Saturday, 1 February 2014

Pelvic floor imaging part 3: what is a rectocoele?

In the first two posts of this series, I covered the symptoms that might indicate you need a pelvic floor test called a proctogram, and what this test involves. In this post, I will describe what is seen on a proctogram when someone has a rectocoele (pronounced rek-tow-seal and spelt rectocele for North American readers). 

A rectocoele is bulge of the front wall of the back passage (the rectum) into the back wall of the vagina. The typical symptoms that this causes are:
  • feeling of a lump or fullness in the back of the vagina
  • needing to press from inside the vagina to empty bowels
  • feeling of stool being trapped and needing to go to the toilet repeatedly

The image above is typical for how a rectocoele looks at the end of a proctogram test. There is barium within the rectum but also in a pouch (seen to the left of the rectum).

The reasons for doing a proctogram when a rectocoele is suspected is:
  • to confirm there is a rectocoele
  • see how small or big it is
  • look for other pelvic floor problems that may influence the choice of treatment, such as rectal prolapse, how far down the pelvic floor drops when straining and an enterocoele (loops of small bowel dropping down low into the pelvis and pressing on the rectum)
This movie clip is from the same proctogram study as the image above and shows the rectocoele developing during straining and evacuation:

Here is another movie clip showing a rectocoele, and this time also showing an enterocoele. Look for the bowel loops containing black (barium) dropping down into the pelvis on top of the rectum. These bowel loops can press down on the rectum and contribute to the symptoms of fullness:

Knowing that other problems such as an enterocoele exist is important as some surgical procedures would fail if only the rectocoele is repaired while other pelvic floor problems persist. Clinical examination may reveal the rectocoele but problems such as enterocoeles and rectal prolapses are often only revealed during a proctogram test.

Please note that there is some confusing terminology about this on the Internet and even amongst hospital specialists. Some sites describe a rectocoele as a rectal prolapse; technically speaking this is not a rectal prolapse. A rectocoele is a weakening of either the front wall of the rectum or the back wall of the vagina, and the effect is a forward bulge of the rectum into the vagina. I will describe true rectal prolapse in more detail in the next post of the series.

Dr Vikas Shah
Consultant Radiologist

(If you think you need this test, it is advisable to see your doctor first and then I am happy to be involved in any consultations. Please see the Contact Me page for more details).

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