Rectocele

　　The occurrence of rectal prolapse is related to factors such as childbirth, age, and long-term effortful defecation. The specific etiology and pathogenesis are described as follows.

　　1. Etiology

　　Rectal prolapse is more common in women with chronic constipation leading to long-term increased intra-abdominal pressure, middle-aged and elderly women who have given birth vaginally, those with poor defecation habits, and elderly women with perineal relaxation.

　　1. Childbirth Childbirth through the vagina can cause the compression and expansion of the posterior vaginal wall, leading to the relaxation of the rectovaginal septum, such as the rupture of the cruralis rectalis muscle's crisscross fibers, making the rectovaginal septum thin. However, the degree of tissue thinning is not related to the number of vaginal deliveries, but rather to the size of the fetus, labor, perineal laceration, episiotomy, and the unique perineal tissue type of the mother.

　　2. Age YearAge plays an important role in the development of anterior rectal prolapse, as the reduction of systemic elastic fibers during menopause makes the rectovaginal septum prone to relaxation, thereby gradually increasing the degree of anterior rectal prolapse.

　　3. Long-term effortful defecation Insufficient fiber intake, long-term neglect of defecation urge, makes the feces dry and hard, difficult to excrete, leading to chronic constipation. Long-term exertion during defecation exerts heavy pressure on the anterior rectal wall and the posterior vaginal wall; with the increase of age, the rectum and perineal tissues are prone to develop anterior rectal prolapse due to long-term continuous trauma and high-pressure action.

　　II. Pathogenesis

　　1. Pathogenesis The lower end of the rectum forms an acute angle pointing forward due to the contraction of the puborectalis muscle, known as the anorectal angle. In a resting state, the anorectal angle maintains a bending angle of 80° to 90°, maintaining the自制 of stool; during defecation, the puborectalis muscle relaxes, the anorectal angle increases, the rectum becomes straight, and the stool can be defecated smoothly. In males, the anterior wall of the rectum is in front of the prostate, and when the contents of the proximal rectum descend to this point, sufficient counterforce can be generated to push the stool into the anal canal and defecate. In females, the anterior wall of the rectum is the rectovaginal septum, which is relatively weak. When the abdominal pressure and the proximal rectal pressure increase, the pressure is transmitted forward and downward through the rectovaginal septum, causing the rectovaginal septum to form a forward bulging pouch, causing the stool to fall into this bulging pouch and not enter the anal canal for defecation. At this time, the harder the patient pushes, the deeper the stool falls, and the more difficult it is to defecate, forming a vicious cycle. However, if the patient inserts their finger into the vagina and compresses the posterior vaginal wall, the stool can enter the anal canal smoothly and be defecated.

　　2. Classification Rectal prolapse can be divided into three types: high, middle, and low.Low rectal prolapse is often caused by perineal tears during childbirth, often accompanied by tears in the levator ani muscle and bulbospongiosus muscle. The middle rectal prolapse is the most common type, with a weak area that is circular or oval, usually located 3 to 5 cm above the levator ani muscle, and can extend to 7 to 8 cm near the proximal end. This type of rectal prolapse is caused by the relaxation of the rectovaginal septum and the gradual relaxation of the anterior rectal wall due to aging, childbirth, poor defecation habits, and increased abdominal pressure. High rectal prolapse is caused by the elongation of the superior third of the vagina and the sacroiliac ligament, with the defect site about 8 cm away from the anal margin, and is usually associated with complete prolapse of the reproductive organs and posterior vaginal hernia.

　　According to the images displayed by defecation radiography, the depth of rectal prolapse is divided into three degrees: mild, moderate, and severe. Normally, 31mm should be considered severe.

　　In patients with rectal prolapse, more than 80% are accompanied by hemorrhoids, anal fissures, and ulcers on the anterior wall of the anal canal. The weakness of the pelvic floor and the rectovaginal septum causes difficulty in defecation, leading to the expansion of rectal prolapse, but it can also cause the symptoms of hemorrhoids and rectal mucosal prolapse to worsen. Women are more prone to anal fissures on the anterior wall of the anal canal, which may be related to rectal prolapse. For example, patients with rectal prolapse who use manual assistance for defecation may cause repeated trauma to the anterior wall of the anal canal, leading to anal fissures.

　　1. Urinary retention The most common, with an incidence of 15% to 44%. It is caused by postoperative pain, the effect of anesthetics, bladder weakness, benign prostatic hyperplasia, and other factors. To avoid urinary retention due to an overfilled bladder before the anesthetic wears off, it is recommended to drink less water and slowly replenish fluids before and after surgery. Other preventive and treatment methods include using fewer sedatives after surgery, getting up early and moving around, and urinating in the toilet. If the patient is unable to urinate or the bladder is full within 6 to 8 hours after surgery, and other methods are ineffective, it is necessary to promptly insert a catheter. For patients undergoing vaginal surgery, to avoid postoperative urinary contamination of the incision, the catheter inserted before surgery should be retained until the suture is removed.

　　2、切口感染 发生率5.6％。预防重在术前，拟经肛门入路时，应作充分的肠道准备，避免在手术中粪便污染术野，扩肛后应彻底消毒直肠黏膜，另外术后预防性应用抗生素也是有效的措施。

　　3、直肠阴道瘘 发生率0.3％～5.1％。经肛门入路缝合时，缝针穿过阴道黏膜，或局部有血肿形成；或经阴道入路时，缝针穿过直肠黏膜等原因可造成。预防的关键是避免缝针穿过阴道或直肠黏膜，可以左手食指在阴道或直肠中作引导；同时在分离直肠阴道隔时，应避免损伤深处的阴道或直肠黏膜，彻底止血，必要时留置引流，避免严重感染。

　　直肠膨出的主要症状为排便困难、费力、肛门阻塞感，因不能排净大便，而有排空不畅感。少数患者有便血或肛门直肠疼痛。部分患者需在肛门周围加压才能排出大便，或将手指伸入阴道以阻挡直肠前壁突出，甚至用手指伸入直肠内抠出粪块。具有较大的直肠前突病人，有时会自己用手指从阴道将突出的直肠还纳至能够排便的位置。利用指压阴道后壁以助直肠排空，可作为一种重要诊断依据。据报道直肠前突病人中20％～75％需手法辅助排便，据这一主诉可以预测手术后排便恢复正常的可能性较大。Khubchandani提出直肠膨出所致的便秘可有以下特点：

　　1、不能排净大便。

　　2、排便时肛门处有持续压力下降感。

　　3、有肛门下坠感。

　　4、排便多需灌肠协助。

　　5、需在直肠周围加压才能排便。

　　6、需用手指插入阴道或直肠内才能排便。

　　7、将卫生纸卷或纸卷插入直肠诱导排便。

　　8、肛门处有陷凹或疝的感觉。

　　部分患者可出现黏液血便，性交困难或疼痛。

　　直肠膨出有效预防措施包括良好生活习惯、排便习惯及分娩时避免产伤等，其具体预防措施如下所述。

　　1、养成良好生活习惯 包括良好的饮食习惯及按时排便习惯，如早上起床后或早饭后，利用胃结肠反射促进排便。

　　2、排便时间不宜过长 一般在3～5min为宜，绝不要在排便时看报及书籍，思想不集中，则延长排便时间。

　　3、避免局部损伤 妇女在分娩时应避免产伤的发生，产后积极进行适宜的体育锻炼(主要为肛提肌锻炼)，以促进恢复。

　　The examination of rectal prolapse includes rectal palpation, vaginal palpation, defecation radiography, anal function examination, and colon transit test. The specific examination methods are described as follows.

　　First, Rectal Palpation In the knee-chest position, palpate the easily deformed thin area on the anterior wall of the rectum at the upper end of the anal canal, and instruct the patient to exert force during defecation (straining), and the area will protrude downward or form a bag-like shape more明显ly.

　　Second, Vaginal Palpation A soft mass can be felt inside the vagina.

　　Third, Defecation Radiography This is a reliable imaging method for diagnosing rectal prolapse. The imaging characteristics are as follows:

　　1. When defecating, the anterior and inferior wall of the rectum protrudes in a sac-like manner, and the rectovaginal septum at the corresponding site is displaced and deformed.

　　2. If barium residue is found in the sac of the prolapse, it is an important basis for the difficulty of defecation caused by rectal prolapse.

　　3. Defecation radiography shows that the depth of rectal prolapse is greater than 6mm, and sometimes a liquid plane can be seen, and most of the prolapse disappears when the anal sphincter is tensed.

　　Fourth, Anal Function Examination Commonly, there is excessive anal sphincter tension, which can be distinguished from megacolon and anal dysfunction.

　　Fifth, Colon Transit Test Eliminate chronic intestinal constipation.

　　Patients with rectal prolapse should eat digestible foods with little residue and avoid spicy and irritating foods. The specific dietary precautions are as follows.

　　1. Foods Beneficial for Rectal Prolapse

　　Eat easily digestible foods with little residue. Eating more high-protein foods is beneficial for wound recovery. Supplement a variety of vitamins, eat more fresh vegetables and fruits. You can eat various lean meats, milk, eggs, and other foods rich in protein.

　　2. Foods to Avoid for Rectal Prolapse

　　Diet should be well-matched in texture. Reduce the intake of strong tea, coffee, and alcohol, and avoid spicy foods to reduce stimulation to the anal canal.

　　Protrusion of the rectum is a symptom of difficult defecation, so the main treatment method is to promote defecation, but the promotion of defecation should differentiate between deficiency and excess, cold and heat. Attack the evil with clearing heat and promoting defecation, harmonizing Qi to promote stagnation as the main approach, nourishing Yin and blood to invigorate, and warming the Kidney Yang as the key, and should not use nitrate and cinnabar like substances.

　　First,辨证选方 Selecting Prescription Based on Syndromes

　　1. Dried Intestine and Stomach Heat

　　Therapeutic Method: Clear Heat and Promote Defecation. Prescription: Modified Suiyao Maziren Pill. Dahuang 5 grams, Huomaren 12 grams, Xingren 10 grams, Baishao 10 grams, Zhishishi 10 grams, Houpu 12 grams. If the stool is dry and hard, add Mangxiao; for those with dry mouth and tongue, and consumption of body fluid, add Shengdi, Xuanshen, and Maidong; for those with bleeding after defecation, add Huaihua and Diyu; for those with heartache, irritability, red eyes, and tinnitus, add Luhui and Zhusha; for those with cough, abundant yellow and thick phlegm, add Huangqin, Guagua, and Sangbaipi.

　　2. Obstruction of Qi

　　Therapeutic Method: Harmonize Qi and Promote Stagnation. Prescription: Modified Liu Mo Decoction. Danggui 10 grams, Guangmuxiang 7 grams, Chenxiang 7 grams, Zhike 10 grams, Dahuang 5 grams, Binglang 12 grams. If there is bitter taste in the mouth and dry throat, add Luhui and Zhusha; for those with piercing pain in the two sides of the ribs, add Taoren, Honghua, and Yuanhu; for those with abundant phlegm and sputum, add Zaojia, Banxia, and Baijiezi; for those with nausea and belching, add Banxia and Dazheshi; for those with dry mouth and thirst due to Yin damage, add Xuanshen, Tiandong, and Maidong; for those with Qi deficiency, add a small amount of raw Huangqi; for those with abdominal distension and pain, add Qingpi, Laiwuzi, and Xiaohuixiang.

　　3. Qi Deficiency and Blood Deficiency, Yin and Jing Deficiency

　　Treatment method: Nourish Yin and blood, benefit Qi and promote defecation. Medication: Siwu Decoction combined with Zengye Decoction with modifications. 10 grams of whole Danggui, 10 grams of Baishao, 12 grams of Shudihuang, 12 grams of Xuanshen, 12 grams of Maidong, 15 grams of raw Huangqi, 12 grams of Hemansen, 7 grams of Muxiang, 10 grams of Chuanxiong, 12 grams of Bai Ziren. If there is severe Qi deficiency, abdominal distension after meals, and soreness in the lower limbs, add Dangshen, Shaoren, Baikou, and Cangzhu; for excessive phlegm, add Chuanbeimu and Baijiezi; for severe blood deficiency, dry throat and restlessness, tongue with glossy desquamation, use more Huangqi and Danggui; for severe Yin deficiency with interior heat, red cheeks, night sweats, add Zhimu and Huangbai; for dry eyes and palpitations, use more Danggui and Baishao; for insomnia, add Ye Jiao Tang and Suanzaoren.

　　4. Yang Deficiency and Cold Congealing

　　Treatment method: Warm the Yang and dispel cold to promote defecation. Medication: Jichuan Decoction with modifications. 12 grams of Rousenong, 15 grams of Danggui, 7 grams of Huai Niuxi, 5 grams of Zhike, 7 grams of Zexie, 3 grams of Shengma, 12 grams of Xianlingpi. If there is Qi deficiency, add Huangqi and Dangshen; for abdominal distension and fullness, add Taiwu; for dry and hard stools, add according to the need; for dampness excess, add Fuling and Gao kou; for weakness of the waist and knees and severe aversion to cold, it can be combined with the consumption of Jin Gui Shenqi Pill. If there is severe Yang cold, it can be combined with the consumption of Banxiu Pill.

　　2. Special Prescriptions

　　1. Ti Pen Powder: take the very fine powder of Caowu, mix with one piece of scallion white, and insert into the anus to relieve constipation.

　　2. Soak raw Dahuang in water: take 6 grams of raw Dahuang, soak in boiling water for consumption.

　　3. Take 3 to 6 grams of Fanzhiai, soak in boiling water for consumption.

　　4. Roast and grind Caojuemingzi to a powder, 5 to 10 grams per time, dissolve in boiling water for consumption.

　　5. Drink the natural juice of spinach.

　　6. Suma Millet Congee: grind Mahua Ren and Sumi into a paste, filter the juice with water, and cook into congee for consumption.

　　7. Take 30 grams of Dahuang, 15 grams of Badou, grind into powder, mix with ten pieces of scallion white, wine lees, and make into a cake, then apply 0.9 grams of Muxiang on the navel, cover with a cloth, and protect from burns. Remove it when the sound in the abdomen is very loud.

　　3. Traditional Chinese Medicine

　　1. Xin Qingning Tablets:5 tablets per time, taken before bedtime, and can be taken continuously. This formula clears heat and detoxifies, promotes blood circulation, and has a mild laxative effect. It is used for internal结实 heat constipation.

　　2. Aloe Vera Capsules:1 to 2 capsules per time, 1 to 2 times a day. This formula clears heat and moistens the intestines, benefits the liver and kidney, calms the mind, and is used for habitual constipation, dry and hard stools, or abdominal distension and abdominal pain caused by not defecating for several days.

　　3. Mahen Runchang Pill:Each pill weighs 6 grams, 1 to 2 pills per time, twice a day. This formula moistens the intestines and promotes defecation, used for internal heat and constipation, chest and abdominal distension.

　　4. Mahen Zishen Pill:Each pill weighs 6 grams, 1 to 2 pills per time, twice a day. This formula moistens the intestines and promotes defecation, used for abdominal distension and constipation caused by dryness and heat in the large intestine.

　　4. Acupuncture and Moxibustion

　　1. Body acupuncture:Acupoints such as DaChangshu, Tianchu, Zigou, etc., should be used for real constipation with purgative method, for虚constipation with tonifying method, for cold constipation with moxibustion, for hot constipation with acupuncture at Hegu, Quji, and Zhongwan, for Qi constipation with acupuncture at Xingjian, and for Qi and blood deficiency with acupuncture at Pishu, Weishu, and Shenque, Qihai. The treatment is administered three times a week, with 6 to 12 sessions as one course.

　　2. Ear point therapy:Styloid ear point seed pressure, acupuncture points: large intestine, angle cavity, rectum. For hot constipation, add blood-letting at the ear apex; for qi constipation, add spleen and heart; for cold constipation, add spleen and stomach. Select 3-4 points each time, alternate between both ears, once a week, and 3 weeks as one course. Take a rest for one week, and then start the second course.

　　3. Acupuncture point injection method:Acupuncture points: Ke gang point (2 cm below Zhizhi, an experienced point that can treat hemorrhoids, constipation, and cough, hence the name Ke gang point), Shenmen. Inject normal saline into each point, 3-5 ml into Ke gang point, 0.5-1 ml into Shenmen point, inject once every other day, and 4 times as one course.

　　V. Integrated treatment of traditional Chinese and Western medicine

　　The integrated treatment of traditional Chinese and Western medicine for rectal prolapse is also an effective treatment method in clinical practice in recent years. Western medicine emphasizes surgical treatment, and there are many kinds of surgical methods, but sequelae and complications are inevitable. Traditional Chinese medicine has small toxic and side effects, focuses on overall adjustment, combines attack and reinforcement, acts slowly and lastingly, and can be taken for a long time. If both are organically combined, complementing each other's strengths and weaknesses, and giving full play to their respective advantages, they will effectively guide clinical practice and improve efficacy.

　　1. Traditional Chinese medicine treatment before and after surgery:An important factor causing rectal prolapse is dry stool. Before surgery, traditional Chinese medicine is used to tonify the spleen and stomach, clear heat and promote bowel movement, such as Dangshen, raw Baizhu, raw Shudi, Maren, Dahuang, Zhishi, Huanglian, etc. Continue to take traditional Chinese medicine after surgery to form a benign cycle, consolidate the efficacy of surgery, and prevent recurrence. Maren Runchang Wan and Liu mo Decoction can be used appropriately.

　　2. Traditional Chinese medicine treatment without surgical indication:For conservative treatment of patients with mild rectal prolapse without obvious surgical indications, Western medicine does not have any medicine that can be taken continuously and long-term. Traditional Chinese medicine can adopt various forms of treatment methods according to the different conditions of the patients, such as acupuncture, moxibustion, massage, etc. However, the main method is still to make an overall adjustment through traditional Chinese medicine, implement dialectical treatment according to the dynamic changes of the patient's condition at different stages, regulate the patient's defecation habits, and guide the patient to change bad living habits.