DYSCHEZIA AND RECTOCELE - A MARRIAGE OF CONVENIENCE - PHYSIOLOGICAL EVALUATION OF THE RECTOCELE IN A GROUP OF 52 WOMEN COMPLAINING OF DIFFICULTY IN EVACUATION

Herniation of the anterior rectal wall into the lumen of the vagina (s o called rectocele) may be encountered in patients who complain of con stipation and emptying difficulties but it is difficult to ascertain w hether this anatomic abnormality is an etiologic factor or a consequen ce of the dyschezia. PURPOSE: The aim of our study was to assess sympt omatic, anatomic, and physiologic features encountered in women with a clearly defined rectocele in order to determine the predisposing fact ors, symptoms, functional associations, and effects on quantified rect al emptying. METHODS: Clinical, physiologic (manometry), and anatomic (evacuation proctography) assessments were carried out in 26 consecuti ve women (mean age, 47.6 +/- 12 years) with dyschezia and a large rect ocele as evidenced by radiography and compared with a group of 26 cons ecutive women complaining of dyschezia without a significant rectocele (mean age, 42.6 +/- 14 years). Both groups were similar with respect to mean age, parity, laxative abuse, manual anal evacuation, fecal inc ontinence, urgency, and weekly stool frequency. RESULTS: Patients havi ng a rectocele differed significantly from those without a rectocele i n having frequent endovaginal digitation during defecation (7 vs. 1, P < 0.05), more frequent symptoms of urinary incontinence (14 vs. 3, P < 0.001), and a surgical history of hysterectomy (9 vs. 2, P < 0. 0 5) . The rectocele group differed in having a delayed rectal emptying (55 .5 +/- 38 vs. 30.3 +/- 23 seconds, P < 0.005), a more frequent incompl ete rectal emptying (23 vs. 11, P < 0.0005), and was more often associ ated with a manometric anismus (16 vs. 6, P < 0.01). During the strain ing effort, there was a correlation between the depth of the rectocele and the duration of rectal emptying (rs = 0.3, P < 0.05). In the grou p without manometric anismus, women with a rectocele (n = 10) had a mo re incomplete rectal emptying than those without rectocele (8/10 vs. 8 /19, P = 0.05). CONCLUSION: Some of our results indicate that the rect ocele itself could be a contributory factor in difficult evacuation. T hese results also exhibit the importance of other disorders, such as a nismus, in the occurrence of dyschezia. Physiologic examination theref ore should be made before considering surgical repair in any patient w ith rectocele and dyschezia.