How is rectocele diagnosed?

Diagnosis of Rectocele

Rectocele diagnosis requires a combination of clinical examination and imaging studies, with MR defecography or fluoroscopic cystocolpoproctography being the most definitive diagnostic tools. 1

Clinical Evaluation

Physical Examination

• Digital rectal examination is the initial diagnostic approach for rectocele assessment 1
• Key findings on examination:
  • Bulging of the anterior rectal wall through the posterior vaginal wall
  • Palpable protrusion during straining
  • Assessment for associated pelvic floor disorders
• Examination should be performed in multiple positions:
  • Standing
  • Squatting
  • During Valsalva maneuver

Symptoms Assessment

• Common presenting symptoms include:
  • Dyschezia (difficult defecation)
  • Need for digital disimpaction or vaginal splinting to complete bowel movements
  • Sensation of incomplete evacuation
  • Pelvic heaviness or pressure
  • Constipation
  • Occasionally anal incontinence 2, 3

Diagnostic Imaging

First-Line Imaging

• MR Defecography with rectal contrast is considered one of the initial imaging tests of choice 1

  • Provides high soft-tissue contrast resolution
  • Allows direct visualization of pelvic organs, pelvic floor muscles and fascia
  • Can detect clinically occult abnormalities
  • Particularly valuable when performed with rectal contrast and during defecation
  • Can identify associated conditions (enteroceles, sigmoidoceles, rectal intussusception)

• Fluoroscopic Cystocolpoproctography (CCP) is an equally valuable initial imaging test 1

  • Demonstrates good agreement with surgical findings
  • Sensitivity for rectocele detection is 94% compared to physical examination
  • Can detect contrast material retention within rectoceles (suggesting clinical relevance)
  • Performed during rest, Kegel, strain, and defecation phases
  • Allows functional evaluation in physiologic upright seated position

Comparative Diagnostic Value

• Physical examination alone detects only 77% of rectoceles seen on CCP 1
• CCP may detect rectoceles that are clinically occult
• MR defecography can reveal additional defects in 34% of cases beyond clinical diagnoses 1

Imaging Considerations

• Upright MR defecography may be preferred over supine positioning, but most centers lack open magnets for upright imaging 1
• Multiple strain/defecation maneuvers should be performed during imaging to maximize detection 1
• CT is not recommended for functional assessment of defecatory dysfunction 1

Diagnostic Algorithm

1. Initial Assessment: Digital rectal examination and detailed symptom history
2. First-line Imaging: Either MR defecography with rectal contrast or fluoroscopic CCP
3. Additional Testing: Consider anorectal manometry and balloon expulsion test for functional assessment 1

Common Pitfalls to Avoid

• Failing to assess all pelvic compartments, as rectocele often coexists with other pelvic floor disorders 4
• Overlooking associated conditions like enteroceles, sigmoidoceles, or rectal intussusception 1
• Not evaluating for functional dyssynergia, which may coexist with rectocele 1
• Relying solely on physical examination, which may miss up to 23% of rectoceles 1
• Not performing imaging during defecation phase, which is critical for accurate diagnosis 1

Special Considerations

• Rectoceles may be classified based on location (low, mid, or high rectum) which affects treatment approach 2
• Prevalence increases with age, affecting approximately 30-50% of women over age 50 2
• Assessment should include evaluation of impact on quality of life, as this determines need for intervention 2