Rectocele Clinical Presentation

Updated: Apr 24, 2017
  • Author: Howard A Shaw, MD, MBA; Chief Editor: Kris Strohbehn, MD  more...
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Presentation

Physical Examination

The pelvic examination findings should define the degree of prolapse and help determine the integrity of the connective tissue and muscular support of the pelvic organs. The pelvic examination is best performed with the patient in the dorsal lithotomy position, with her head elevated 45° (which allows for maximal Valsalva). Rectocele is suspected when posterior wall bulging is noted. [11]

The extent of prolapse must be documented. One method is to measure the degree of descent with respect to the hymenal ring. The Pelvic Organ Prolapse Quantitation examination is the most widely accepted at this time and has been adopted by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons. The 9 measurements made are 6 topographical points on the vaginal walls, 2 topographical points on the perineum, and vaginal length. [16]

All portions of the vagina should be evaluated. This includes the vaginal apex, the anterior wall, and the posterior wall. The posterior wall is assessed while supporting the vaginal apex and anterior wall with a Sims speculum or with the posterior blade of a Graves speculum. This allows identification of the specific location of the defect in the rectovaginal fascia. The examiner may note that the rugae in the vaginal epithelium are lost overlying the defect in the endopelvic fascia. Generally, a pocket is observed just above the anal sphincter. Anterior displacement of the rectal wall observed upon rectovaginal examination is diagnostic of rectocele. [17]

A rectovaginal examination provides information regarding the integrity of the rectovaginal fascia, perineal body, and possible identification of an enterocele.

In a healthy woman, the perineum should be located at the level of the ischial tuberosities or within 2 cm of them. Diagnosis of perineal descent is made if the perineum is noted to be below this level either at rest or with straining. In a patient with perineal descent, widening of the genital hiatus and perineal body and flattening of the intergluteal sulcus may be seen. The degree of perineal descent can be objectively measured with a thin ruler placed in the posterior introitus at the level of the ischial tuberosities. Descent is measured as the distance the perineal body moves when the patient strains.

The bimanual examination is used to investigate the location, size, and tenderness of the cervix, uterus, bladder, and adnexa. The pelvic diaphragm should be assessed for integrity, as should the strength, duration, and anterior lift of the contraction. The firm muscular sling of the puborectalis should be palpable posteriorly because it creates a 90° angle between the anal and rectal canals. Voluntary contraction of this muscle pulls the examining finger anteriorly toward the muscle's insertion on the pubic rami.