Rectocele – diverticulosis protrusion of the rectal wall in the direction of the vagina (anterior rectocele) or, more rarely, in the direction Ecopsychology ligament (posterior rectocele).
The causes of the disease are:
- pathological changes in the recto vaginal septum;
- the divergence of the front portions of the muscles, lifting the anus;
- congenital weakness of ligament-muscular skeleton of the pelvic floor;
- dysfunction of the colon, most often in the form of long-term chronic constipation;
- violation of the functional state of the anal sphincters;
- age-related degeneration and atrophy of the recto vaginal septum and pelvic floor muscles;
- diseases of the female genital organs.
As a result of polyetiological of the disease is difficult to detect the root cause of the development of a rectocele. The prevailing role in its development belongs to the factors influencing chronic increased intra-abdominal pressure, and factors leading to trauma and weakening of the recto vaginal septum. Found that the majority of women the onset of symptoms associated with childbirth. Of these, more than half of the patients noted severe childbirth large fruit with perineal tears. An equally important factor is the chronic increased intra-abdominal pressure. 83% of patients had constipation, forcing them to resort to laxative drugs. 15% of patients, the profession involves heavy physical labor. У18 % of patients the development of the disease contributed to postponed the hysterectomy. It was found that 63 % of women had a rectocele occurs when the combination of at least two etiological factors.
Violation of the integrity of the recto vaginal septum often occurs as a result of birth injury involving tearing of the posterior wall of the vagina to varying degrees. Rough obstetric manipulations, multiple births lead to weakness of the pelvic floor muscles and development of a rectocele.
The discrepancy, or trauma of the front portions of the muscles that raise the anus, leads to a weakening of the muscular frame of the pelvic floor muscles and tissues of the recto vaginal septum. Thus it becomes thinner, and the back wall of the vagina, intimately associated with the rectum, acquires mobility. By increasing intra-abdominal pressure is a bulging of the anterior wall of the rectum in the direction of the thinned posterior wall of the vagina.
In the congenital weakness of connective tissue structures and muscles of the pelvic floor bulging of the wall of the rectum into the vagina may develop at a young age after first childbirth or heavy physical labor. It is impossible not to consider the impact of a permanent increase in intra-abdominal or intrapelvical pressure with persistent constipation, leading to degenerative changes in the wall of the rectum. Obviously, these factors are driving when you experience back rectocele both women and men.
Rectocele is characterized not only anatomical variations of the relationship of the tissues of the perineum, but also a violation of motor-evacuation function of the rectum with pronounced changes in reflex activity of the obturator apparatus of the rectum.
One of the first symptoms rectocele marked difficulty in emptying the colon. With the development of the disease is characterized by a complaint becomes a feeling of incomplete emptying of the rectum. There is a need for evacuation of its contents by the manual benefits by extruding the fecal bolus through the back wall of the vagina in the anus.
By incomplete evacuation of fecal lump causes a frequent urge to defecate. Violation of the process of evacuation of feces and delay it in the pocket of the anterior wall of the rectum in turn is accompanied by inflammatory changes in the distal colon.
The development of the disease takes place in several stages. Initially, patients report difficulty in emptying the rectum, forcing them to push hard during a bowel movement. Then attaches a feeling of incomplete emptying of the rectum, there is a need for a two-stage defecation. During this period, patients are beginning to use laxatives or resort to cleaning enemas. In the later stages of the disease, on average, in 2-3 years, there is a need for manual AIDS in defecation. In the subsequent prolonged straining at stool leads to mucosal trauma of the anal canal and the emergence of a number of related gynecological diseases (chronic hemorrhoids, anal fissure, fistula of the rectum, chronic cryptic, etc.).
The vast majority of patients with rectocele complain of stiffness due to minor defecation, feeling of incomplete emptying of the rectum, the need for manual payments in the stool. Manual manual running them by pressing on the perineum, posterior vaginal wall, or the gluteal region. In addition, most patients can’t do without laxatives (Senna preparations, Bisacodyl, guttalaks, etc.) or cleansing enemas. Many patients in the survey revealed complaints due to concomitant diseases of the anal canal and distal rectum. This is the release of blood during bowel movements, prolapse of internal hemorrhoids, pain and discomfort during bowel movements.
According to the severity of the clinical manifestations are three degrees of rectocele front:
Grade I is detected only by digital examination of the rectum as a small pocket of her front wall. At this stage, female complaints, as a rule, do not show.
II degree is characterized by the presence of strong pockets of the rectum, reaching to the vestibule of the vagina. Patients complain of a feeling of incomplete evacuation, obstructed defecation.
Grade III is characterized by a bulging of the posterior vaginal wall to the far edge of the genital slit, which is determined by alone, but particularly pronounced in intra-abdominal pressure increase. Patients note frequent urge to defecate, feeling of incomplete emptying of the rectum. In the final stage, when digital examination is determined by the protrusion of the anterior wall of the rectum outside of the vagina, the disease may be complicated by insufficiency of the anal sphincter accompanied by prolapse and uterine prolapse, and cystocele. To determine the degree of rectocele, in addition to clinical used x-ray examination, namely proctography with straining.
Radiographic criterion for determining the extent of a rectocele is the size of the protrusion of the rectal wall:
- Rectocele grade I — less than 2.0 cm,
- Rectocele grade II — 2,0-4,0 cm
- Rectocele grade III — more than 4.0 cm.
Diagnosis of rectocele is not very difficult. You need to carefully collect medical history and pay attention to the complaints of the patients. Characterized by complaints of obstructed defecation, protrusion of the posterior wall of the vagina, the need for manual benefits by pushing on the back wall of the vagina to release the rectum from fecal material are sufficient for a presumptive diagnosis.
The primary method for diagnosing a rectocele is a clinical inspection. It is carried out on the gynecological stool in the supine position with legs bent at the knee joints and the stomach. Straining reveal bulging of the posterior vaginal wall and anterior wall of the rectum. When digital examination of the rectum to confirm this symptom, and to determine the extent of the disease size and the prevalence of this protrusion outside of the vagina. State of the reproductive organs evaluated at vaginal examination. Holding sigmoidoscopy is mandatory in all diseases of the rectum and anal canal. At the same time determine the state of the rectum and identify comorbidities. At II, and especially in III degree rectocele may develop insufficiency of the anal sphincter. Therefore, in this stage of the disease is necessary to conduct functional studies of the obturator apparatus of the rectum, the results of which take into account in choosing a method of treatment in the future. To determine the amount of protrusion of the rectum and a clear idea about its location did make proctography with straining, during which figure out the ratio of the rectum, vagina.
Instrumental methods of research allow to objectify the size of diverticulitisdog protrusion of the rectum, to determine the degree of severity of disorders of motor-evacuation function of the colon, to identify the most characteristic disorders of the obturator apparatus of the rectum when rectocele.
The differential diagnosis should mainly conduct two diseases: hernia cystocele and recto vaginal septum. Rectocele at entry into the cavity of the vagina is in front of prolabium protrusion of the rectum, and when cystocele the back of the protrusions. Unlike rectocele hernia of recto vaginal septum bulging is due to its polarization and is characterized by the presence of the hernia SAC from the peritoneum covering the Douglas space, the contents of which are often loops of small intestine. In this pathological state is not marked bulging and changes of the anterior wall of the rectum.
The diagnosis of rectocele, established by clinical examination and confirmed by instrumental methods of the study, is a relative indication for surgical treatment. All patients with rectocele treatment begins with conservative correction of violations of motor-evacuation function of the colon. The scheme of conservative therapy is applied in the pre – and postoperative periods. In particular, it includes:
- a diet with increased fiber;
- osmotic laxatives;
- eubiotics used to normalize intestinal flora.
This therapy aimed at the normalization of evacuation function of the colon, and it must be assigned a 1.5-2 months. prior to the surgery.
In the initial stage is useful a comprehensive set of physical therapy. This complex is primarily aimed at strengthening the pelvic floor muscles, eliminate constipation and inflammatory diseases of the vagina and rectum.
The primary and most effective method of treatment of rectocele is surgical intervention. It is indicated for degree II—III disease. In that case, when the patient’s age or severity of comorbidities surgical intervention is contraindicated, prescribe a conservative treatment, physiotherapy, and most importantly — the wearing of the pessary, prevent loss of reproductive organs. It should be remembered that prolonged wear may lead to significant sores, so it is periodically necessary to control its position or remove it for a while and to carry out reorganization of the vagina.
More than 500 proposed methods of surgical treatment of rectocele, the meaning of which has two main provisions: elimination of vbuhanie anterior wall of the rectum and the strengthening of the recto vaginal septum. To eliminate vbuhanie in the transverse direction to produce closure of the rectal wall. The strengthening of the recto vaginal septum is achieved by suturing the muscle that lifts the anus, and posterior wall of the vagina.
The operational allowance is performed under General anesthesia, usually under epidural-sacral anesthesia.
The prognosis after surgical treatment of rectocele favorable. The absolute majority of treated patients restores the function of the pelvic floor muscles and normal defecation.