Rectocele

What is a Rectocele?

A rectocele, also known as a posterior vaginal prolapse, occurs when the supportive tissue between the rectum and the vagina (the rectovaginal septum) weakens. This allows the front wall of the rectum to bulge into the back wall of the vagina. While small rectoceles are common and often cause no symptoms, larger ones can create a noticeable bulge in the vagina and may lead to problems with bowel movements. Rectoceles are a form of pelvic organ prolapse and frequently occur along with prolapse of other pelvic organs, such as the bladder (cystocele) or small intestine (enterocele). They are most common in women after menopause and those who have had multiple vaginal deliveries.

Common Symptoms of a Rectocele

Many women with a small rectocele do not experience any symptoms. When symptoms do occur, they are often related to the size of the bulge and its effect on bowel function. Common symptoms include:

• A soft bulge of tissue in the vagina that may or may not protrude through the vaginal opening.
• A feeling of rectal pressure or fullness.
• Difficulty having a bowel movement, often described as "obstructed defecation."
• The need to press on the vagina or perineum (splinting) to help complete a bowel movement.
• A sensation of incomplete rectal emptying after a bowel movement.
• Pain or pressure in the rectum.
• Discomfort or pain during sexual intercourse (dyspareunia).

What Causes a Rectocele?

A rectocele is caused by pressure on the pelvic floor that weakens the rectovaginal septum, the tissue separating the rectum and vagina. Several factors can contribute to this weakening:

• Childbirth: Vaginal delivery, especially multiple deliveries or traumatic deliveries involving forceps or vacuum, is a primary cause. The process of childbirth can stretch and damage the supportive tissues of the pelvic floor.
• Chronic Constipation: Long-term straining to have bowel movements puts significant and repeated pressure on the pelvic floor.
• Chronic Coughing: Conditions like chronic bronchitis or a smoker's cough increase pressure within the abdomen, which is transmitted to the pelvic floor.
• Repetitive Heavy Lifting: Jobs or activities that involve frequent heavy lifting can strain and weaken pelvic support structures over time.
• Obesity: Excess body weight increases the overall pressure on the pelvic organs and floor.
• Aging and Menopause: The natural decline in estrogen levels after menopause leads to a loss of elasticity and strength in pelvic tissues.
• Prior Pelvic Surgery: Procedures such as a hysterectomy can alter the pelvic anatomy and weaken support for the rectum and vagina.

How is a Rectocele Diagnosed?

Diagnosis typically involves a physical examination and, in some cases, imaging studies.

• Pelvic Exam: Your doctor will perform a physical exam of your rectum and vagina. You may be asked to strain or bear down as if you are having a bowel movement. This helps the doctor to see the rectocele bulge into the vagina and assess its size and the strength of your pelvic floor muscles.
• Defecography: This is an imaging test that provides a detailed view of the rectum and pelvic floor during defecation. You will be given a contrast paste to insert into your rectum, and then X-ray or MRI images are taken while you sit on a special toilet and evacuate the paste. This test is very effective at showing how large the rectocele is, whether it traps stool, and if other problems like an enterocele or internal rectal prolapse are present.

Treatment for a Rectocele

Treatment depends on the severity of your symptoms. If your rectocele is small and not causing problems, you may not need any treatment.

Nonsurgical Options

• Dietary and Lifestyle Changes: Preventing constipation is key. This includes eating a high-fiber diet, drinking plenty of fluids, and avoiding straining. A stool softener may be helpful.
• Pelvic Floor Muscle Exercises (Kegels): These exercises can strengthen the pelvic floor muscles, which may help support the weakened rectovaginal septum and alleviate mild symptoms. A physical therapist can provide specific training.
• Pessary: A pessary is a removable device made of plastic or silicone that is placed into the vagina to support the bulging tissues. It can be an effective way to manage symptoms without surgery.

Surgical Repair

Surgery may be an option for women with significant and bothersome symptoms. The goal of surgery is to repair the weakened tissue between the rectum and vagina to eliminate the bulge. The repair can be performed through an incision in the vagina (transvaginal), through the perineum (transperineal), or through the rectum (transanal). In some cases, especially if there is a recurrence, a surgeon may use a piece of biologic graft or synthetic mesh to reinforce the repair. If other pelvic organ prolapse is present, it is often repaired at the same time.

Lifestyle and Self-Care Measures

To manage symptoms and prevent your rectocele from getting worse, you can:

• Perform Kegel exercises regularly to strengthen your pelvic floor muscles.
• Avoid constipation and straining. Eat high-fiber foods, drink plenty of fluids, and use a fiber supplement if needed.
• Avoid heavy lifting. When you do lift, use your legs and not your back or abs.
• Control chronic coughing. Get treatment for bronchitis or allergies, and if you smoke, quit.
• Maintain a healthy weight. Losing excess weight reduces pressure on the pelvic floor.

Can I prevent a rectocele?

While you can't always prevent a rectocele, you can reduce your risk by maintaining a healthy weight, avoiding chronic straining from constipation or coughing, and performing Kegel exercises, especially after childbirth.

Is surgery for a rectocele always necessary?

No, surgery is only recommended for women with symptoms that significantly impact their quality of life. Many women can manage their rectocele with nonsurgical treatments.

What is the difference between a rectocele and an enterocele?

A rectocele is a bulge of the rectum into the vagina. An enterocele is a bulge of the small intestine into the space between the rectum and the vagina. The two conditions often occur together and can have similar symptoms.

• 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.
• Mayo Clinic. Posterior vaginal prolapse (rectocele). https://www.mayoclinic.org/diseases-conditions/rectocele/symptoms-causes/syc-20353459
• Cleveland Clinic. Rectocele. Accessed September 28, 2026. https://my.clevelandclinic.org/health/diseases/17415-rectocele
• 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