What is the recommended management approach for a patient with a rectocele (rectal prolapse) diagnosed on computed tomography (CT) scan?

Management of Rectocele Diagnosed on CT Scan

For a patient with a rectocele diagnosed incidentally on CT scan, initial management should focus on conservative measures, with surgical intervention reserved for cases with significant symptoms that affect quality of life and fail to respond to non-operative management.

Initial Assessment

When a rectocele is identified on CT scan, the following steps should be taken:

1. Symptom evaluation:

   • Assess for evacuatory symptoms: incomplete evacuation, straining, digital assistance needed
   • Check for pelvic heaviness, dyspareunia, fecal incontinence
   • Determine impact on quality of life

2. Clinical examination:

   • Digital rectal examination to assess rectocele size and reducibility
   • Pelvic examination to identify associated pelvic floor disorders

3. Additional testing (for symptomatic patients):

   • Dynamic imaging (defecography or MRI defecography) to assess functional significance 1
   • Anorectal manometry if indicated

Management Algorithm

1. Asymptomatic Rectocele

• No treatment required
• Patient education and reassurance

2. Symptomatic Rectocele - First-Line Treatment

Conservative management should be attempted first:

• Behavioral therapy and biofeedback:

  • Shown to provide partial symptom relief in the majority of patients 2
  • Can lead to major symptom relief in some cases
  • Addresses pelvic floor incoordination

• Dietary modifications:

  • Increased fiber intake
  • Adequate hydration

• Stool softeners or bulking agents as needed

• Pelvic floor exercises

3. Persistent Symptomatic Rectocele

For patients with persistent symptoms affecting quality of life despite conservative management:

• Surgical intervention based on rectocele location 1:

  a) Low or mid-rectum rectocele or isolated rectocele:

  • Approach from below (transanal, transperineal, or transvaginal)

  b) High rectocele and/or associated with other pelvic floor disorders:

  • Transabdominal rectopexy

Special Considerations

• Complicated rectocele (irreducible or strangulated):

  • In hemodynamically stable patients, perform contrast-enhanced abdomino-pelvic CT scan to detect complications and assess for colorectal cancer 3
  • For incarcerated rectocele without ischemia/perforation, attempt gentle manual reduction under sedation 3
  • For patients with signs of shock, gangrene, or perforation, immediate surgical treatment is required 3

• Surgical approach selection:

  • For uncomplicated cases, the choice between abdominal and perineal procedures should be based on patient characteristics and surgeon expertise 3
  • For patients with peritonitis, an abdominal approach is suggested 3
  • For hemodynamically unstable patients, an abdominal open approach is recommended 3

Common Pitfalls to Avoid

1. Overtreatment of asymptomatic rectocele found incidentally on imaging
2. Rushing to surgery without adequate trial of conservative management
3. Attributing non-specific symptoms to rectocele without proper functional assessment
4. Failing to identify associated pelvic floor disorders that may require simultaneous treatment
5. Treating rectocele in isolation when it may be part of a more complex pelvic floor dysfunction 4

Key Point

The question of whether rectocele is a cause or consequence of obstructive defecation syndrome remains controversial 4. Therefore, indications for surgical correction should be considered cautiously, and surgery should only be pursued after failure of conservative measures and when symptoms significantly impact quality of life 1, 5.