What is the initial management for a patient with rectocele?

From the Guidelines

The initial management for a patient with rectocele is typically conservative and non-surgical, focusing on dietary modifications, pelvic floor muscle training, and symptomatic relief measures. The goal of this approach is to improve stool consistency, reduce straining during defecation, and alleviate symptoms associated with the rectocele. According to the most recent and highest quality study available, which is from 2022 1, the initial evaluation of patients with rectocele symptoms should be clinical, including a digital rectal examination, anal manometry, and balloon expulsion test.

Some key measures to consider in the initial management of rectocele include:

• Dietary modifications to improve stool consistency, including increased fiber intake (25-30g daily) and adequate hydration
• Stool softeners such as docusate sodium (100mg twice daily) to prevent constipation
• Pelvic floor muscle training (Kegel exercises), performing 3 sets of 10 contractions daily, holding each contraction for 10 seconds
• Manual techniques such as applying pressure on the posterior vaginal wall during defecation for symptomatic relief
• Fitting a pessary device for those with significant prolapse symptoms
• Weight loss for overweight patients, as excess weight increases intra-abdominal pressure

These conservative measures are recommended as first-line treatment because they are non-invasive, have minimal side effects, and can effectively manage symptoms in many patients, with approximately 80% of patients with mild to moderate rectoceles experiencing symptom improvement with these approaches 1. Surgical intervention, such as stapled transanal rectal resection (STARR) or ventral rectopexy, is typically reserved for cases that fail to respond to conservative management after 3-6 months of consistent effort, due to the potential risks and complications associated with these procedures, as highlighted in the study from 2017 1.

From the Research

Initial Management for Rectocele

The initial management for a patient with rectocele involves a range of approaches, including non-surgical and surgical options.

• Non-surgical management: Biofeedback therapy has been shown to be effective in managing symptoms of rectocele, particularly for patients with impaired rectal evacuation 2, 3. This approach leads to major symptom relief in a minority and partial symptom relief in a majority of patients.
• Surgical management: Surgical repair of rectocele can be considered for patients with symptomatic rectocele who have not responded to non-surgical management. The indications for surgical repair include defecation requiring manual assistance, anterior defect >2 cm, incomplete evacuation, and the absence of perineal descent on magnetic resonance imaging defecography (MRID) 4.
• Surgical techniques: Various surgical techniques have been described, including transvaginal mesh repair (TVMR) and stapled transanal rectal resection (STARR) 5, as well as posterior vaginal mesh suspension 6. These techniques have been shown to be effective in improving symptoms and quality of life for patients with rectocele.

Key Considerations

When considering the initial management for a patient with rectocele, the following factors should be taken into account:

• Symptom severity: The severity of symptoms, such as impaired rectal evacuation and defecation requiring manual assistance, should be assessed.
• Anatomic abnormalities: The presence and severity of anatomic abnormalities, such as rectocele size and perineal descent, should be evaluated using imaging studies such as MRID.
• Patient compliance: Patient compliance with non-surgical management, such as biofeedback therapy, should be considered.
• Surgical risks and benefits: The potential risks and benefits of surgical repair should be carefully weighed, including the risk of recurrence and complications.