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Prolapse 101 - focus on the rectocele.

Updated: Mar 16, 2019

Pelvic organ prolapse (POP) is a common condition. In this blog we focus on the rectocele, and answer some of the questions we have received over the past few weeks.

I’ve been told I have a rectocele: what is this?

A rectocele is a type of POP. It happens when the rectum bulges into the back wall of the vagina.

How does a rectocele happen?

A rectocele happens when the rectovaginal septum - the body part which separates the rectum (the end of the digestive tract) from the back wall of the vagina - is damaged or weakened. In most cases this is temporary.

I’ve been given a number to grade my rectocele but I don’t understand what it means.

A POP can be graded according to severity:

Grade 0: no prolapse

Grade 1: descent not reaching vaginal entrance

Grade 2: descent up to vaginal entrance

Grade 3: visible at vagainal entrance

Grade 4: passes beyond vagainal entrance.

How do I know if I have a rectocele?

Without an assessment, this can be tricky! In a 2014 study examining over 200 pre-menopausal women, all of whom had had one baby, 70% of women had a rectocele but 80% of those were asymptomatic. Of those who do experience symptoms the following have been described:

  • a bulging/foreign object sensation in the vagina

  • heaviness in the vagina

  • a feeling of sitting on something when nothing is there

  • a visible or palpable presence at the entrance or inside the vagina

  • difficult defecation/the need to splint the rectum (eg with finger or pad – there is a specifically designed device to help with this called The Femmeze) in order to defecate

  • a sense of incomplete emptying

  • faecal incontinence

  • a sensation when you pass stool/gas that it is about to come out through the vagina or bulges into the vagina on its way through.

It is also common for any symptoms of a rectocele to fluctuate – some days you may notice nothing at all, other days it may feel worse. This can be due to, for example, where you are in your menstrual cycle or your level of activity.

Do certain things put me more greatly at risk of POP/rectocele?

POP has been correlated with joint hypermobility, vertebral hernia, varicose veins, asthma and high type III collagen levels. Other known risk factors are forceps delivery or pelvic avulsion (attributed with birth trauma). It is also no coincidence that rectoceles are more prevalent in the western world - along with rising obesity and upright toileting habits, both of which can significantly contribute to their development.

I’ve been told my only option for treating my rectocele is surgery. Is this correct?

The NICE guidelines (2018) state that the full range of non-surgical options should be offered before any surgery. The non-surgical options include:

  • pelvic health physiotherapy

  • pessary

  • medications (eg laxatives, topical oestrogen)

  • lifestyle modifications

  • weight loss (only if your BMI is too high)

  • good voiding and defecation dynamics (positioning & not straining etc).

Can I reverse my rectocele or do anything to minimise its impact, or avoid getting a rectocele if I don’t already have one?

Our top tip is to get to a pelvic health physiotherapist who will be able to guide you through all the non-surgical options. Beyond that:

  • maintain a healthy body weight

  • try at practise good toileting habits by: eating plenty of fruit and veg and drinking lots of water everyday to avoud constipation; where possible, going to the loo as soon as you feel the urge to poo, as putting it off will just make it harder (literally!) to go; putting your feet up on a stool when you are pooing to mimic a squat position - this will mechanically make it easier to go; breathing into your tummy while you poo - your diaphragm will act like a plunger going up and down giving you all the pressure you need to pass your stool; avoiding breath-holding when you poo (NB: if you strain you are breath holding!); avoiding rushing on the toilet - it's normal to take up to 10mins to defecate so take a book/paper/phone in with you to read if necessary; and finally being patient and persevering - the above tips biomechanically and anatomically will make it easier for you to poo, but it can take practice to get your body into these good habits

  • ensure your pelvic floor muscles are well looked after - do a few squeezes everyday (a few short & a few long, ensuring full relaxation in between each one) to maintain their strength. You can access a blog we wrote on this very topic here.

  • if you enjoy high impact exercise or weight training, it may well be worth getting seen by a women’s health physiotherapist for a quick MOT to ensure you have the correct technique when squeezing and assess your pelvic floor muscles’ strength.

I’ve been told I can’t do any lower body work/running/weights because of my rectocele. Is this correct?

Strictly this is not correct. It used to be thought that any high impact exercise would worsen a POP. Those not up to date with current research and thinking, or those being unnecessarily over-cautious may still give such advice as a result. In theory, doing more than your body is trained for could potentially have worsen a POP. Reassuringly, though, the evidence tells us that doing the right thing at the right time with regard to high impact exercise actually helps to strengthen our pelvic floor muscles, and therefore, have a beneficial effect on a rectocele. Eliminating high impact exercise entirely will contribute to weakening and deconditioning, which is detrimental for a POP.

When trying to get back to or commence an exercise programme with a rectocele, there are no hard and fast rules about what you can do and what you should avoid: everyone is individual. We would suggest, though, that you try to follow the principle of progressive overload, monitoring symptoms as you go. For example, we wouldn’t suggest launching straight into an explosive move like squat jumps, until you are confident with bodyweight squats and, after that, loaded squats. With an activity like running, a staged walk-to-run programme would enable you to build up your running time very gradually, allowing you an opportunity to check-in with symptoms both during and after each run.

If you experience symptoms during exercise, we would recommend scaling back: try dropping reps/load/intensity by 50% until you are symptom free. If you experience symptoms after exercise, scale back as described by 10%. Keep cutting back until no symptoms are felt wither during or after workouts and then build back up gradually. If you play around with this without any success, go back to see a women’s health physio. If you are symptom free, you may wish to return to your physio for a further MOT after a few months in any event, with a view to final sign off.