An Overview of Rectocele

A rectocele is a condition that can occur in females where the front wall of the rectum (the last part of the large intestine) pushes into the back wall of the vagina. A rectocele, which may also be called a posterior vaginal prolapse, is a common condition, especially after age 50.

A rectocele does not always cause symptoms, especially if it is small. It may cause discomfort, but it is not usually painful.

Understanding the Pelvic Floor Anatomy

The rectum and the vagina are located near each other in the pelvis. They are both tunnel-shaped, and they are held in place by supportive tissue.

The muscles and ligaments between the front of the pelvis to the bottom of the spine are called the pelvic floor. The pelvic floor is shaped somewhat like a hammock between the pubic bone and the coccyx.

The pelvic floor supports the organs in the pelvis and the abdomen, especially during activity.

Rectum

The rectum is the part of the colon where stool is held before it enters the anus for a bowel movement. Like the small and large intestine, it is shaped like a tube.

In adults, the rectum is about 12 centimeters (4.7 inches) long. Because it is lined with muscles that have elastic tissue, the rectum can stretch to a certain degree to accommodate stool.

Vagina

The vagina is the opening on a female's body that leads from the outside of the body up to the uterus. This opening is located between the opening of the urethra (which is the tube urine passes through to get from the bladder to outside the body) and the opening of the anus.

The vagina is lined with muscles that are elastic, and it can stretch enough to allow a baby to pass through from the uterus during birth and then contract back to its pre-pregnancy shape.

What Are Symptoms of a Rectocele?

It's not uncommon to have a small rectocele. In many cases, a small rectocele doesn't cause any signs or symptoms. Many instances of rectocele are found incidentally during a routine gynecological pelvic exam.

When they do occur, symptoms of a rectocele are usually mild.

Symptoms of a rectocele in the rectum include:

• Being unable to empty the bowels
• Constipation
• Feeling that stool is getting “stuck”
• Having more frequent bowel movements
• Having to strain to have a bowel movement
• Incontinence
• A need to use vaginal splinting (putting pressure in the vagina such as with the fingers) to have a bowel movement
• Pain in the rectum

Symptoms of a rectocele that may be felt in the vagina include:

• A bulge in the vagina
• A feeling of fullness in the vagina
• Tissue extending outside the vagina
• Painful intercourse
• Vaginal bleeding

What Causes a Rectocele?

There is a thin layer of tissue between the rectum and the vagina called the rectovaginal septum. A rectocele may result from pressure on the pelvic floor, which can occur from pregnancy, chronic constipation, overweight or obesity, a chronic cough, or repetitive heavy lifting.

Rectoceles are more common with advancing age. In most cases, the exact cause won’t be known, especially because so many of the potential causes are common. Sometimes, more than one factor contributes to the development of a rectocele.

Pregnancy, Labor, and Delivery

During pregnancy, labor, and delivery, the muscles of the vagina are stretched. Even though this is normal, the process can weaken those muscles, and people who have more pregnancies and vaginal deliveries tend to have a higher risk of developing a rectocele.

Having more interventions during vaginal delivery—including the use of vacuum or forceps, having an episiotomy, and vaginal tearing—can also contribute to the development of a rectocele.

However, mothers who give birth by C-section can also develop a rectocele.

Surgeries

Surgery can contribute to the weakening of the pelvic floor. Having surgeries in the rectovaginal area, including surgery on the rectum and gynecological surgery such as a hysterectomy, can also contribute to the development of a rectocele. 

Diagnosis

In many cases, a rectocele will be diagnosed during a pelvic exam, such as during a yearly visit with a gynecologist, but sometimes other tests might be used.

Pelvic Exam

A pelvic exam may be done with gloved fingers (a bimanual exam) or with the use of a device called a speculum, which is a metal instrument that’s used to help a physician see the vagina and the cervix.

During a pelvic exam, a female lies down on an exam table and places the feet in stirrups located on either side of the table in order for the physician to be able to examine the vulva, vagina, and cervix.

• A bimanual exam is a diagnostic procedure where a physician inserts a gloved, lubricated finger into the vagina. By doing this, the walls of the vagina can be felt to see if there are any structural abnormalities. The physician will also place their other hand on the abdomen over the uterus and press down (palpate) and feel for any abnormalities.
• If a speculum is used, the speculum is placed inside the vagina and opened up so that the physician can see inside the vagina to the cervix, which is the lower part of the uterus. A PAP test might also be done at this time, where a cotton swab or brush is used to collect some cells from the cervix, which are then sent to a lab for testing to ensure they are not showing any abnormalities.

Digital Rectal Exam

During a digital rectal exam, a gloved, lubricated finger is inserted into the rectum. By doing this, a physician can feel for any abnormalities or check for mucus or bleeding in the area. If there is a rectocele, the muscles in the wall of the rectum that is closest to the vagina may feel weaker.

The digital rectal exam might be done with or without a pelvic exam. In some cases, both are done during a routine yearly exam or when a rectocele is suspected.

Defecography.

A defecography is a type of X-ray that is done to look at what happens during a bowel movement. This test is not often used, but it can help to locate the exact location and size of a rectocele.

Preparing for this test might include using an enema prior to the test and then fasting for a few hours beforehand.

• During the test, a type of paste that includes contrast dye is then inserted into the rectum.
• Patients are then asked to expel the paste just like having a bowel movement. While this is happening, X-rays or X-ray videos are taken.
• For females, some contrast material might also be put into the vagina in order to better visualize it during the X-rays.

It’s not painful, but it may be uncomfortable to have this test.

Some rectoceles only become visible during straining, such as during a bowel movement, which is why this test might be helpful. Contrast material might also get “stuck” in the rectum, which would mean that stool might also get left in the rectum, causing the feeling of being unable to completely evacuate the bowel.

Treatment

Rectoceles don’t always cause signs or symptoms, and for those that don't cause any problems, there might not be any treatment needed. However, when a rectocele is having an impact on a person's quality of life (such as causing pain or the inability to complete bowel movements), treatments that may be used include diet modifications, biofeedback, or surgery.

Diet Modifications

If you experience constipation or if you have to strain to have a bowel movement, making some changes to your diet may help. Adding more fiber to meals can make stool softer and easier to pass.

Most people in the United States do not get the 20 to 35 grams of fiber that is recommended every day. Beans, fruits, vegetables, and whole grains all contain fiber that can help prevent stool from becoming too hard and difficult to pass.

Drinking enough water or other liquids during the day may also help in preventing constipation and straining on the toilet. For most people with smaller rectoceles that are causing rectal symptoms, making these changes to diet and being consistent about them may help relieve symptoms.

Biofeedback

Biofeedback is a specialized type of therapy that can be used as part of physical therapy for the pelvic floor. This may include the use of a monitoring device that measures muscle tightening and doing exercises such as Kegels in order to strengthen the pelvic floor. A certified physical therapist that specializes in pelvic floor abnormalities can help in advising on the type of exercises and other therapies that will help in treating the rectocele.

One small study showed that biofeedback for women with large rectoceles (larger than 2 cm) gave some symptom relief for many of the study participants and complete relief for a minority of patients. More recent studies have also found that biofeedback may be helpful.

How to do Kegel exercises:

• Tighten the muscles in the pelvic floor as if holding in gas or stool
• Keep the muscles tightened for 2 seconds and then release for 5 seconds, and then repeat.
• As the exercises get easier, work up to tightening the muscles for 5 seconds and then releasing them for 10 seconds.
• Gradually continue to increase the time holding the muscles tight to 10 seconds.
• Repeat the exercises for 10 sets of tighten/release, and do it for 3 rounds a day.

Surgery

If signs and symptoms of a rectocele continue to be troublesome even after you try non-invasive treatment methods, surgery might be considered. There are several different types of surgeries that may be done to repair a rectocele.

The surgeon may access the area of the rectocele through the vagina, through the rectum, or sometimes through the abdominal wall.

• In certain cases, some of the weakened muscle tissue that is forming the rectocele may be removed and the wall between the rectum and the vagina may need to be reinforced.
• Your surgeon may also use a specialized mesh to further support the muscles.
• A stapled transanal rectal resection (STARR) procedure involves stapling the rectocele tissue together. It is only used for certain situations, such as where there is a prolapse that is causing the tissue to extend out of the vagina. One large study showed that 86 percent of patients were satisfied with the surgery one year after the STARR procedure.

Risks of surgery include bleeding, infections, painful intercourse, incontinence (stool leaking), a rectovaginal fistula (an abnormal tunnel that forms between the rectum and vagina), and a recurrence or worsening of the rectocele. Surgical success rates vary widely and depend on many factors, including the size of the rectocele and the type of surgery used.

A Word From Verywell

You might be anxious about being diagnosed with a rectocele. In some cases, it might also be a relief to find out what is causing your symptoms and to know that there are effective treatments available. A physical therapist can help with exercises and biofeedback to help you strengthen the muscles of your pelvic floor and cope with a rectocele.

In some cases, pelvic floor therapy and dietary changes may help to relieve symptoms—being consistent with these lifestyle changes is going to be key. Talk with a gynecologist and other healthcare professionals about your rectocele and be honest about how much it is affecting your life so you can get the right treatment.