Diagnosis of Rectocele

Clinical Examination

The American College of Radiology recommends a thorough digital rectal examination in the left lateral position to diagnose rectocele, specifically observing perineal descent during simulated defecation and assessing for posterior vaginal wall bulging 1
Patient positioning in left lateral decubitus with buttocks separated is essential to observe perineal descent during simulated evacuation and elevation during squeeze maneuvers 2
Digital rectal examination should evaluate resting sphincter tone and augmentation with squeezing, puborectalis muscle contraction during squeeze, and patient instructed to "expel my finger" to assess expulsionary forces 2
Palpation for posterior vaginal wall bulging suggestive of rectocele is a crucial part of the digital rectal examination 2
A normal digital rectal examination does not exclude rectocele or other defecatory disorders, and physical examination detects only 7% of rectoceles compared to CCP 2, 1

MR defecography with rectal contrast is one of the initial imaging tests of choice for suspected rectocele, offering high soft-tissue contrast resolution and detecting clinically occult abnormalities in 34% of cases beyond clinical diagnosis 3, 1
MR defecography has moderate to good correlation with surgical findings for rectocele detection and detects 45% of enteroceles seen on physical examination 3, 4
CCP is one of the imaging tests of choice, particularly for posterior compartment prolapse, with a sensitivity of 94% for rectocele detection compared to physical examination 4, 1
CCP has good agreement with surgical findings for rectocele detection and detects clinically occult rectoceles that physical examination misses 1, 4

The diagnostic algorithm should begin with a detailed digital rectal examination in the left lateral position with simulated defecation maneuvers, followed by imaging if rectocele is suspected clinically or if the patient has obstructive defecation symptoms 2, 1
The choice of imaging modality depends on availability and suspicion of multiple compartment defects, with MR defecography preferred for comprehensive pelvic floor evaluation and CCP for focused posterior compartment evaluation 3, 1, 4
Imaging must include dynamic/defecation phase to adequately assess rectocele 3, 1

Patients with rectocele typically present with obstructive defecation symptoms, sensation of vaginal bulging or pelvic heaviness, incomplete evacuation, and constipation requiring straining 2, 4