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Rectocele: Causes, Symptoms and Treatment

A rectocele is a bulge of the front wall of the rectum into the vagina. It commonly occurs after childbirth and causes difficulties with bowel emptying.

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Things worth knowing about "Rectocele"

A rectocele is a bulge of the front wall of the rectum into the vagina. It commonly occurs after childbirth and causes difficulties with bowel emptying.

What Is a Rectocele?

A rectocele (also called a posterior vaginal prolapse) is an abnormal bulging of the front wall of the rectum into the back wall of the vagina. It develops when the connective tissue and muscles between the rectum and vagina become weakened or damaged and can no longer withstand the pressure from within the abdomen. A rectocele is classified as a type of pelvic floor disorder and occurs almost exclusively in women.

Causes

The most common cause of a rectocele is pelvic floor weakness, which can result from various contributing factors:

Vaginal childbirth, especially after prolonged or difficult labor, forceps deliveries, or perineal tears
Chronic constipation and repeated straining during bowel movements
Hormonal changes during and after menopause (estrogen deficiency weakens connective tissue)
Connective tissue weakness, which may have a genetic component
Obesity and chronically elevated intra-abdominal pressure
Heavy physical lifting over extended periods of time

Symptoms

The symptoms of a rectocele can vary considerably depending on its severity. Common symptoms include:

Difficulty emptying the bowel: Stool becomes trapped in the bulge and cannot be fully expelled.
Feeling of incomplete bowel emptying after using the toilet
Manual assistance for defecation: Many women press on the perineum or the back wall of the vagina to help push stool out.
Pressure or a sensation of fullness in the vagina or the pelvic area
Pain during sexual intercourse (dyspareunia)
In severe cases: visible protrusion of tissue from the vaginal opening

Diagnosis

A rectocele is typically diagnosed through a gynecological and proctological examination. The following diagnostic methods may be used:

Physical examination: The healthcare provider manually examines the vagina and perineum, often using a speculum.
Defecography: An imaging study (using X-ray or MRI) that records the process of bowel emptying to visualize the bulge.
Pelvic MRI: Provides detailed images of pelvic floor structures and helps assess the extent of the prolapse.
Endoanal ultrasound: An ultrasound performed from within the bowel to evaluate the sphincter muscles and surrounding tissue.

Treatment

Conservative Treatment

For mild to moderate rectoceles, conservative approaches are typically recommended first:

Pelvic floor exercises: Targeted exercises strengthen the pelvic floor muscles and can significantly reduce symptoms.
Dietary changes: A high-fiber diet and adequate fluid intake help prevent constipation and reduce straining during bowel movements.
Pessary: A silicone device inserted into the vagina can provide mechanical support to the pelvic floor.
Biofeedback therapy: Helps patients regain better control over their pelvic floor muscles.
Topical estrogen therapy: In postmenopausal women, local estrogen treatment can help strengthen connective tissue.

Surgical Treatment

When conservative measures are insufficient or the rectocele is severe, surgery may be required:

Posterior colporrhaphy: The most common surgical procedure, in which the posterior vaginal wall is tightened and reinforced.
Transanal repair: A surgical approach through the rectum to correct the bulge from inside the bowel.
Mesh implantation: In selected cases, a synthetic mesh is used to support the pelvic floor (used more cautiously today due to potential complications).

References

Bump RC, Mattiasson A, Bo K et al. - The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. American Journal of Obstetrics and Gynecology, 1996;175(1):10-17.
Pucciani F - Rectocele: pathophysiology, clinical aspects, and therapy. Techniques in Coloproctology, 2016;20(9):585-595.
National Institute for Health and Care Excellence (NICE) - Urinary incontinence and pelvic organ prolapse in women: management. NICE guideline NG123, 2019.

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