Rectocele and Enterocele

What are rectoceles and enteroceles?

Rectoceles and enteroceles are types of pelvic organ prolapse, which is the weakening of the muscles and tissues that support the pelvic organs. These conditions primarily affect women.

• A rectocele occurs when the front wall of the rectum bulges into the back wall of the vagina. The tissue between the rectum and the vagina is known as the rectovaginal septum, and a rectocele represents a weakening or a defect in this layer. Small rectoceles are very common and are considered a normal finding in many women. They only become a problem when they are large and cause symptoms.

• An enterocele is a type of hernia where the small intestine bulges downward into the space between the rectum and the vagina (the pouch of Douglas). This is most common after a hysterectomy. A sigmoidocele is similar, but it involves the sigmoid colon herniating into this space instead of the small intestine.

Common Symptoms

Many small rectoceles and enteroceles do not cause any symptoms. When they become larger, they can cause a variety of pelvic floor symptoms.

Rectocele symptoms often relate to difficulty with bowel movements (obstructed defecation):

• A feeling of a bulge or pressure in the vagina.
• Difficulty having a complete bowel movement.
• The need to press on the back wall of the vagina or the perineum (splinting) to help empty the rectum.
• A feeling of rectal fullness or pressure even after a bowel movement.
• Constipation.

Enterocele symptoms are often more vague:

• A sense of pelvic pressure or fullness, often worse with standing and relieved by lying down.
• A pulling sensation or low back pain.
• Pain during intercourse (dyspareunia).

What causes rectoceles and enteroceles?

These conditions are caused by a weakening of the pelvic floor muscles and the connective tissues that support the rectum, vagina, and other pelvic organs. The most common risk factors include:

• Childbirth: Vaginal delivery, especially multiple deliveries or a delivery involving a large baby or forceps, can stretch and damage the pelvic floor.
• Chronic Straining: Long-term straining to have bowel movements due to chronic constipation puts immense pressure on the rectovaginal septum.
• Hysterectomy: Removal of the uterus can sometimes alter the support of the pelvic organs, increasing the risk for an enterocele.
• Aging: The pelvic floor muscles and tissues naturally lose strength and elasticity with age.
• Obesity: Excess body weight increases the pressure on the pelvic floor.
• Chronic cough or heavy lifting.

How are rectoceles and enteroceles diagnosed?

Diagnosis is usually made during a physical examination.

• Pelvic Examination: The doctor will examine the vagina and rectum while you are lying down and possibly while standing or straining. A rectocele will be visible as a bulge from the back wall of the vagina. An enterocele may also be seen as a bulge from the top of the vagina.

• Defecography: This is a specialized imaging study that is very helpful for evaluating obstructed defecation. It is a video X-ray (or MRI) that shows how the rectum and pelvic floor work during a simulated bowel movement. Defecography can clearly show the size of a rectocele and whether stool gets trapped in it during evacuation. It is also the best test to diagnose an enterocele or sigmoidocele, which may only be apparent during straining.

How are these conditions treated?

Treatment is only necessary if the prolapse is causing significant symptoms. The approach depends on the severity of the symptoms and the size of the prolapse.

Non-Surgical Treatment:

• Dietary Changes: For symptoms of obstructed defecation, the most important first step is to ensure stools are soft and easy to pass. This involves a high-fiber diet, plenty of fluids, and avoiding straining.
• Pelvic Floor Physical Therapy: A specialized physical therapist can teach you exercises (Kegels) to strengthen the pelvic floor muscles and techniques to coordinate them properly during defecation.
• Pessary: A pessary is a removable device placed inside the vagina to help support the bulging tissues. It can be an effective non-surgical option for many women.

Surgical Treatment:
Surgery is an option for women with persistent, bothersome symptoms who have not had success with conservative measures. The goal of surgery is to repair the weakened tissue and reinforce the support between the rectum and vagina. There are several surgical approaches:

• Transvaginal Repair (Colporrhaphy): The surgeon makes an incision in the back wall of the vagina and repairs the weakened rectovaginal septum by placating the fascia. This is the most common approach for a rectocele.
• Transanal Repair: An incision is made inside the rectum to repair the rectocele. This approach is less common and may be associated with a higher risk of recurrence and new-onset dyspareunia.
• Transperineal Repair: The repair is performed through an incision in the perineum (the space between the vagina and the anus).
• Abdominal Repair (Ventral Mesh Rectopexy): For patients with a combination of a rectocele and an internal or external rectal prolapse, a laparoscopic or robotic procedure can be performed. A piece of mesh is used to lift the rectum and vagina and secure them to the sacrum. This procedure is also effective for treating enteroceles.

Can a rectocele cause fecal incontinence?
A rectocele itself doesn't typically cause fecal incontinence. However, the same underlying pelvic floor weakness that leads to a rectocele can also contribute to weakness of the anal sphincter muscles. Additionally, some women with large rectoceles experience post-defecation leakage because stool trapped in the rectocele can seep out later.

Will I need a hysterectomy if I have an enterocele?
Not necessarily. An enterocele is a hernia of the small bowel, not the uterus. If you also have uterine prolapse, a hysterectomy may be part of the overall surgical plan, but it is not required to fix the enterocele itself.

Can these conditions come back after surgery?
Yes, there is a risk of recurrence after any type of pelvic organ prolapse surgery. The risk depends on the surgical technique used, the strength of your tissues, and ongoing risk factors like chronic constipation or obesity. Long-term success rates are improved by maintaining good bowel habits and a healthy weight.

• Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol. 1993;36(4):976-83.
• Zutshi M, Oliveira LCC. Treatment of Difficult/Obstructive Defecation. In: Steele SR, Hull TL, Hyman N, Maykel JA, Read TE, Whitlow CB, eds. The ASCRS Textbook of Colon and Rectal Surgery. 4th ed. Springer; 2022:1007-1017.
• American Society of Colon and Rectal Surgeons. Rectocele Expanded Information. Accessed September 28, 2026. https://fascrs.org/Web/Patients/Diseases-and-Conditions/A-Z/Rectocele-Expanded-Information.aspx