Rectocele
Introduction
Introduction to rectal bulging Rectoceele is a special type of outlet obstructive constipation. Because the anterior rectal wall, rectal vaginal septum and posterior vaginal wall are weak, it protrudes into the vaginal forehead, changing the direction of intra-abdominal pressure during defecation, leading to functional obstruction of rectal anal canal during defecation, and thus causing difficulty in defecation. And constipation and other symptoms. basic knowledge The proportion of illness: 0.005% - 0.009% Susceptible people: no specific population Mode of infection: non-infectious Complications: urinary retention, rectal vaginal fistula, anal fissure
Cause
Rectal bulging cause
Childbirth (35%):
The vaginal delivery of the fetus, the compression and expansion of the posterior wall of the vagina can lead to relaxation of the rectal vaginal septum, such as the cross-fiber breakage of the puborectal muscle, making the rectal vaginal septum weak, but the degree of tissue weakness is not related to the number of vaginal delivery. Large, and related to the size of the fetus, labor, perineal tear, genital incision and maternal-specific perineal tissue types.
Age (25%):
Age plays an important role in the development of rectocele. During the menopause, the body's elastic fibers are reduced, and the rectal vaginal septum is relaxed. The degree of rectocele is gradually increased.
Long-term forced defecation (25%):
Eat less cellulose, long-term neglect of the intention, so that the stool is dry and hard, difficult to discharge, leading to chronic constipation, long-term defecation force, heavy pressure on the anterior rectal wall and the posterior wall of the vagina; with age, the rectum and perineal tissue bear long-term continuous Trauma and high pressure, easy to develop into rectocele.
Pathogenesis
1. Pathogenesis: The lower end of the rectum forms a convex forward angle due to the contraction of the puborectalis muscle, which is called the anal right angle. At rest, the right anal angle is maintained at a bending angle of 80° to 90° to maintain the self-made stool; During defecation, the puborectalis muscle relaxes, the anus is increased at right angles, and the rectum is straightened, so that the feces can be smoothly discharged. In the male, the anterior anal rectal anterior anterior wall is the prostate in front of the right ankle. When the proximal end of the rectum is lowered to this point, it can produce enough The reaction force causes the feces to enter the anal canal and is discharged. In women, the anterior wall of the rectum is rectal vaginal fistula, which is relatively weak. When the abdominal pressure and the proximal rectal pressure rise, the intestinal contents are pushed to the distal rectum. The rectal vaginal fistula is transmitted forward and downward, so that the rectal vaginal fistula forms a forward pocket-like bulge, so that the feces are trapped in the protruding pocket, and cannot enter the anal canal and be discharged. At this time, the patient is more forceful, and the feces are deeper. The more difficult it is to discharge, the vicious circle is formed. However, if the patient puts his finger into the vagina and presses the posterior wall of the vagina, the feces can smoothly enter the anal canal and be discharged.
2. Classification: rectal bulging can be divided into high, middle and low 3, low rectal protuberance due to perineal tears during childbirth, often accompanied by levator ani muscle, corpus cavernosum tear, median rectum The most common type is the weak area, which is round or oval, mostly located 3 to 5 cm above the levator ani muscle, and can also extend to the proximal 7 to 8 cm. This type of rectal prolapse is due to the relaxation of the rectal vaginal septum. With age, birth, poor bowel habits and increased abdominal pressure, the progressive rectal anterior wall is loose. The high rectal progeny is caused by the 1/3 of the vagina and the elongation of the humeral ligament. The anal margin is about 8 cm and is usually associated with complete prolapse of the genital organs and posterior vaginal vagina.
According to the image displayed by defecating angiography, the depth of rectocele is divided into light, medium and heavy three degrees, normal should be <5mm; 6~15mm is mild; 16~30mm is moderate; >31mm is severe.
Prevention
Rectal bulging prevention
1. Develop good habits: including good eating habits and regular bowel habits, such as morning waking or after breakfast, using gastric colon reflex to promote bowel movements.
2. Defecation time should not be too long: generally 3 to 5 minutes is appropriate, never read newspapers and books during defecation, if the mind is not concentrated, then extend the defecation time.
3. Avoid local damage: women avoid birth injury during childbirth, and actively carry out appropriate physical exercise (mainly levator ani muscle exercise) after childbirth to promote recovery.
Complication
Rectal bulging complications Complications, urinary retention, rectal vaginal fistula, anal fissure
More than 80% of rectal bulging patients with sputum, anal fissure, anal anterior wall ulcer, weak pelvic floor and rectal vaginal septum cause difficulty in defecation, leading to enlargement of rectocele, but also can cause paralysis of rectal mucosa Symptoms are aggravated, women are prone to anal fissures in the anterior wall of the anus, which may be related to rectocele. For example, patients with rectocele can use the manual method to assist the anterior wall of the anus and cause anal fissure.
1. Urinary retention: the most common, the incidence rate of 15% to 44%, due to postoperative pain, anesthetic effect, bladder weakness, prostatic hypertrophy, etc., less water before and after surgery, slow rehydration, can avoid before the anesthesia disappears The bladder is prematurely filled and causes urinary retention. Other prevention and treatment methods include less sedatives after surgery, early waking activities, urination in the toilet, etc., 6 to 8 hours after surgery, or urinary filling. If other methods are not effective, the catheter should be left in time. Urine, for transvaginal access, in order to avoid postoperative urine contamination incision, the catheter left before surgery should be retained until the line is removed.
2. Incision infection: the incidence rate is 5.6%. Prevention is important before surgery. When the anus is approached, adequate bowel preparation should be made to avoid contamination of the surgical field during the operation. After the anus is enlarged, the rectal mucosa should be thoroughly disinfected. Postoperative prophylactic antibiotics are also effective measures.
3. Rectal vaginal fistula: the incidence rate is 0.3% to 5.1%. When the suture is sutured through the anus, the needle passes through the vaginal mucosa, or a local hematoma is formed. Or when the vagina is approached, the needle passes through the rectal mucosa. Cause, the key to prevention is to avoid needles through the vagina or rectal mucosa, can be guided by the left index finger in the vagina or rectum; at the same time when separating the rectal vaginal septum, should avoid damage to the deep vaginal or rectal mucosa, completely stop bleeding, necessary Indwelling drainage to avoid serious infection.
Symptom
Rectal bulging symptoms Common symptoms Sputum constipation Rectal pain Blood in the stool
The main symptoms are difficulty in defecation, laborious, anal obstruction, because the stool can not be drained, but there is a sense of emptying; a small number of patients have blood in the stool or anorectal pain; some patients need to pressurize around the anus to discharge stool, or finger Extend into the vagina to block the anterior wall of the rectum, and even use your fingers to reach into the rectum to remove the fecal mass. Patients with large rectal protrusions sometimes use their fingers to take the protruding rectum from the vagina to the position where they can defecate. The use of finger pressure on the posterior wall of the vagina to assist rectal emptying can be used as an important diagnostic basis. It is reported that 20% to 75% of rectal prolapse patients need manual assisted bowel movements. According to this complaint, the possibility of bowel movements returning to normal after surgery can be predicted. Sexually large, Khubchandani proposed that constipation caused by rectal bulging can have the following characteristics:
1 can not drain stools;
2 There is a continuous pressure drop in the anus at the time of defecation;
3 has an anal fall feeling;
4 bowel movements require more enema assistance;
5 need to press around the rectum to defecate;
6 need to use your fingers to insert into the vagina or rectum to defecate;
7 insert a toilet paper roll or paper roll into the rectum to induce bowel movements;
8 There is a feeling of depression or sputum at the anus.
Some patients may have mucous bloody stools, difficulty in intercourse or pain.
Examine
Rectal bulging examination
1. Rectal examination: knee chest position, the anterior rectal wall of the rectum on the upper end of the anal canal and the weak area that is easy to sag. When the force of the sputum is defecation (stool), the area protrudes forward or downward or the bag is more obvious. .
2. Vaginal digital examination: soft blocks can be touched in the vagina.
3. Defecation angiography: It is a reliable imaging basis for the diagnosis of rectocele. The imaging features are:
1 When the bowel movement, the front lower wall of the rectum protrudes in a capsular bag shape, and the rectal vaginal septum of the corresponding part is deformed.
2 If the expectorant remains in the anterior capsular bag, it is an important basis for the rectocele to cause difficulty in defecation.
3 Defecation angiography showed that the depth of the rectocele was >6mm, and sometimes the liquid level was visible.
4. Anal function test: common sphincter tension is excessive, which can be distinguished from megacolon and anal dysfunction.
5. Colonic transmission test: Excluding colonic slow transit constipation.
Diagnosis
Diagnosis and identification of rectal bulging
Diagnostic criteria
Middle-aged and old women, who have had a history of birth injury or chronic constipation, have difficulty in defecation and have difficulty in discharge, accompanied by anal fall and row of insufficiency, or need to assist with defecation, should consider the possibility of this disease, use your fingers to insert into the vagina Internal compression of the posterior wall of the vagina can discharge feces, which is a unique symptom of rectocele. The rectal examination touches the rectal anterior wall depression and the sphincter tension is weakened. Defecation angiography: When the bowel movement is seen, the anterior and posterior wall of the rectum protrudes in a capsular shape. Depth > 6mm, or have a gas-liquid level to confirm the diagnosis.
Simple rectocele is less common, and more commonly with pelvic floor loose or spasmodic constipation such as rectal prolapse, pelvic floor spasm syndrome, puborectalis syndrome.
Differential diagnosis
1. megacolon and anal dysfunction: anal function tests can be identified, excessive rectal sphincter tension, and sphincter relaxation of megacolon and anal dysfunction.
2. Vaginal posterior iliac crest: high rectal protuberance should be differentiated from vaginal posterior iliac crest. Vaginal posterior iliac crest refers to the peritoneal hernia sac between the vagina and the rectum. The contents include the small intestine, mesentery, omentum, etc. The patient has many pelvic weights. Feelings and feelings of falling, especially when standing, this is due to the gravity traction of the mesentery in the contents of the hernia sac. Diagnosis: When the patient is standing and has a sense of falling, the Valsalva technique is used for both rectal and vaginal examinations. If there is a feeling of fullness between the thumb and the index finger, it indicates that there is a vaginal posterior iliac crest. If the vaginal posterior iliac crest is misdiagnosed as a rectocele and the operation is performed, the intraperitoneal contents are easily damaged during the operation, and the rectocele is recurred soon after repair.
