Rectocele (Posterior Vaginal Wall Prolapse)

What is a rectocele?

Between the rectum and the vagina lies a layer of supportive connective tissue, the rectovaginal fascia. When it stretches or tears, the front wall of the rectum pushes forward into the vagina. During a bowel movement, stool can then be pushed into this pocket rather than out of the anus, which is why emptying feels incomplete.

A rectocele is one form of pelvic organ prolapse. It often occurs together with others:

Symptoms

• A soft bulge in or out of the vaginal opening, especially after standing or straining
• Vaginal pressure or a feeling of fullness
• Difficulty having a bowel movement, straining and a feeling of incomplete emptying
• Splinting: needing to press on the back wall of the vagina, the perineum (the skin between vagina and anus) or beside the anus to empty the bowel
• Stool leakage or soiling after a bowel movement
• Pain or discomfort during sex
• Lower back ache that eases when lying down

Many small rectoceles are found on examination and cause no symptoms.

Causes and risk factors

• Vaginal childbirth, particularly large babies, long pushing, forceps delivery or tears
• Chronic constipation and long-term straining
• Aging and menopause: lower estrogen weakens connective tissue
• Heavy lifting, chronic coughing and obesity, which raise pressure in the belly
• Previous hysterectomy or pelvic surgery
• Genetic connective tissue weakness

Rectoceles can rarely occur in men after prostate surgery, but they are almost always a female condition.

Grades of rectocele

Doctors grade prolapse by how far the bulge comes down. A common simplified grading:

• Grade 1 (mild): bulge stays well inside the vagina
• Grade 2 (moderate): bulge reaches the vaginal opening
• Grade 3 (severe): bulge comes out beyond the opening

The more formal POP-Q system measures exact distances. Symptoms do not always match size.

Diagnosis

• Pelvic and rectal examination: your doctor asks you to bear down while examining you, lying and sometimes standing.
• Defecography: an X-ray or MRI taken while you empty contrast paste from the rectum. It shows rectocele size, whether stool gets trapped and related problems such as intussusception.
• Anorectal manometry: measures pressures and coordination of the pelvic floor muscles. It identifies dyssynergic defecation, where muscles tighten instead of relaxing, which affects treatment choice.
• Colonoscopy: if there are other bowel symptoms, bleeding or age-appropriate screening is due.

Treatment

Bowel care (first line for everyone)

• 25 to 30 grams of fiber a day from food or a supplement such as psyllium, with plenty of water
• Do not strain; use a footstool so knees are higher than hips
• Respond promptly to the urge to go
• Gentle laxatives or stool softeners when needed
• Splinting is a reasonable self-help technique if it helps you empty

Pelvic floor physical therapy

A specialist physical therapist teaches pelvic floor muscle training (Kegels done correctly), coordination exercises and, when needed, biofeedback. It is particularly helpful when pelvic floor muscles do not relax properly during bowel movements. See pelvic floor dysfunction.

Pessary

A silicone device placed in the vagina supports the vaginal walls. Pessaries help many types of prolapse, though rectoceles can be harder to support than front-wall or uterine prolapse. Pessaries need regular cleaning and checks.

Vaginal estrogen

After menopause, low-dose vaginal estrogen can improve tissue health and comfort, especially with a pessary.

Surgery

Surgery is considered when a bulge or emptying problems persist despite conservative care:

• Posterior colporrhaphy (posterior repair): through the vagina, the surgeon tightens the tissue between the rectum and vagina. It is the most common operation.
• Site-specific defect repair: stitches only the torn area.
• Transanal repair: done through the anus, mainly by colorectal surgeons.
• Combined repairs when other prolapse is present.

Synthetic mesh is generally not used for posterior wall repair because it has not improved results and carries risks.

Surgery improves bulge symptoms in most women. Bowel emptying improves in many but not all, especially if constipation has another cause. Possible downsides include pain with sex, recurrence and bleeding or infection.

Prevention

• Avoid constipation and straining
• Do regular pelvic floor exercises, especially during and after pregnancy
• Keep a healthy weight
• Use good lifting technique
• Treat chronic cough and stop smoking

Frequently asked questions

What does a rectocele feel like?

Many people feel a soft bulge or pressure in the vagina, often worse at the end of the day or after standing. The most typical symptom is difficulty emptying the bowel, with a feeling that stool is stuck. Some need to press on the vagina or perineum to finish a bowel movement.

Can a rectocele be fixed without surgery?

Many can be managed without surgery. Fiber, fluids, not straining, a toilet footstool, pelvic floor physical therapy and a vaginal pessary help most mild to moderate rectoceles. These measures do not shrink the bulge but often control symptoms. Surgery is for persistent, bothersome symptoms.

What is splinting with a rectocele?

Splinting means pressing with your fingers on the back wall of the vagina, the perineum or beside the anus during a bowel movement. This blocks stool from slipping into the rectocele pocket so it can pass out. It is a common and safe self-help technique.

Can a rectocele get worse?

It can, gradually, especially with continued straining, heavy lifting, chronic cough, weight gain or after menopause. Many stay stable for years. Managing constipation and strengthening the pelvic floor can help slow progression. Report a bulge that is growing or coming outside the vagina.

What is the recovery time after rectocele surgery?

Most people go home the same day or after one night. Light activity resumes within days, but avoid heavy lifting, straining and sex for about 6 weeks while tissues heal. Stool softeners are usually prescribed to prevent straining after surgery.