An Overview of Rectocele

A Weakening of the Wall Between the Vagina and the Rectum

In This Article

A rectocele is a condition that can occur in women where the front wall of the last part of the large intestine (the rectum) extends out and pushes into the back wall of the vagina. A rectocele, particularly small ones that may go unnoticed, is a common condition, especially in women over the age of 50. It may also be called a posterior vaginal prolapse.

A rectocele does not always cause any symptoms, although it may be uncomfortable. However, it is not usually painful.

Pelvic Floor Anatomy

The rectum is the last part of the colon that is located between the large intestine and the anus. Like the small and large intestine, it is shaped like a tube. The rectum is where stool is held until it is time to have a bowel movement. In adults, the rectum is about 12 centimeters (4.7 inches) long. The rectum is lined with muscles that are fairly elastic and the rectum can then stretch, to a certain degree, in order to accommodate varying amounts of stool. 

The vagina is the opening on a woman’s body that leads from the outside of the body up to the uterus. It is located between the urethra (which is the tube urine passes through to get from the bladder to outside the body) and the rectum. The vagina is lined with muscles that are elastic and can stretch enough to allow a baby to pass through from the uterus during birth and then contract back to its pre-pregnancy shape. 

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. Certain muscles in the pelvic floor help resist the increased pressure in the pelvis that happens when, for instance, a person coughs, sneezes, or vomits.

The pelvic floor also serves to support the organs in the pelvis and the abdomen, especially during activity. The pelvic floor muscles also help prevent incontinence, so that women don’t urinate or defecate while sneezing, for example. If the muscles of the pelvic floor become weakened, it can result in issues such as incontinence.

Symptoms

In many cases, there may not be any signs or symptoms of a rectocele. Many instances of rectocele are found during a routine gynecological pelvic exam, in what’s called an incidental finding.

If there are signs or symptoms of a rectocele, they can be either in the rectum or in the vagina.

In some cases, the symptoms can be subtle enough that they might not initially spark investigation or seem to be from a rectocele.

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
  • Needing 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

Causes

There is a thin layer of tissue between the rectum and the vagina called the rectovaginal septum. A rectocele may be the result of pressure on the pelvic floor which can occur from pregnancy, chronic constipation, overweight or obesity, a chronic cough, or repetitive heavy lifting. In most cases, the exact cause won’t be known, especially as so many of the potential causes are common in women. There could be many factors at work that contribute 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 women who have more pregnancies and deliver babies vaginally tend to have a greater risk of developing a rectocele. However, women who have given birth by C-section can also develop 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. 

Surgeries

Surgery can further 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 be a factor in 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 open up the vaginal walls so a physician can see the vagina and the cervix. 

During this test, a woman lays 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 look at the organs and structures of the reproductive system, including the vulva, vagina, and cervix. A bimanual exam is one 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 issues such as a rectocele. 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.

No matter which method is used, the exam may be uncomfortable. However, it shouldn’t be painful and it should only take a minute or two to complete.

Digital Rectal Exam

In 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. In the setting of 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. Though 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 anymore, 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. 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. 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.

In women, 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.

Treatment

Rectoceles don’t always cause signs or symptoms, and for those that go unnoticed by the patient, 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

When there is constipation or straining to have a bowel movement, making some changes to the 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.

Fiber supplements may also help, and a physician can make recommendations as to which type to try and how much to use.

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 larger rectoceles (greater than 2 cm) gave some symptom relief for many of the study participants and complete relief for a minority of patients.

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 trying non-invasive methods, surgery might be considered. There are several different types of surgeries that may be done to repair a rectocele. The surgeon may decide to access the area of the rectocele through the vagina, through the rectum, or sometimes through the abdominal wall.

In certain cases, the surgery might be done by removing some of the weakened muscle tissue that is forming the rectocele and reinforcing the wall between the rectum and the vagina. A surgeon may also use a specialized mesh to further support the muscles.

Another type of procedure is a stapled transanal rectal resection (STARR). This is a newer surgery that is done by 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 will depend on many factors, including the size of the rectocele, the type of surgery used, and the training of the surgeon.

A Word From Verywell

Having a rectocele can be an unsettling diagnosis to receive. In some cases, it might also be a relief to find out what is causing signs and symptoms and that there are effective treatments available. Know that with a referral to a physical therapist who can help with exercises and biofeedback is going to be key to coping with a rectocele and in strengthening the muscles of the pelvic floor.

In some cases, pelvic floor therapy and some changes to diet may help to relieve symptoms, but being consistent with these lifestyle changes is going to be key. Talking with a gynecologist and other healthcare professionals about a rectocele and being honest about how much it is affecting one’s life is important to get the right treatment. 

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Article Sources

  • Giarratano G, Toscana C, Toscana E, Shalaby M, Sileri P. Stapled transanal rectal resection for the treatment of rectocele associated with obstructed defecation syndrome: a large series of 262 consecutive patients. Tech Coloproctol. 2019 Feb 16. DOI: 10.1007/s10151-019-01944-9.

  • Mayo Clinic Staff. Posterior vaginal prolapse (rectocele). Mayo Clinic. 8 March 2018.

  • Mimura T, Roy AJ, Storrie JB, Kamm MA. Treatment of impaired defecation associated with rectocele by behavorial retraining (biofeedback). Dis Colon Rectum. 2000;43:1267-1272.