Rectocele

　　Rectocele is a special type of outlet obstructive constipation. Patients have a strong urge to defecate but have difficulty expelling faeces from the anal canal and rectum. Sometimes, manual assistance is needed for defecation. Patients often have relaxation and structural abnormalities of the entire pelvic floor and its viscera. So, what are the causes of rectocele?

　　Causes of rectocele one

　　Childbirth, maldevelopment, fascial degeneration, and long-term increased abdominal pressure can all damage the pelvic floor and cause it to relax. Especially during childbirth, it can cause the interwoven fibers in the levator ani gap to tear, the perineal fascia to stretch or tear excessively, thereby damaging the strength of the rectovaginal septum, affecting its resistance to the horizontal force of defecation and gradually protruding forward. Most patients develop the condition postpartum, suggesting a relationship with vaginal delivery; the condition often occurs in middle-aged individuals, suggesting a possible connection with the degeneration of connective tissue.

　　Causes of rectocele two

　　Rectocele is a pathological condition where the anterior wall of the rectum over-protrudes into the vagina during defecation.

　　Normal defecation involves an increase in abdominal pressure, relaxation of the pelvic floor muscles, blunting of the anorectal angle, the pelvic floor taking on a funnel shape, and the anal canal becoming the lowest point. Faeces are expelled under the force of defecation pressure. Due to the influence of the sacral curve, the vertical division of the descending faecal mass becomes the defecation force, while the horizontal force acts on the anterior wall of the rectum, causing it to protrude forward. In males, due to the firmness in front, the rectum is not easily protruded forward; whereas in females, due to the relatively empty space in front, this horizontal force acts on the anterior wall of the rectum, causing it to protrude forward. The rectovaginal septum contains the perineal fascia, and there are fibers of the levator ani that intersect at the midline, both of which can greatly strengthen the rectovaginal septum, resisting the above horizontal force and preventing the anterior wall of the rectum from over-protruding during defecation, thus changing the direction of faecal mass movement.

　　Editor's Note:The main causes of rectocele are these two points. We hope that through the introduction of this article, you have a deeper understanding of rectocele. If you have any doubts about this article or want to learn more health information, welcome to visit Feihua Health Network, where we have more health content and experts waiting for you. We sincerely wish you good health, happiness in life, and a happy family.

　　Rectocele (RC) refers to the forward protrusion of the anterior rectal wall and the posterior vaginal wall into the vaginal fornix. It is caused by the weakness of the anterior rectal wall, rectovaginal septum, and posterior vaginal wall, which bulge into the vagina under the pressure of feces during defecation for a long time, causing constipation, also known as rectal anterior bulging syndrome. Rectocele is divided into low, middle, and high positions. Low rectocele is often caused by perineal tears during childbirth; middle rectocele is the most common, often caused by birth trauma; high rectocele is caused by the destruction or pathological relaxation of the upper one-third of the vagina, the cardinal ligament, and the uterosacral ligament, often accompanied by posterior vaginal hernia, vaginal prolapse, and uterine prolapse.

　　In the treatment of this disease, conservative treatment is first adopted, but it is not recommended to use strong purgatives and enemas, and emphasizes the 'three more': more consumption of coarse staple foods or fruits and vegetables rich in dietary fiber. Drink more water, with a total daily amount of 2000 to 3000 ml, and more physical activity. Through the above treatment, the symptoms of most patients are improved to varying degrees. For those who do not improve or show poor efficacy after 3 months of regular non-surgical treatment, surgical treatment can be considered.

　　Complications of this disease are common, and if not treated in time, they often include rectal mucosal prolapse, rectal intussusception, perineal descent, intestinal hernia, and other complications.

　　Rectocele (RC) refers to the forward protrusion of the anterior rectal wall and the posterior vaginal wall into the vaginal fornix. It is caused by the weakness of the anterior rectal wall, rectovaginal septum, and posterior vaginal wall, which bulge into the vagina under the pressure of feces during defecation for a long time, causing constipation, also known as rectal anterior bulging syndrome.

　　Difficult defecation is the main symptom of rectal prolapse. When straining to defecate, abdominal pressure increases, and fecal masses are pushed forward into the prolapse under the pressure, and after stopping the effort, the fecal masses are pushed back into the rectum, causing difficult defecation. Due to the accumulation of fecal masses in the rectum, patients feel a sinking sensation, incomplete defecation, and straining to defecate, which further increases abdominal pressure, causing the already relaxed rectovaginal septum to bear greater pressure, thus deepening the prolapse, forming a vicious cycle, and making defecation difficulty worse. Some patients may need to apply pressure around the anal area and vagina to assist defecation, or even insert fingers into the rectum to extract fecal masses. Some patients may experience hematochezia and anal pain.

　　1. Difficulty in defecation and a sinking sensation, some patients may need to apply pressure around the anal area and vagina to assist defecation, or even insert fingers into the rectum to extract fecal masses.

　　2. Delayed rectal emptying and incomplete rectal emptying;

　　3. Some patients may experience hematochezia and anal pain (anal spasm);

　　4. Symptoms may be accompanied by bladder and urethral prolapse.

　　Traditional Chinese medicine believes that poor living habits are an important cause of rectal prolapse. Therefore, to prevent rectal prolapse, attention should be paid to living habits and diet first.

　　1. Develop good living habits: This includes good eating habits and regular defecation habits, such as after waking up in the morning or after breakfast, using the gastrocolonic reflex to promote defecation.

　　2. Do not defecate for too long: It is generally recommended to take 3-5 minutes, and absolutely do not read newspapers or books during defecation, as lack of concentration will prolong defecation time.

　　3. Avoid local injury: Women should avoid birth injuries during childbirth and actively engage in appropriate physical exercises (mainly pelvic floor muscle exercises) after childbirth to promote recovery.

　　Rectal prolapse is more common in women with chronic constipation leading to long-term increased intra-abdominal pressure, multiparous women, those with poor defecation habits, and elderly women with perineal relaxation. What kind of examination should be done for rectal prolapse? The following is an introduction to the examination methods of rectal prolapse:

　　1. Digital examination

　　Digital rectal examination can palpate a circular or oval weak area protruding into the vagina on the anterior wall of the rectum at the upper end of the anal canal. The protrusion is more obvious when exerting force to defecate.

　　2. Defecation imaging

　　It can be seen that the anterior wall of the rectum protrudes forward, and it is difficult for barium to pass through the anal canal. The shape of the protrusion is mostly bag-like, goose head-shaped, or hill-shaped, with smooth edges. If the protrusion depth exceeds 2cm, there is often barium retention in the bag; if combined with puborectalis muscle abnormalities, it often presents as a goose sign.

　　3. Interval defecation test

　　Insert a catheter connected to a balloon into the anal ampulla and inject 100ml of gas. Ask the patient to exert a defecation action to understand the rectal excretion function. Normal individuals can expel the balloon within 5 minutes, and those taking longer than 5 minutes are considered delayed excretion.

　　Based on the above typical medical history, symptoms, and signs, the diagnosis of rectal prolapse is not difficult. In normal people, when exerting force to defecate, an anterior bulge can sometimes be seen above the anal-rectal junction, with a longer length but generally not more than 5cm in depth. The Chinese medical community proposes rectal prolapse defecation contrast examination, which can be divided into three degrees: mild, with a protrusion depth of 0.6-1.5cm; moderate, 1.6-3cm; severe ≥3.1cm.

　　In addition, Nichols et al. suggest that rectal prolapse be divided into three types: low, middle, and high. Low rectal prolapse is often caused by perineal tears during childbirth; middle rectal prolapse is the most common, often caused by birth injuries; high rectal prolapse is due to the destruction or pathological relaxation of the upper third of the vagina, the cardinal ligament, and the uterosacral ligament, often accompanied by vaginal posterior hernia, vaginal inversion, and uterine prolapse.

　　When rectal prolapse occurs, it should be given sufficient attention and treated actively.

　　Patients with rectal prolapse should eat in moderation, with regular meals at fixed times and in appropriate amounts, and avoid overeating or hunger. Remember to strictly avoid smoking, alcohol, strong tea, strong coffee, and greasy foods, as well as animal internal organs and spicy foods. Also, avoid eating hard-to-digest foods.

　　Eating more fiber-rich foods, coarse fiber foods can increase the weight and volume of feces, increase the physiological stimulation of gastrointestinal smooth muscle, promote peristalsis, and induce normal defecation reflex. Coarse fiber foods mainly include vegetables, fruits, and coarse staple foods, especially spinach, radish, cabbage, and garlic contain high amounts. Drinking more water, with a daily amount of 3000 ml, can increase the water content of feces, soften the feces, and facilitate defecation.

　　Rectocele (RC) refers to the protrusion of the anterior rectal wall and the posterior vaginal wall into the vaginal fornix. It is caused by the weakness of the anterior rectal wall, rectovaginal septum, and posterior vaginal wall, which are pushed into the vagina under the pressure of feces during defecation for a long time, thus causing constipation, also known as rectal prolapse. Rectocele is divided into low, middle, and high types. Low rectocele is often caused by perineal laceration during childbirth; middle rectocele is the most common, often caused by birth trauma; high rectocele is caused by the destruction or pathological relaxation of the upper third of the vagina, the cardinal ligament, and the uterosacral ligament, often accompanied by posterior vaginal hernia, vaginal inversion, and uterine prolapse.

　　In the treatment of this disease, conservative treatment is first adopted, but it is not recommended to use drastic purgatives and enemas, and emphasizes 'three plenties': eating more coarse staple foods or fruits and vegetables rich in dietary fiber; drinking more water, with a total daily amount of 2000 to 3000 ml; and engaging in more physical activity. Through the above treatment, the symptoms of most patients are improved to varying degrees. For those patients who do not improve or show little efficacy after 3 months of regular non-surgical treatment, surgical treatment can be considered. Some scholars believe that when patients with rectal prolapse experience constipation, rectal pain, and need to push the prolapsed rectum, fecal sac, bulge, and need to repair vesical prolapse, it is generally considered necessary to repair the rectal prolapse surgically.

　　The main surgical methods include the following types:

　　1. Transrectal repair

　　The patient assumes a prone position, with the lower limbs hanging at about 45 degrees, and the lower abdomen and pubic symphysis slightly elevated. Lumbar or sacral anesthesia can be used. The buttocks are adhered with wide adhesive tape and pulled apart to expose the anal region. The buttocks, anus, and vagina are routinely disinfected, and the anus is gently dilated with fingers to accommodate 4 to 6 fingers. A straight or S-shaped retractor is inserted into the anus, and the assistant assists in exposing the anterior rectal wall. The specific surgical method is divided into two types.

　　1. Sehapayah method

　　At the lower end of the rectum, 0.5 cm above the dentate line, a longitudinal incision of about 7 cm is made, reaching the submucosal layer, exposing the muscular layer. According to the width of the anterior bulge, the mucosal flaps on both sides are freed, which is 1 to 2 cm wide. The left index finger is inserted into the vagina, pushing the posterior vaginal wall towards the rectum to facilitate hemostasis and prevent injury to the vagina. Then, it is sutured with 2/0 chromic catgut suture, and the distance from the needle entry point to the midpoint can be determined according to the degree of anterior bulge. Generally, the needle entry point is chosen at the edge of the normal tissue of the anterior bulge, from the outer to the inner edge of the right levator ani muscle, and then from the left levator ani muscle edge to the end. With the right index finger, a vertical and firm muscle column can be felt. During the suture, the needle tip should not penetrate the posterior vaginal wall mucosa to prevent the occurrence of a rectovaginal fistula. Finally, the two mucosal flaps are corrected, and the mucosal incision is sutured with chromic catgut suture in an interrupted manner. A gauze swab soaked in vaseline is placed in the rectum and pulled out through the anus.

　　2. Khubchandani method

　　A transverse incision is made at the dentate line, about 1.5-2 cm long. At both ends of the incision, longitudinal incisions are made upwards, each about 7 cm long, forming a 'U' shape. The mucosa and muscular layer flap with a wide base (the flap must contain muscular layer) is freed. The separation of the mucosa and muscular layer flap upwards must exceed the fragile part of the rectovaginal septum. First, 3-4 interrupted transverse sutures are made, transversely overlapping the relaxed rectovaginal septum; then, 2-3 interrupted vertical sutures are made, shortening the anterior wall of the rectum, reducing the tension of the sutured mucosa and muscular layer flap, and promoting healing. Excessive mucosa is excised, and the edge of the mucosa and muscular layer flap is sutured with the dentate line in an interrupted or continuous manner. Finally, the two longitudinal incisions are sutured in an interrupted or continuous manner.

　　2. Khubchandani method

　　According to the size of the bulge, the rectal mucosa layer is clamped longitudinally with a curved hemostat, and then the mucosa and muscular layer are sutured continuously from bottom to top with 2/0 chromic catgut suture until the symphysis pubis. The suture should be wider at the bottom and narrower at the top to avoid forming a mucosal flap at the top, which may affect defecation. This method is only suitable for smaller (1-2 cm) rectal prolapse.

　　Advantages of repairing rectal prolapse through rectal approach:

　　① The method is simple; it can treat other accompanying anal-rectal diseases at the same time;

　　② The operation can be completed under local anesthesia;

　　③ It can approach the superior anal sphincter area more directly, fold the puborectalis muscle forward, and reconstruct the anal-rectal angle.

　　The disadvantage of this method is that it is different from correcting bladder prolapse or posterior vaginal hernia. For those with anal stenosis, it is not recommended to repair through the anal canal. For those with the above conditions, vaginal repair is preferred.

　　3. Rectal endoscopic suture method for repairing rectal prolapse

　　The key points of the operation are to perform double continuous locked suture at the anterior rectal bulge, suture the mucosa, submucosal tissue, and muscular layer together at this place, and eliminate the pouch on the anterior wall of the rectum. The continuous locked suture should be tightened to achieve a strangulation effect, thereby causing mucosal necrosis and shedding. The wound surface heals quickly with the submucosal and muscular tissue at this place. This type of surgery is suitable for middle-positioned anterior rectal bulge, characterized by rapidity, simplicity, ease of operation, and less bleeding. The disadvantages are that sometimes the bulge is not completely sealed, and recurrence may occur after surgery.

　　Note: Cutting part of the puborectalis muscle often leads to better efficacy.

　　Method: At 6 o'clock, 1.5 cm from the anal margin, the anal margin skin and subcutaneous tissue are incised radially for about 1.0 cm. The index finger of the left hand is inserted into the rectum, the tip of the coccyx is felt, which is the water mark of the superior margin of the puborectalis muscle. The puborectalis muscle is elevated towards the incision direction with the right hand, and the curved hemostat is carefully separated along the intestinal wall and the gap between the puborectalis muscle. The part of the puborectalis muscle is cut with scissors (about 1/3 to 1/2 of the puborectalis muscle). After the incision, a 'v'-shaped defect can be felt on the posterior wall of the rectum. After the anal canal is dilated again, the wound surface is compressed for 2 minutes, the rectum is disinfected, and a lanolin sand strip is left in the anal canal for drainage. Then, the wound is packed with pressure bandage, and the incision does not need to be sutured. Patients with other anal diseases should be treated simultaneously.

　　4. Vaginal repair method

　　Take the lithotomy position, perform routine disinfection of the perineal area with 0.2% iodophor, and then disinfect the vagina with 0.2% iodophor; sequentially disinfect the anal canal and lower rectum with hydrogen peroxide and 0.2% iodophor. Use two tissue forceps to clasp the lower ends of the labia minora on both sides, pull them outward to form a straight line, and make a transverse incision at the level of the vaginal orifice width at the posterior perineal joint skin. The incision can reach the lower ends of the labia minora on both sides. Then, at the midpoint of the incision, use the tip of a curved tissue scissors to separate the vaginal-rectal space upwards and to the left and right, extending beyond the anterior protuberant area. Clamp the midpoint of the upper edge of the separation with a tissue forceps, and pull with three forceps to make it slightly shorter than the length of the transverse incision (the amount of vaginal mucosa on both sides reserved should be as much as possible, which can be trimmed again during suture), and cut the vaginal mucosa on both sides near the isosceles trapezoid. Flip the separated vaginal mucosa upwards and again separate it upwards and to the left and right, reaching the upper third of the vagina and both rectal columns. The separation should reach the anterior edge of the levator ani muscles on both sides. At the same time, the assistant inserts one index finger into the rectum to guide, pushing the anterior wall of the rectum into the vagina, separating the vaginal mucosa from the rectal wall tissue bluntly, and allowing the prolapsed anterior wall of the rectum to be completely free. In the center of the protuberance, push up to make the protruding rectum spherical (if the protrusion area is large and irregular, it can be divided into 1 to 3 spherical areas according to size, with the center of the sphere at the weakest part of the protrusion), and use 2.0 absorbable suture to make 2 to 3 concentric purse-string sutures around the prolapsed rectum, tying knots from the inside out, and then suturing the lateral and rectal column tissue on both sides in an interrupted manner from top to bottom. Simultaneously, suture the upper and middle segment of the vaginal wall in an interrupted manner (check the vaginal width after suturing to ensure it can accommodate two fingers or more), pushing the lower rectum forward and upwards as you sew, and sewing it to the top of the flipped vaginal mucosa. Then, on the anterior edge of the levator ani muscle, from the corresponding site of the protuberance, suture 4 to 5 needles obliquely upwards and forwards to the submucosal layer of the rectal wall, with a needle distance of about 0.5 cm and an upward slope of about 35° to 55°. Then, suture the anterior edges of the levator ani muscles on both sides as much as possible in an interrupted manner across from side to side, with a needle distance that should be staggered from the previous ones. Fold and suture the lower muscle tissue of the posterior vaginal wall horizontally. Pull down the flipped vaginal mucosa, trim it according to the size after the protuberance is sutured, and lay it flat on the posterior vaginal wall, slightly larger than the protuberant surface and after destroying the superficial glandular tissue, as a complement, suture it in an interrupted manner on the lower muscle tissue of the posterior vaginal wall to reinforce the rectovaginal septum. Finally, ligate the corresponding bleeding points and suture the vaginal mucosa, subcutaneous tissue of the perineum, and local skin with 2.0 absorbable suture in sequence.

　　Postoperative Management: Apply Vaseline gauze to cover the wound, disinfect the wound and vagina with iodophor, and place one metronidazole suppository in the vagina once a day; indwelling catheter for 3 to 5 days; routine antibacterial and antiphlogistic treatment, and symptomatic treatment.

　　Fifth, Perineal Rectal Protrusion Repair Surgery

　　Shi Enhui et al. treated rectal intussusception by using perineal rectovaginal septum patch repair surgery. An arched incision about 3 to 4 cm long is made at the anterior edge of the subcutaneous part of the anal external sphincter at the perineum, and after cutting the skin, the superficial perineal fascia and the midline crural muscle cross-fibers entering the rectovaginal septum are bluntly separated in sequence, and then bluntly separated in depth and on both sides. A patch of the appropriate size is placed (usually 3 to 4 cm in size), and the two sides of the patch are fixed to the edge of the levator ani muscle.

　　Note: Many literature journals report that a patch is used during the repair process.

　　Attention must be paid: isolated rectal intussusception is rare, and it is often accompanied by rectal mucosal prolapse, rectal intussusception, perineal descent, intestinal hernia, and other conditions. Treatment should address the associated diseases at the same time; otherwise, it will affect the efficacy. In addition, careful preoperative preparation and postoperative care are required. Oral intestinal antibiotics should be taken 3 days before surgery, soft food should be consumed 2 days before surgery, and fasting is prohibited on the day of surgery, along with cleaning enema and vaginal flushing. After surgery, continue to use antibiotics or metronidazole to prevent infection, consume liquid food, and keep bowel movements infrequent for 5 to 7 days.