What is a rectocele and its classification
Within the field of pelvic floor disorders, clinical attention is usually directed towards conditions such as urinary incontinence or the varying degrees of pelvic organ prolapse. Among these, rectocele represents a less frequent but clinically significant condition, particularly due to its diagnostic implications and its correlation with anatomical and functional differences between the sexes. A rectocele is defined as a partial or total protrusion or herniation of the rectal wall towards adjacent anatomical structures, which may include the vagina, anus, and other components of the pelvic compartment. This protrusion results from the loss of support of the rectal wall, which tends to become displaced from its physiological position. From a clinical perspective, rectocele is classified according to the extent of the protrusion:
- Grade I rectocele: protrusion less than 2 cm;
- Grade II rectocele: protrusion between 2 and 4 cm;
- Grade III rectocele: protrusion greater than 4 cm, with possible eversion of the rectum into the vaginal area.
Rectocele in females
In females, rectocele represents the most common form of rectal wall prolapse and mainly presents as an anterior rectocele, that is, a protrusion of the rectum towards the posterior vaginal wall. Its onset is closely associated with risk factors that cause a weakening of the rectovaginal septum and of the pelvic floor support structures. The main triggering factors include:
- Vaginal delivery (especially in cases of prolonged labour, large foetus size, or multiple pregnancies);
- Traumatic procedures related to childbirth;
- Menopause with resulting tissue hypotrophy due to oestrogen deficiency;
- Chronic conditions such as persistent constipation, chronic cough, obesity, or repeated heavy lifting.
From a clinical standpoint, female rectocele may be asymptomatic or present with symptoms such as evacuation difficulties, sensation of incomplete rectal emptying, the need for vaginal or perineal digitisation to facilitate defecation, and, in more advanced cases, pelvic discomfort or pain. Diagnosis is based on a gynaecological and proctological clinical examination, complemented by instrumental investigations such as defecography and magnetic resonance imaging, which are essential for quantifying the degree of protrusion and assessing its functional impact.
Rectocele in males
In males, rectocele is a much less common condition than in females, mainly due to the presence of the prostate, which provides structural support to the rectum and the pelvic floor. When it does occur, it tends to present as a posterior rectocele, that is, a protrusion of the posterior rectal wall towards the anus or the rectum itself. Risk factors in men include:
- Pelvic surgery;
- Trauma;
- Chronic constipation;
- Persistent cough;
- Other conditions that increase intra-abdominal pressure.
Although often asymptomatic, male rectocele can lead to evacuation disorders, sensation of incomplete rectal emptying, constipation resistant to conservative treatments and, in rare cases, pelvic pain or pelvic floor-related dysfunctions. Diagnosis is based on a proctological clinical examination, possibly supplemented by defecography, endorectal ultrasound, and magnetic resonance imaging, which are useful tools for assessing the extent of the protrusion and planning the most appropriate therapeutic approach.
Therapeutic management of rectocele
The treatment of rectocele varies according to the severity of symptoms and the impact on the patient’s quality of life. In mild cases, the approach is mainly conservative and aims to improve bowel function and strengthen the pelvic floor. This includes a balanced diet rich in fibre, adequate hydration, and targeted exercise programmes for the perineal muscles, such as Kegel exercises or biofeedback therapies, which promote correct muscular coordination. In some situations, support devices such as vaginal pessaries may be useful, helping to contain the prolapse and reduce symptoms.
In advanced cases, where symptoms are particularly significant or the rectocele involves marked prolapse, surgical treatment is required, usually performed by a specialist in colorectal surgery. The operation may be carried out using different approaches: abdominal, perineal, transanal, transvaginal, or through combined techniques, depending on the patient’s characteristics and the severity of the prolapse. The main goal of surgery is to restore the correct anatomical position of the rectum, thereby improving bowel function and continence, and re-establishing the functional balance of the ano-recto-vaginal area, while minimising the risk of complications. Post-operative recovery times vary according to the method used and the severity of the condition.
The contents of this page are for informational purposes only and should in no way replace the advice, diagnosis, or treatment prescribed by your physician. Responses to the same treatment may vary from patient to patient. Always consult your doctor regarding any information related to diagnoses and treatments, and meticulously follow their instructions.
