Rectoceles are a pelvic floor disorder that present as a weakness in the rectovaginal septum causing herniation or bulging into the vagina. The significance of finding a rectocele is poorly understood but may contribute to the problem of obstructed outlet defecation. Rectoceles are an acquired condition that begins as a gradual thinning which then may progresses. Patients with symptomatic rectoceles are predominantly vaginally parous women, who complain of difficult evacuation with straining and digital manipulation to facilitate having a bowel movement (1,2). Although the etiology is unknown, rectocele formation has been associated with chronic constipation with straining against a weakened rectovaginal septum. The first step in management should be optimizing bowel consistency with bulking agents, dietary fiber, and hydration (1,2,3).

Evaluation of a rectocele begins with physical examination. On digital rectal examination, the rectocele is detected as a laxity in the anterior wall of the rectum. The examination should be performed on women with specific complaints including feeling a bulge in the vagina or in those patients who describe splinting by placing a finger into the vagina to defecate. Rectocele and other pelvic floor abnormalities may be more easily demonstrated by having the patient examined in the standing position. The patient can then confirm whether the observed bulge is noticeable with straining during defecation requiring splinting for evacuation.

Fluoroscopic defecography allows measurement of the bulge as well as confirms trapping of barium consistent with the patient history. Rectoceles less than 2 cm in size are generally considered to be not clinically significant, whereas rectoceles greater than 3 cm are thought to be abnormal. Although larger rectoceles are more likely to trap barium, size is not correlated with degree of symptoms or with outcome of rectocele repair (2,4,5). Preoperative evaluation should also include consideration for colonoscopy for cancer screening in appropriate patients. Sitz Marker study may also be useful in distinguishing slow transit constipation, which may need to be treated prior to attempting surgical repair of the rectocele. Finally, attempts to standardize rectocele evaluation and staging should be performed using the validated pelvic organ prolapse quantification system.

The use of mesh in rectocele repair was described initially in 1962 by Adler. Interest in mesh support of the rectovaginal septum has been driven by both the high recurrence rates and operative failure with the traditional tissue repair of rectocele and the evolution of mesh itself. Placement of mesh to reinforce the facial repair of the rectovaginal septum
has been used more frequently in the past few years. Use of mesh to provide support for the rectovaginal septum must take into consideration maintenance of bowel continence and sexual function.