Rectocele/Enterocele Repair (Rectal Repair)
A rectocele occurs when the wall that separates the rectum and the vagina is torn, thus allowing the rectum to bulge as a hernia. When the bulge into the vagina comes from the rectum it is called a rectocele or rectal prolapse. However if the bulge into the vagina is caused by small bowel pushing the vaginal tissues this is called an enterocele. It can occur at the same time as a cystocele and a rectocele. Modern repair uses mesh or donor tissue with excellent success found. This repair is technically quite challenging and few are trained in the modern repair of this problem. Surgical repair consists of using sutures to bunch up the bulging tissues together. Rectocele Repair is done in the surgery center or operating room under general, regional, or local anesthesia. The procedure takes 60 minutes to perform.
Causes and Risk Factors of Enterocele / Rectocele
A rectocoele or a enterocele usually occurs when the vaginal and rectum supports become stretched or damaged. Stretching, weakening, and tearing of the fascia (a fibrous membrane) and muscles of the female pelvic floor are often caused by trauma from the descent of the baby’s head through the pelvic diaphragm.
Additionally, the loss of estrogen due to aging, vaginal deliveries perhaps breech extractions or forceps rotations, strenuous work and inadequate episiotomy can lead to these problems. Multiple births, large pelvic tumors, marked obesity, ascites, and lifelong chronic constipation (rectocele-related only) are other elements that may produce weakening of the musculofascial supports.
Symptoms of Enterocele / Rectocele
Rectocele and enterocele maybe asymptomatic while other cases may produce the following symptoms:
- Bulging vaginal mass
- Vaginal pressure and fullness constipation or difficult bowel movements (rectocele only)
- Pelvic discomfort
- Back ache
- Urinary problems
- Pain during sexual intercourse
Diagnosis of Enterocele/Rectocele
Diagnosis is made by a pelvic and a rectovaginal exam. The bulges are felt by the doctor when the woman holds her breath and “bears down” during the pelvic examination. During the rectovaginal examination the woman is asked to stand and squat slightly while straining.
Treatment of Enterocele / Rectocele
Nonsurgical and surgical methods are available for treating symptomatic patients with rectocele. For the more sever cases, surgery may be needed to move the bladder or rectum back into place. Generally, treatment is determined by the age of the patient, the desire for future fertility, the desire for coital function, the severity of symptoms, the degree of disability, and the presence of medical complications.
Rest in bed (with the foot of the bed elevated) and wet packs applied to the vagina will reduce edema and allow replacement of the vagina, and vaginal packing can be used to maintain reduction until local conditions permit operative correction (surgery).
If immediate operative correction is not essential, a rigorous program of weight reduction for several months may be extremely beneficial for the very obese patient and may increase her chance of eventually obtaining a successful repair.
If the woman is postmenopausal, with mild to moderate symptoms, the doctor may suggest estrogen therapy. Estrogen hormone vaginal cream or oral hormone treatment may help restore a more normal, resilient vaginal and urethral lining as well as improve bladder control.
Simple exercises, called Kegel exercises, are also suggested to strengthen the muscular supports for the vagina and urethra, improve bladder control and experience effective penile stimulation during intercourse. “Kegels” involve contracting the muscle of the urethra, vagina and rectum for a set period of time and then relaxing them.
Different approaches used to treat Enterocele/Rectocele
Rectopexy and anterior resection are the two most common abdominal surgeries used to treat rectal prolapse. The patient is usually placed under general anesthesia for the duration of surgery. During rectopexy, an incision into the abdomen is made, the rectum isolated from surrounding tissues, and the sides of the rectum lifted and fixed to the sacrum (lower backbone) with stitches or with a non-absorbable mesh. Anterior resection removes the S-shaped sigmoid colon (the portion of the large intestine just before the rectum); the two cut ends are then reattached. This straightens the lower portion of the colon and makes it easier for stool to pass. Rectopexy and anterior resection may also be performed in combination and may lead to a lower rate of prolapse recurrence.
As an alternative to the traditional laparotomy (large incision into the abdomen), laparoscopic surgery may be performed. Laparoscopy is a surgical procedure in which a laparoscope (a thin, lighted tube) and various instruments are inserted into the abdomen through small incisions. Rectopexy and anterior resection have been performed laparoscopically with good results. A patient’s recovery time following laparoscopic surgery is shorter and less painful than following traditional abdominal surgery.
Perineal repair of rectal prolapse involves a surgical approach around the anus and perineum. The patient may be placed under general or regional anesthesia for the duration of surgery.
The most common perineal repair procedures are the Altemeier and Delorme procedures. During the Altemeier procedure (also called a proctosigmoidectomy), the prolapsed portion of the rectum is resected (removed) and the cut ends reattached. The weakened structures supporting the rectum may be stitched into their anatomical position. The Delorme procedure involves the resection of only the mucosa (inner lining) of the prolapsed rectum. The exposed muscular layer is then folded and stitched up and the cut edges of mucosa stitched together.
A rarely used procedure is anal encirclement. Also called the Thiersch procedure, anal encirclement involves the insertion of a thin circular band of non-absorbable material under the skin of the anus. This narrows the anal opening and prevents the protrusion of the rectum through the opening. This procedure, however, does not address the underlying condition and therefore is generally reserved for patients who are not good candidates for more invasive surgery.
Prevention of Enterocele /Rectocele
With better obstetric care, better use of episiotomies to prevent tearing of the pelvic muscles, immediate repair of all tears, and the trend toward fewer pregnancies and births per woman, fewer women should require vaginal wall repairs late in life.
Neglected, obstructed labor and traumatic delivery, which weaken uterovaginal supports, should be avoided. Perineal exercises practiced after delivery help to prevent relaxation. Factors that increase intrabdominal pressure (obesity, chronic cough, straining, ascites, large pelvic tumors) should be corrected promptly.
Frequently Asked Questions
Q: What should I expect after surgery?
A: General anesthesia is usually used for repair of a rectocele or enterocele. Most women can return to their normal activities in about 6 weeks. Avoid strenuous activity for the first 6 weeks, and increase your activity level gradually.
Normal bowel function returns within 2 to 4 weeks. It is important to avoid constipation during this time. Your doctor will give you special bowel care instructions, but it is important to include sources of fiber and an adequate fluid intake in your diet. Try to drink about 6 to 8 glasses of water a day. Most women are able to resume sexual intercourse in about 6 weeks.
Q: Why is this surgery done?
A: Surgical repair of rectoceles and enteroceles is used to manage symptoms such as pelvic discomfort, low back pain, and painful intercourse. An enterocele may not cause symptoms until it is so large that it bulges into the midpoint of the vaginal canal.
Rectocele and enterocele often occur with other pelvic organ prolapse, so tell your doctor about other symptoms you may be having. If your doctor finds a bladder prolapse (cystocele), urethral prolapse (urethrocele), or uterine prolapse during your routine pelvic exam, that problem can also be repaired during surgery.
Q: What are the risks?
Risks of rectocele and enterocele repair are uncommon but include:
- Urinary retention
- Bladder injury
- Bowel or rectal injury
- Urinary problems
- Painful intercourse
- Formation of an abnormal connection or opening between two organs (fistula)
Q: What should I consider before undergoing the Surgery?
A: Pelvic organ prolapse is strongly linked to labor and vaginal delivery, so you may want to delay surgical repair of a rectocele or enterocele until you have finished having children.
Surgical repair may relieve some, but not all, of the problems caused by a rectocele or enterocele.
- If pelvic pain, low back pain, or pain with intercourse is present before surgery, the pain may still occur after surgery.
- Symptoms of constipation may return following surgery.
- The success rate is lower if you have had previous pelvic surgery or radiation therapy to the pelvis.
You can control many of the activities that contributed to your rectocele or enterocele or made it worse. After surgery:
- If pelvic pain, low back pain, or pain with intercourse is present before surgery, the pain may still
- Stay at a healthy weight for your height.
- Avoid constipation.
- Avoid activities that put strain on the lower pelvic muscles, such as heavy lifting or long periods of standing.