RECTOCOELE (REC-tow-seel) REPAIR
WHAT IS A RECTOCOELE?
A rectocoele is a prolapse or ‘falling down’ of the bowel, which is slipping into the vagina. It is actually a problem with a weakness of the back wall of the vagina which prolapses, carrying with it the rectum, (part of the bowel), which lies directly behind the vagina. Other types of prolapse may also be present. The uterus or bladder or small bowel can also prolapse.
WHAT SYMPTOMS MIGHT A RECTOCOELE CAUSE?
Only a small percent of women who have rectocoeles actually have any symptoms which may include;
- a lump in the vagina
- constipation, faecal incontinence or diarrheoa
- difficulty with evacuation of the bowel, requiring straining or pressing against the back wall of the vagina to empty the rectum
- pelvic pain, discomfort or a dragging sensation
- back pain
- a feeling of incomplete emptying after using the bowels
- pain with intercourse
- leakage of gas or stool with intercourse
A rectocoele is also not the only cause for these symptoms
HOW IS IT DIAGNOSED?
By vaginal and rectal examination either lying down or standing whilst you are straining or bearing down.
OTHER TEST MAY BE RECOMMENDED
Occasionally a special X-ray is required to assess the size of the rectocoele and if it empties with evacuation.
WHAT CAUSES A RECTOCOELE?
Tearing of supports to the vagina and pelvic floor may occur during childbirth, or with chronic straining form coughing, constipation or heavy lifting. Tissues may be weakened after the menopause and by aging or obesity. Damage to the nerves to the supporting pelvic floor muscles may also occur with childbirth, other injuries or pelvic surgery.
WHEN SHOULD A RECTOCOELE BE TREATED?
Generally if it causes symptoms treatment options will be discussed. If it is not causing any symptoms is may just be checked on periodically as we can’t predict whether or not it will get any worse with time. Rectocoeles that are not causing symptoms generally do not need to be treated. Sometimes if other vaginal surgery is being performed it is recommended to correct a rectocoele at the same time if it is large.
WHAT ARE THE TREATMENT OPTIONS?
Avoiding heavy lifting or straining can be recommended for all patients.
Pelvic Floor Exercises
These strengthen the muscles surrounding the openings of the urethra, vagina, and rectum. They can help reduce stress incontinence, urgency to pass urine and protect against prolapse.
Constipation should be treated to avoid straining, by eating a high fibre diet and drinking plenty of fluids, 6-8 glasses of water a day.
Oestrogen as a cream or pessary inserted into the vagina, can improve symptoms and strengthen the tissues around the vagina.
A pessary is a device that may be inserted into the vagina to support the pelvic organs, holding them in place. Pessaries must be removed, cleaned, and reinserted on a regular basis, usually about every 3-6 months. If it is not cleaned, they can cause a bad-smelling discharge or infection and even ulceratopm in the vagina. If used correctly, a pessary can last for years. The doctor will need to fit you with the right size so it is comfortable. A pessary can be a good option in women who do not want surgery or are not suitable for surgery.
If you cannot completely empty the bowel you can get up and return later to try again. Holding pressure with a finger in the vagina to support the rectocoele can encourage the stool to go in the correct direction, (called splinting). This may be accomplished by pressing against the lower back wall of the vagina or along the posterior rim of the vagina. Avoid placing a finger inside the anus to pull the stool out as this may cause harm.
This can be done through the vagina. It may also be combined with other prolapse repair or stress incontinence surgery. Surgical correction is usually put off until a woman has completed her family. Surgical repair can help improve symptoms of splinting, a feeling of a vaginal mass or incomplete evacuation.
Will it work?
Early results are reasonably good with about 70-80% success but your rectal prolapse may recur. The risk of this can be quite high, up to 50% recurring within 5 years.
What are the risks with surgery?
If you decide to have surgery, you should be aware of the risks:
- The operation may fail to correct your symptoms, requiring more surgery.
- A new prolapse may occur at another site; eg: bladder, uterus, or vault.
- Chronic pain, discomfort or pain during sex may persist if they were present before the surgery or may occur as a new symptom. Pain with intercourse is usually due to tightening of the vagina and can occur in up to 30% of women.
- Your vagina may be smaller, tighter or shorter after surgery. It is uncommon to be so small that you will not be able to have sex.
- If you have had prior surgery or radiation, there is a much lower success rate.
- The rectum can be injured.
- Also if the anal sphincter is weak, faecal incontinence can occur after surgery. This is generally because previously the rectocoele had been causing obstruction and thus preventing leakage from a weak sphincter. Once the rectocoele and obstruction is fixed the weak sphincter becomes apparent.
- Problems with bladder function after surgery such as urinary incontinence or urinary retentions requiring a catheter are rare.
What are the other risks and complications?
It is often not possible to warn patients of every possible risk or potential complication with surgery especially if very rare. Yet it is important that you are aware of what risks are involved, especially the more common ones. This information is not meant to alarm you but allow you to make an informed consent to have surgery. It is very rare but unfortunately some patients can suffer complications and end up worse off as a result of their surgery.
There are general medical risks of abdominal, cardiovascular (heart), and pulmonary (lung) illnesses; 2-5%. These include Deep Vein Thrombosis (blood clots in deep leg veins), Pulmonary Embolus (these clots dislodging and going to the lungs), pneumonia, Myocardial Infarction (heart attack) and Cerebro-Vascular Accident (stroke).
There is a small risk of death; 5 in 10,000.
There is a small risk of bleeding requiring a blood transfusion; 3-5%.
Bowel, nerve or vascular injuries are rare.
There is a small risk of urine infection, wound infection, wound breakdown, haematoma (collection of blood) or seroma (collection of fluid) post-operatively; 5-10%. Other rare complications include a significant pelvic haematoma (collection of blood), infection or abscess, a rectal fistula (leak). A fistula or communication between the vagina and the rectum and can causes continuous leakage of faeces from the vagina requiring further surgery to repair, including a colostomy.
If a synthetic mesh is used in the repair this can erode into the bowel or vagina.
The overall risk of complication after the operation requiring another operation is about 2-5%
HOW LONG DOES THE OPERATION TAKE?
About an hour but this may vary if combined with other procedures.
WHAT KIND OF ANAESTHETIC IS REQUIRED?
Usually a general or spinal anaesthetic. Your anaesthetist will discuss the options with you.
You will need to fast beforehand.
WHAT DOES THE OPERATION INVOLVE?
Through a cut in the back wall of the vagina sutures are placed to put the rectum back into a more normal position. Sutures are also usually placed to reinforce the posterior rim of the opening to the vagina, (called the perineum).
WHAT IS THE NORMAL POST-OPERATIVE COURSE?
The usual hospital stay is 2 to 3 days. A pack placed in the vagina during the operation is usually removed the next day and a catheter in the bladder removed after 1-2 days. It is not unusual to not use your bowels for the first day or two. After this time, laxatives can be given to assist bowel emptying comfortably, prior to your hospital discharge.
It is usual following surgery to have some spotting, bleeding or discharge from the vagina. This usually stops by about 3 to 4 weeks. When this has stopped and the vaginal wound has healed you can have sexual intercourse, as comfortable (usually by 6 wks).
It is usual to have some pain post-operatively but this mainly resolves by 4 weeks and is usually controlled with paracetemol. You can take up to 2 every 6 hrs (max. 8/day). You can usually return to your normal daily activities in about 4 to 6 weeks. You should avoid strenuous activity during this time and increase your activity level gradually. Avoid moderate lifting or straining for 6 and heavy lifting or straining for 12 weeks.
POST-OPERATIVE FOLLOW UP
You will be given a follow up appointment. If you experience any of the following problems after discharge you should seek medical attention;
- Severe pain not controlled with pain killers
- Wound problems – infection or breakdown
- Or any other significant trouble.
If at any stage your prolapse returns you should arrange a review visit.
You can control many of the activities that caused your rectocoele or made it worse. After surgery it is important to avoid smoking, maintain a healthy weight for your height, avoid constipation, and avoid activities that put strain on the lower pelvic muscles (such as heavy lifting or long periods of standing). You should continue with your pelvic floor exercises for life.
Version: V4, July 2017