Rectocele

A rectocele is a pouch-like bulging of the front wall of the rectum, the last part of the large bowel, towards the back wall of the vagina. It is a type of pelvic organ prolapse affecting the back wall of the vagina and occurs in women.

Small rectoceles are quite common and may cause no complaints at all. A rectocele seen on examination or imaging does not on its own mean that there is a disease or that an operation is needed.

In some women a rectocele can make it difficult for stool to pass. Stool can collect inside this pouch, leading to a feeling of incomplete emptying, prolonged straining or the need to support the vagina by hand.

The treatment decision is not based only on the size of the rectocele in centimetres. The severity of the complaints, whether the rectocele empties during a bowel movement, accompanying pelvic floor problems and quality of life are assessed together [1–4].

What symptoms does a rectocele cause?

Small rectoceles often cause no symptoms. With rectoceles that affect bowel movements, the following complaints may occur:

• Difficulty passing stool
• Prolonged or excessive straining
• A feeling of incomplete emptying
• Needing to go to the toilet again shortly afterwards
• A feeling that stool is collecting in the pouch formed towards the vagina
• Supporting the back wall of the vagina with a finger during a bowel movement
• Needing to press on the perineum by hand
• A feeling of fullness in the vagina or of tissue coming out
• Pressure and heaviness in the pelvic area
• Discomfort during sexual intercourse
• Sometimes difficulty controlling wind or stool

Supporting the back wall of the vagina, or the perineum (the area between the vagina and the anus), with a finger to make a bowel movement easier is called digital support or splinting.

This complaint may suggest a rectocele, but on its own it does not establish a definite diagnosis.

Is every difficulty with bowel movements due to a rectocele?

No. Outlet-type constipation can develop for many different reasons:

• The pelvic floor muscles not relaxing during a bowel movement
• Internal rectal prolapse
• Excessive downward displacement of the rectum
• Enterocele or sigmoidocele
• Slow bowel movement (slow transit)
• Irritable bowel syndrome
• Anal narrowing or painful anal conditions
• Certain medicines and neurological diseases

Even if a rectocele is seen on imaging, the real cause of the complaints may be uncoordinated working of the pelvic floor muscles. An operation carried out without correcting this problem may not bring the expected benefit [1,3].

Why does a rectocele develop?

A rectocele develops when the supporting tissues between the rectum and the vagina become weak.

Factors that can increase the risk include:

• Difficult or multiple vaginal births
• Damage to the pelvic floor muscles and perineal tissue during childbirth
• Long-term constipation and excessive straining
• Older age and tissue changes after the menopause
• Excess weight
• Chronic cough
• Heavy lifting
• Previous pelvic or gynaecological operations
• Prolapse of the womb or bladder
• Certain diseases affecting connective tissue

A rectocele can also occur in women who have given birth by caesarean section or who have never given birth.

Diagnosis begins with listening carefully to the patient’s complaints and examining the pelvic floor.

Your doctor will ask about:

• How long you have had constipation,
• How much you strain during bowel movements,
• Any feeling of incomplete emptying,
• Whether you need to support the vagina or perineum by hand,
• Urinary incontinence or difficulty passing urine,
• Any feeling of prolapse in the vagina,
• Sexual function,
• Your history of childbirth and operations.

A rectal and vaginal examination is carried out to assess whether a rectocele is present, the condition of the perineal tissue and any accompanying prolapse of the bladder, womb or vaginal vault.

What tests may be carried out?

Not every test is needed for every patient. Depending on the symptoms and whether an operation is being considered, the following investigations may be used:

• Defecography: Shows the rectocele forming while the patient passes stool, and whether its contents empty.
• MR defecography: Can show internal rectal prolapse, enterocele and other pelvic organ prolapses together with the rectocele.
• Anorectal manometry: Assesses the pressure of the anal muscles and how the pelvic floor works during a bowel movement.
• Balloon expulsion test: Investigates whether the pelvic floor relaxes enough during a bowel movement.
• Colonic transit study: May be carried out when slow bowel movement is suspected.
• Endoanal ultrasound: Can assess damage to the anal muscles in patients with faecal incontinence.
• Colonoscopy: May be carried out if there is bleeding, anaemia, a new change in bowel habits or a need for bowel cancer screening.

The aim of dynamic imaging is not only to measure the size of the rectocele. Whether the rectocele empties during a bowel movement and other accompanying pelvic floor problems are also assessed [1,2].

The aim of treatment is not only to correct the bulge in the vaginal wall but to improve the patient’s bowel movements and quality of life.

In patients who have a rectocele on imaging but no complaints, no treatment is needed. In patients with symptoms, the first step is usually non-surgical methods [1,3].

Regulating the bowels

Reducing constipation and excessive straining is the basis of treatment.

Depending on your doctor’s advice, the following may be helpful:

• Adjusting fibre intake to suit the individual
• Drinking enough fluid
• Regular physical activity
• Suitable stool softeners or osmotic medicines
• Avoiding sitting on the toilet for long periods
• Not forcing when there is no urge to open the bowels
• Placing the feet on a small raised support.

More fibre does not work well for every patient. Too much fibre can increase bloating in some patients or cause stool to collect inside the rectocele. For this reason, the diet should be planned individually.

Pelvic floor physiotherapy and biofeedback

When the pelvic floor muscles contract instead of relaxing during a bowel movement, this is called pelvic floor dyssynergia. This condition can be present together with a rectocele and can be an important cause of difficulty with bowel movements.

In biofeedback therapy, the patient learns:

• To relax the pelvic floor muscles at the right time,
• To use the abdominal muscles effectively,
• To open the bowels without excessive straining,
• The correct position on the toilet.

The ASCRS 2024 guideline and the 2026 pelvic floor consensus recommend that functional problems of the pelvic floor are investigated and treated before rectocele surgery is considered [1,3].

Pelvic floor physiotherapy may not remove the anatomical rectocele completely, but it can considerably reduce complaints related to bowel movements.

Vaginal pessary

If the rectocele is accompanied by prolapse of the vagina, womb or bladder, support devices called a pessary, placed inside the vagina, can be used.

A pessary:

• Can reduce the feeling of vaginal fullness.
• Can support the prolapse.
• Can be an option for patients who do not want an operation or for whom surgery carries a high risk.

Check-ups at regular intervals, cleaning and replacement when necessary are required. A pessary may not fully correct the problem with bowel movements in every patient [4].

When is rectocele surgery considered?

Surgery is generally considered when the following conditions are present together:

• Marked difficulty with bowel movements or a vaginal bulge
• Frequently needing support by hand during bowel movements
• A rectocele shown on defecography to trap stool and not empty sufficiently
• Not enough benefit from diet, medicines and pelvic floor treatment
• Complaints that markedly impair quality of life
• Functional causes, such as failure of the pelvic floor muscles to relax, having been assessed and treated

According to the ASCRS 2024 guideline, in a rectocele causing significant outlet difficulty, surgical repair may be considered after any accompanying functional problems have been addressed [1].

How are rectocele operations performed?

A rectocele can be repaired by different routes:

• Vaginal approach: The weak supporting tissues in the back wall of the vagina are strengthened.
• Transanal approach: The repair is carried out from inside the anus and rectum.
• Transperineal approach: The repair is carried out through the area between the vagina and the anus.
• Abdominal approach: May be used through the abdomen in selected patients with internal rectal prolapse or prolapse of more than one pelvic organ.

Which method is suitable is decided according to:

• The structure of the rectocele,
• Whether there is vaginal prolapse,
• Internal rectal prolapse,
• The condition of the anal muscles,
• Complaints of faecal incontinence,
• Sexual function,
• Previous operations.

No surgical method is superior for all patients. Treatment may require a joint assessment by a colorectal surgeon, a doctor experienced in female pelvic floor disorders, a gastroenterologist, a radiologist and a pelvic floor physiotherapist [1,3,4].

Does surgery cure constipation completely?

Not always. If the rectocele is really trapping stool, emptying may become easier after the operation. However, if:

• Uncoordinated working of the pelvic floor muscles,
• Slow bowel movement,
• Irritable bowel syndrome,
• Internal rectal prolapse persists, constipation and a feeling of incomplete emptying may continue.

“Correcting the anatomy” does not always mean “completely correcting bowel function”. For this reason, choosing the right patients before surgery is important.

The recovery time varies according to the method of the operation and any other pelvic floor procedures carried out at the same time. You may need to stay in hospital for the day or for a few days.

After the operation:

• Pain is controlled.
• You start walking early.
• Treatment to prevent constipation is given.
• The aim is to keep the stool soft.
• Excessive straining is avoided.

In the first weeks there may be slight spotting from the vagina or the anus. Increasing bleeding or the development of foul-smelling discharge should not be considered normal.

Returning to desk work is usually possible within 2–4 weeks. The time for returning to heavy lifting, strenuous exercise and sexual intercourse is set by the doctor according to the method used.

You should contact your healthcare team in the following situations:

• High fever
• Pelvic or abdominal pain that keeps getting worse
• Heavy bleeding from the vagina or the anus
• Foul-smelling discharge
• Inability to pass urine
• Inability to pass wind or stool
• Persistent vomiting
• A marked prolapse in the vagina again

A rectocele can come back after treatment. Constipation, constant straining, chronic cough, excess weight and weakness of the connective tissue can increase the risk of recurrence.

1. Alavi K, Thorsen AJ, Fang SH, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Evaluation and Management of Chronic Constipation. Diseases of the Colon & Rectum. 2024;67(10):1244–1257. doi:10.1097/DCR.0000000000003430. PubMed record
2. Gurland BH, Khatri G, Ram R, et al. Consensus Definitions and Interpretation Templates for Magnetic Resonance Imaging of Defecatory Pelvic Floor Disorders. American Journal of Roentgenology. 2021;217(4):800–812. doi:10.2214/AJR.21.26488. PubMed record
3. Van de Bruaene C, De Schepper H, Surmont M, et al. Guideline on Pelvic Floor Disorders: Consensus on Obstructed Defecation Syndrome. Acta Gastro-Enterologica Belgica. 2026;89(2):385–405. doi:10.51821/89.2.15231. PubMed record
4. American College of Obstetricians and Gynecologists and American Urogynecologic Society. Pelvic Organ Prolapse: ACOG Practice Bulletin No. 214. Obstetrics & Gynecology. 2019;134(5):e126–e142. ACOG guideline