**2. Conservative treatment**

Initial management is conservative and symptomatic. Different non-surgical options can be offered. Those conservative treatments are taken into consideration for cases with a mild degree of prolapse [7, 8]. The treatment choice depends on the profile of the patient (conservative treatment is considered too for frail patients), on how symptomatic is the prolapse, the severity of it, or the preferences of the patient.

The interventions can be physical or lifestyle. The first group is based on the hypothesis that an improvement of the structural support por pelvic organs will occur due to the improvement of the pelvic floor muscle function.

That means exercise to train strength, endurance, and coordination of the pelvic floor contractions, as the Cochrane review about conservative prevention and management of pelvic organ prolapse in women named as "pelvic floor muscle training" [8]. This way pelvic floor rehabilitation can be a successful treatment for rectocele or even recto-rectal intussusceptions.

In cases of small rectocele, there may be a regression in a percentage of cases, so observation should be considered while starting conservative treatment, not being the case in large rectoceles, which do not usually return. Talking about ODS, around 20% [2] of the cases need surgical treatment, taking into account that the cause of it can be the reflection of many other pathologies apart from rectocele, such as anismus, rectal hypo sensation, anxiety, or depression.

Hygienic-dietetic measures should be taken in case of constipation, such as increased water intake, a diet rich in fiber, even oral laxatives, which are the most used alternatives. Foods that increase the viscosity may be avoided.

Another alternative reported as effected for several authors is hydrocolontherapy or lavage. It consists in irrigation through a tube into the anorectum. We have to take into account that the abuse of enemas can cause microtrauma and anorectal fibrosis secondarily [2].

Biofeedback or pelvic floor training helps to increase the quality of the pelvic floor muscles and therefore the support of the pelvic organs, it is also a treatment with hardly any adverse effects [8], and it is more indicated in cases of anismus and rectal hypo sensation, as well as botulinum toxin A treatment [2]. The use of electrostimulation is used in pudendal neuropathy and rectal hyposensation. Physiological counseling should be offered and can be helpful in several patients with depression or anxiety. Psycho-echo-biofeedback has been recently proposed as a procedure that is successful in half of the cases [2].

The use of the pessary can be recommended, usually in patients older than 70 years, serving as a support, occupying the space in lieu of the rectocele. It can improve symptoms of pressure, feeling of occupation and mass, even urinary ones in up to 50% of cases. There are different types of pessaries that can be adapted to the patient situation as their sexual life, active or not.
