A rectocele is a type of pelvic organ prolapse. It happens when the supporting ligaments and muscles weaken in the pelvic floor. Other names for a rectocele are a posterior vaginal wall prolapse or proctocele.
Childbirth, age, and a range of other factors can cause the normally tough, fibrous, sheet-like divider between the rectum and vagina to weaken.
A bulge may protrude as a hernia into the back of the vagina during a time of straining, such as a bowel movement.
A rectocele can lead to constipation and discomfort, but if it is small, there may be no symptoms.
Most people can treat a rectocele at home, but a severe case may need surgery.
A rectocele is one type of pelvic organ prolapse. In a woman, the rectum bulges into the back wall of the vagina.
Other types of prolapse are:
- anterior vaginal wall prolapse, or cystocele, where the urinary bladder bulges into the front wall of the vagina
- uterine prolapse, when the uterus sags down into the vagina
- vault prolapse, in which the top (vault) of the vagina bulges down after a hysterectomy
A pelvic prolapse can vary in severity. Some people may experience different types of prolapse at the same time, such as both an anterior and posterior vaginal wall prolapse.
A small rectocele may cause no symptoms.
According to the American Society of Colon and Rectal Surgeons, health professionals carrying out routine physical examinations find a rectocele is present in around 40 percent of women, although they may not notice it.
In mild cases of rectocele, the individual may notice pressure within the vagina, or they may feel that their bowels are not completely empty after using the bathroom.
In moderate cases, an attempt to evacuate can push the stool into the rectocele rather than out through the anus.
There may be pain and discomfort during evacuation. There is a higher chance of having constipation, and there may be pain during sexual intercourse.
Some say it feels as if “something is falling out” or down within the pelvis.
In severe cases, there may be fecal incontinence, and sometimes the bulge may prolapse through the mouth (opening) of the vagina, or through the anus.
A rectocele usually happens with pregnancy and childbirth, but the risk also increases with age, and other factors can play a role.
The underlying cause is a weakening of the pelvic support structures and of the rectovaginal septum, the layer of tissue that separates the vagina from the rectum.
Pregnancy and childbirth
It is more likely to occur as a result of childbirth if the baby was large (weighing over 9 pounds) if labor was prolonged, or if there was a multiple birth, for example, twins.
The more vaginal deliveries a woman has had, the more chance she has of developing a rectocele.
The risk is lower with a cesarean delivery, but a rectocele can still happen.
By the age of 50 years around half of all women have some symptoms of a pelvic organ prolapse, and by the age of 80 years, over 1 in every 10 will have had surgery for prolapse.
If the rectocele is small, the person may not notice it. If it is large, they may notice tissue protruding through the vaginal opening. There may be some discomfort, pressure, and, in some cases, pain.
Those who have never given birth can also develop a rectocele.
The following are risk factors:
- a drop in estrogen levels at menopause, making pelvic tissues less elastic
- a hysterectomy or other pelvic surgery
- chronic constipation
- long-term coughing, such as in chronic bronchitis
- sexual abuse during childhood
- being obese or overweight
- regularly lifting heavy objects
There may be an indirect link with hemorrhoids. If a person with other risk factors also has chronic constipation, for example, a forced bowel movement may increase intra-abdominal pressure during straining. This could trigger a rectocele.
If a person undergoes several gynecological or rectal surgeries, this can also weaken the pelvic floor and lead to a rectocele.
Women are more likely than men to have a rectocele.
A doctor will normally make a diagnosis after examining the vagina and rectum. An imaging study can then determine the size of the rectocele.
The individual’s account of how the rectocele impacts their life may help to assess the degree of prolapse.
If a doctor finds something unusual during a physical examination, they may recommend an imaging test, such as MRI or X-ray, to check for possible causes of the problem.
A defecogram is a particular type of X-ray study that helps the doctor determine the size of the rectocele and how well the patient is evacuating.
Depending on how severe the rectocele is, a doctor may suggest home remedies, medication, or, in some cases, surgery.
The following tips can help prevent a rectocele from developing, and — if a rectocele is already present — stop symptoms from getting worse.
- Pelvic floor exercises, such as Kegel exercises, can strengthen the pelvic floor muscles.
- Drinking plenty of fluids and eating high-fiber foods can reduce constipation.
- Avoiding any type of heavy lifting can also prevent a worsening of symptoms.
- Getting treatment for prolonged coughing can reduce strain on the pelvic floor muscles.
- Losing weight may be advisable if a person has obesity or excess weight.
Straining for a long time when defecating can make the problem worse. Avoiding constipation can help prevent this.
The doctor may prescribe:
- stool softeners to ease constipation
- hormone replacement therapy (HRT) for use after menopause.
- a vaginal pessary — a plastic or rubber round disk inserted into the vagina — to support the protruding tissues
Interventions for different kinds of pelvic organ prolapse include:
- sacral colpopexy
- sacrospinous colpopexy
- uterosacral colpopexy
- transvaginal mesh
The surgeon can remove the stretched or damaged tissue. Sometimes they may use a mesh inlay to reinforce the wall between the vagina and the rectum.
The technique can vary from open surgery to a minimally invasive procedure. In some cases, a surgeon will repair the damaged tissue, usually through an incision in the vagina.
The gynecologist will discuss the options with the patient, and the choice is likely to depend on the extent of prolapse, and the individual’s situation, including age, general health and whether or not they want to have more children.
A number of actions can reduce the chance of developing a rectocele or making it worse.
After childbirth: Anyone who has recently given birth should do the recommended Kegel exercises regularly.
Chronic cough: Anyone with a persistent cough, chest infections, and other lung problems should seek medical attention. Smoking tobacco makes lung conditions more likely and should be avoided.
Healthy body weight: Maintaining a healthy body weight can reduce the risk. A healthy diet and drinking plenty of water can help to avoid constipation. In the case of constipation, individuals should avoid prolonged straining when trying to empty the bowels.
Anyone who already has a prolapse should avoid activities such as heavy lifting, as they can make it worse.