Rectocele is a condition that can occur in women where the front wall of the rectum (the last part of the large intestine) pushes into the back wall of the vagina. Rectocele, also known as retrovaginal prolapse, is a common condition, especially after age 50.
A rectocele doesn’t always cause symptoms, especially if it’s small. It may cause discomfort, but is usually not painful.
Learn about pelvic floor anatomy
The rectum and vagina are close to each other in the pelvis. They are both tunnel-shaped and held in place by supporting tissue.
The muscles and ligaments between the front of the pelvis and the base of the spine are called the pelvic floor. The pelvic floor is shaped a bit like a hammock between the pubic bone and coccyx.
The pelvic floor supports the organs of the pelvis and abdomen, especially during activities.
The rectum is the part of the colon where stool is held before entering the anus for defecation. Like the small and large intestines, it is shaped like a tube.
In adults, the rectum is about 12 cm (4.7 inches) long. Because it’s lined with muscles with elastic tissue, the rectum can stretch enough to hold stool.
The vagina is the opening in a woman’s body that leads from the outside of the body to the uterus. This opening is located between the opening of the urethra (where urine travels from the bladder to the body through a tube) and the opening of the anus.
The vagina is lined with elastic muscles that stretch enough to pass the baby through the uterus at birth and then contract back to its pre-pregnancy shape.
What are the symptoms of rectocele?
It is not uncommon to have a small rectal protrusion. In many cases, a small rectocele does not cause any signs or symptoms. Many cases of rectocele are discovered incidentally during routine gynecological pelvic examinations.
If there are signs or symptoms of rectocele, they may affect the rectum or vagina.
When they do occur, symptoms of rectocele are usually mild.
Symptoms of rectorectal protrusion include:
- inability to empty the bowel
- Feels like the stool is “stuck”
- more frequent bowel movements
- having to force a bowel movement
- need to use a vaginal splint (pressing the inside of the vagina with your fingers, etc.) to have a bowel movement
- rectal pain
Symptoms of rectocele that may be felt in the vagina include:
- vaginal bulge
- A feeling of fullness in the vagina
- tissue extends outside the vagina
- painful intercourse
- vaginal bleeding
What causes rectocele?
There is a thin layer of tissue between the rectum and vagina called the rectovaginal diaphragm. A rectocele can be caused by pressure on the pelvic floor, which can be due to pregnancy, chronic constipation, being overweight or obese, chronic cough, or repetitive heavy lifting.
Protrusion of the rectum is more common with age. In most cases, the exact cause is unknown, especially since many underlying causes are common. Sometimes, more than one factor contributes to the development of a rectocele.
Pregnancy, childbirth and childbirth
During pregnancy, labor, and delivery, the vaginal muscles are stretched. Although this is normal, the process weakens these muscles, and people with more pregnancies and vaginal deliveries are at higher risk for rectoceles.
More interventions during vaginal delivery—including the use of vacuum cleaners or forceps, episiotomy, and vaginal tears—may also lead to rectoceles.
However, rectoceles can also be present in mothers who deliver by cesarean section.
Surgery may weaken the pelvic floor muscles. Surgery on the rectovaginal area, including gynecological procedures such as rectal surgery and hysterectomy, can also lead to the development of a rectocele.
In many cases, a rectocele is diagnosed during a pelvic exam, such as during an annual visit with a gynecologist, but other tests may sometimes be used.
A pelvic exam can be done with gloved fingers (two-handed exam) or using a device called a speculum, a metal instrument used to help doctors see the vagina and cervix.
During a pelvic exam, a woman lies on an examination table with her feet in stirrups on either side of the table so that the doctor can examine the vulva, vagina, and cervix.
- A bimanual examination is a diagnostic procedure in which a doctor inserts a gloved, lubricated finger into the vagina. By doing this, the vaginal walls can be felt to see if there are any structural abnormalities. The doctor will also place the other hand on the abdomen above the uterus and press (palpate) and feel for anything unusual.
- If a speculum is used, the speculum is placed in the vagina and opened so the doctor can see the inside of the vagina to the cervix, the lower part of the uterus. A PAP test can also be done at this time, using a cotton swab or brush to collect some cells from the cervix and send them to a lab for testing to make sure they don’t show anything abnormal.
No matter which method is used, the exam can be uncomfortable. However, it shouldn’t be painful and should only take a minute or two to complete.
digital rectal examination
During a digital rectal exam, a gloved, lubricated finger is inserted into the rectum. By doing this, the doctor can feel any abnormalities or check the area for mucus or bleeding. If there is a rectocele, the muscles in the wall of the rectum closest to the vagina may feel weak.
A digital rectal exam can be performed with or without a pelvic exam. In some cases, both are performed at a routine annual check-up or when a rectocele is suspected.
Defecation angiography is an X-ray test used to see what happens during a bowel movement. This test is not used often, but it can help locate the exact location and size of the rectocele.
Preparing for this test may include using an enema before the test and then fasting a few hours beforehand.
- During the test, a paste containing a contrast dye is then inserted into the rectum.
- The patient is then asked to pass the paste like a bowel movement. In this case, X-rays or X-ray videos are taken.
- In women, some contrast material may also be put in the vagina to better see it during the X-ray.
It’s not painful, but doing this test can be uncomfortable.
Some rectoceles are only visible with exertion, such as during a bowel movement, which is why this test may be helpful. Contrast can also be “stuck” in the rectum, which means stool may also remain in the rectum, causing the sensation that the bowel cannot be completely emptied.
Rectal protrusion does not always cause signs or symptoms, and for those who do not cause any problems, no treatment may be needed. However, when rectocele has an impact on a person’s quality of life (such as causing pain or being unable to complete a bowel movement), treatments that can be used include dietary modification, biofeedback, or surgery.
If you’re experiencing constipation or you have to force a bowel movement, making some changes to your diet may help. Adding more fiber to your meals can make stools softer and easier to pass.
Most Americans don’t get the recommended 20 to 35 grams of fiber per day. Beans, fruits, vegetables, and whole grains all contain fiber, which can help keep stools from becoming too hard and difficult to pass.
Fiber supplements may also help, and a doctor can advise on which types to try and how much to use.
Drinking enough water or other fluids during the day may also help prevent constipation and straining on the toilet. For most people with small rectoceles that cause rectal symptoms, making these changes to diet and being consistent may help relieve symptoms.
Biofeedback is a special therapy that can be used as part of pelvic floor physical therapy. This may include using monitoring devices to measure muscle tightening and performing exercises such as Kegels to strengthen the pelvic floor. A certified physical therapist who specializes in pelvic floor abnormalities can help advise on the types of exercises and other treatments that can help with rectocele.
A small study showed that biofeedback in women with large rectal protrusions (greater than 2 cm) relieved symptoms in many study participants and completely relieved symptoms in a minority of patients. Recent research has also found that biofeedback may be helpful.
How to perform Kegel exercises:
- Tighten the pelvic floor muscles, as if you were holding your breath or a bowel movement
- Hold the muscle tight for 2 seconds, then relax for 5 seconds, then repeat.
- As the exercise gets easier, gradually tighten the muscles for 5 seconds, then relax for 10 seconds.
- Gradually continue to increase the duration of the clenched muscles to 10 seconds.
- Repeat the exercise for 10 sets of tightening/relaxing, 3 rounds per day.
What is Pelvic Floor Physical Therapy?
If the signs and symptoms of rectocele are bothersome even after you’ve tried non-invasive treatments, surgery may be considered. There are several different types of surgery to repair a rectocele.
The surgeon can access the rectocele area through the vagina, rectum, or sometimes through the abdominal wall.
- In some cases, some of the weakened muscle tissue that forms the rectocele may be removed, and the wall between the rectum and vagina may need to be strengthened.
- Your surgeon may also use specialized mesh to further support the muscles.
- A sutured transanorectal resection (STARR) procedure involves suturing the rectal protrusion tissue together. It is only used in certain conditions, such as prolapse that causes tissue to stick out of the vagina. One large study showed that one year after STARR surgery, 86% of patients were satisfied with the procedure.
Risks of surgery include bleeding, infection, painful intercourse, incontinence (leakage of stool), rectovaginal fistula (an abnormal passage that forms between the rectum and vagina), and recurrence or worsening of the rectocele. Surgical success rates vary widely and depend on many factors, including the size of the rectal protrusion and the type of surgery used.
You may be concerned about being diagnosed with a rectocele. In some cases, finding out what’s causing your symptoms and knowing there are effective treatments can also be a relief. A physical therapist can help you with exercises and biofeedback to help you strengthen your pelvic floor muscles and deal with rectocele.
In some cases, pelvic floor therapy and dietary changes may help relieve symptoms—alignment with these lifestyle changes will be key. Discuss your rectocele with your gynecologist and other healthcare professionals and be honest about how much it affects your life so you can get the right treatment.
Learn how to get help with pelvic floor dysfunction