severe POP saw a notable reduction in prolapse severity after using FemiCushion.
• Rapid Benefits: Improvements were observed within just one month of use.

These findings underscore FemiCushion’s potential as a non-invasive alternative to pessaries for managing POP, offering comparable benefits while minimizing associated risks. The study indicates promising progress in the treatment of severe pelvic organ prolapse.

Supervising Doctor of This Article

Koichi Nagao, MD PhD

Professor, Department of Urology, Toho University Faculty of Medicine
Director of Urinary tract reconstruction center, Toho University Omori Medical Center
Director of Reproduction Center, Toho University Omori Medical Center

Professor Nagao specializes in plastic surgery in the field of reproductive medicine. He completed eight years of plastic surgery training at Showa University before majoring in urology at Toho University. With his meticulous surgical techniques and careful examinations that combines urology and plastic surgery, Professor Nagao became a Board Certified Specialist with multiple associations including the Japanese Urological Association, the Japan Society for Reproductive Medicine, and the Japanese Society for Sexual Medicine.