Which bowel symptoms are most strongly associated with a true rectocele?

Background: Posterior vaginal wall prolapse is common in parous women and may be due to rectocele, enterocele or perineal hypermobility. Translabial ultrasound can be used to detect defects of the rectovaginal septum, that is, a 'true rectocele', potentially avoiding the need for defecation proctography. However, it is currently unknown whether specific sonographic appearances are associated with bowel symptoms. Aims: To correlate symptoms of bowel dysfunction and sonographic findings. Methods: In a prospective observational study, 505 women were seen during attendance at tertiary urogynaecological clinics and underwent a standardised interview, which included a set of questions regarding bowel function. They were assessed clinically and by translabial ultrasound, supine and after voiding. The presence of a rectocele was determined on maximal Valsalva. Results: Clinically, 314 women (64%) were found to have a rectocele. There were associations between clinical staging and ampullary descent on ultrasound (P < 0.001), the presence of a true rectocele (P < 0.001) and the depth of a defect (P < 0.001). Defects of the rectovaginal septum ('true rectocele') were identified in 54%. They were associated with symptoms of incomplete bowel emptying (P < 0.001) and digitation (P = 0.002), and less so with dyschezia (P = 0.01), faecal incontinence (P = 0.02) and chronic constipation (P = 0.04). Conclusions: True rectoceles are found in more than half of women presenting with pelvic floor disorders. This finding correlates strongly with clinical prolapse grading - large clinical rectoceles are more likely to be caused by a fascial defect. Incomplete bowel emptying and digitation are significantly associated with such defects detected on ultrasound.