Do you experience difficulty passing stool, a feeling that your bowels have not emptied completely, or pressure and heaviness in the pelvic area? These symptoms may seem minor at first, but they can sometimes be associated with a condition known as rectocele (rectal prolapse into the vagina), a type of pelvic floor disorder that may affect a woman’s comfort and quality of daily life. Rectocele is a condition that may not receive enough attention despite its potential impact on bowel movements and everyday activities, particularly in some women after childbirth or as they get older. Symptoms vary from one woman to another. They may be mild and require only monitoring and lifestyle changes, while other cases may need specialized treatment.In this article on Dalili Medical, we will take a simple medical overview of what a rectocele is, what causes it, its symptoms, and how it is diagnosed and treated. We will also answer frequently asked questions and explain when medical consultation is necessary, helping you understand the condition and manage it with greater awareness and confidence.

What Is a Rectocele?

A rectocele is a medical condition that occurs when the supporting tissue (fascia) separating the rectum from the posterior vaginal wall becomes weakened or torn, causing the rectum to bulge toward the vaginal cavity.

Is a Rectocele the Same as Hemorrhoids?

No. A rectocele differs from hemorrhoids in terms of both its nature and location. A rectocele occurs when the rectum bulges toward the vagina due to weakness of the supporting tissues, whereas hemorrhoids are enlarged or swollen blood vessels in the anal area or lower rectum. Both conditions may occur in the same person.

Does a Rectocele Occur Only in Women?

A rectocele is more common in women because of the anatomical relationship between the rectum and vagina. Men may develop other types of rectal prolapse or pelvic floor disorders, but a rectocele, in the commonly used anatomical sense, is associated with weakness of the tissue separating the rectum from the vagina.

Is a Rectocele a Serious Condition?

A rectocele is not considered serious in most cases and may not require treatment if it causes no symptoms or does not affect quality of life. However, persistent difficulty passing stool, a feeling of incomplete bowel emptying, or an increasingly prominent bulge warrants medical evaluation to assess the condition and determine the appropriate treatment.

Can a Rectocele Return After Surgery?

Yes. A rectocele may recur after surgery, or some symptoms may persist despite the procedure. This depends on several factors, including the degree of weakness in the supporting tissues, the type of surgery performed, and the presence of other bowel movement disorders or pelvic floor muscle problems. Therefore, medical follow-up after surgery is important for evaluating the results and reducing the risk of recurrence.

Does a Rectocele Affect Sexual Intercourse?

A rectocele may cause pressure, discomfort, or pain during sexual intercourse in some women. However, it does not necessarily affect sexual relations in every woman with the condition, as symptoms vary depending on the degree and severity of the rectocele.

Can a Woman Become Pregnant and Give Birth With a Rectocele?

Yes. Pregnancy may be possible with a rectocele, but determining the most appropriate delivery method depends on the severity of the rectocele, the intensity of symptoms, the woman's medical history, and any previous pelvic floor surgeries. Women are therefore advised to consult an obstetrician-gynecologist before pregnancy or delivery to assess their condition and determine the most suitable options.

Does a Rectocele Increase in Size Over Time?

The bulge may become larger or symptoms may worsen over time, particularly if constipation, repeated straining during bowel movements, and weakness of the pelvic floor supporting tissues persist. However, the condition does not worsen in every woman and may remain stable without noticeable changes.

Can a Rectocele Disappear on Its Own?

The anatomical bulge caused by a rectocele usually does not disappear completely on its own. However, symptoms may improve by treating constipation, avoiding excessive straining during bowel movements, and reducing pressure on the pelvic floor. The appropriate treatment depends on the severity of the rectocele and its impact on daily life.

Does a Rectocele Cause Gas and Bloating?

A rectocele may be associated with bloating or difficulty passing gas in some women. It may also occur alongside difficulty passing stool or a feeling of incomplete bowel emptying. However, these symptoms are not specific to rectocele and may result from constipation or other digestive disorders.

Does a Rectocele Affect Bowel Control?

A rectocele alone does not usually cause loss of bowel control. However, it may coexist with other disorders affecting the pelvic floor muscles or anal sphincter, which can affect the ability to control bowel movements. If stool leakage or significant difficulty controlling bowel movements occurs, medical evaluation is recommended to identify the cause and determine the appropriate treatment.

Can a Rectocele Cause Lower Back Pain?

A rectocele may be associated with pressure or heaviness in the pelvic area, but lower back pain is not a characteristic symptom. If the pain is persistent or severe, medical evaluation is recommended to determine its cause and rule out other conditions that may be responsible.

Can Lifting Heavy Objects Worsen a Rectocele?

Lifting heavy objects, particularly while holding one's breath or straining, may increase intra-abdominal pressure and worsen rectocele symptoms in some women. It is advisable to avoid lifting weights that increase the sensation of pressure or bulging, use proper lifting techniques, and breathe normally during movement.

Can a Vaginal Pessary Be Used to Treat a Rectocele?

Yes. In some cases, a vaginal pessary can help support the pelvic organs and relieve symptoms of bulging. However, it does not permanently repair the weakened supporting tissues. The appropriate pessary should be selected, fitted, and monitored under the supervision of a specialist.

Does a Rectocele Affect Fertility?

A rectocele is not usually a direct cause of infertility because it does not directly affect the ovaries or fallopian tubes. However, if other pelvic problems or difficulties conceiving are present, a separate medical evaluation may be necessary to identify potential causes.

Can a Rectocele Develop or Recur After Childbirth?

Yes. A rectocele may develop after childbirth, or pre-existing symptoms may worsen because the pelvic floor supporting tissues have stretched or sustained injury during delivery. The likelihood varies depending on the type of delivery, the condition of the tissues, the strength of the pelvic floor muscles, and other contributing factors.

Can a Rectocele Cause Bowel Obstruction?

A rectocele does not usually cause a complete intestinal obstruction, but in some cases, it may interfere with stool passage and make it difficult to empty the rectum. However, an inability to pass stool or gas, particularly when accompanied by severe pain or significant abdominal swelling, requires urgent medical evaluation to rule out an intestinal obstruction or another serious condition.

Does Excess Weight Affect a Rectocele?

Excess weight or obesity may increase pressure on the pelvic floor muscles and tissues, potentially worsening rectocele symptoms. When appropriate, gradual weight loss, along with treating constipation and avoiding activities that increase pelvic pressure, may help relieve symptoms and limit further worsening.

Can a Rectocele Cause a Feeling of Incomplete Rectal Emptying Even After Passing Stool?

Yes. Some stool may collect in the pocket created when the rectum bulges toward the posterior vaginal wall. This can lead to a feeling of incomplete bowel emptying or the need to try again. However, this sensation may also result from problems with pelvic floor muscle coordination during defecation, so medical evaluation may be necessary to determine the exact cause.

Types of Rectocele

A rectocele can be broadly classified into three grades according to the degree and severity of the bulge.

1. Mild Rectocele

• The rectum bulges only slightly toward the vagina.

• It may cause no noticeable symptoms and may be discovered incidentally during a medical examination.

• Treatment may not be necessary if it causes no symptoms or does not affect daily life.

2. Moderate Rectocele

• The bulge is more noticeable within the vaginal canal.

• It may cause constipation, difficulty passing stool, or a feeling of incomplete bowel emptying.

• The woman may experience heaviness or pressure in the vaginal and pelvic areas.

3. Severe Rectocele

• In advanced cases, the bulge may reach or extend beyond the vaginal opening.

• Difficulty passing stool may become more pronounced, and the woman may need to use her fingers to help evacuate stool.

• Specialized treatment may be required, and surgery may be considered if symptoms are severe and do not respond to conservative treatments.

Note: Medical assessment of rectocele severity is based on a clinical examination and the degree of vaginal wall descent, not solely on the size of the bulge.

Are There Different Types Based on the Location of the Bulge?

Yes. It is important to distinguish a rectocele from several other conditions that may cause similar symptoms:

• Rectocele: The rectum bulges toward the posterior vaginal wall due to weakness of the supporting tissues separating the two structures.

• Enterocele: A hernia-like descent of a sac that usually contains part of the small intestine toward the upper portion of the vagina.

• Rectal prolapse: Part of the rectum protrudes through the anus. This is different from a rectocele.

• Associated pelvic organ prolapse: A rectocele may occur alongside a cystocele, in which the bladder bulges toward the anterior vaginal wall, or uterine prolapse, in which the uterus descends into the vaginal canal.

Causes of Rectocele and Risk Factors

A rectocele develops when the supporting tissues of the rectum and posterior vaginal wall become weakened. Several factors may contribute to its development or increase the risk of developing the condition.

1. Weakness of the Pelvic Floor Muscles and Supporting Tissues

When the muscles and tissues supporting the rectum and vagina become weak, the anterior wall of the rectum may bulge toward the vagina. This can create a protrusion or pocket that may trap some stool.

2. Vaginal Childbirth

Vaginal delivery is an important risk factor, particularly in the following circumstances:

• Multiple vaginal deliveries.

• Prolonged or difficult labor.

• Delivery of a large baby.

• Tears or injuries to the pelvic floor tissues during childbirth.

3. Aging and Decreased Estrogen Levels

As women age, particularly after menopause, the elasticity and strength of the supporting tissues may change. This may increase the likelihood of developing a rectocele in some women.

4. Chronic Constipation and Repeated Straining

Repeated straining during bowel movements increases pressure on the pelvic floor muscles and supporting tissues. This may contribute to the development of a rectocele or worsen existing symptoms.

5. Repeated Increases in Intra-Abdominal Pressure

Several factors may increase pressure on the pelvic floor, including:

• Chronic coughing.

• Repeated heavy lifting, especially while holding one's breath.

• Obesity and excess body weight.

6. Other Factors

A rectocele may also be associated with additional factors, such as:

• Connective tissue weakness or a genetic predisposition.

• Previous pelvic, rectal, or vaginal surgery.

• Prolapse of other pelvic organs, such as the bladder or uterus.

Symptoms of Rectocele

Symptoms vary from one woman to another depending on the severity of the rectocele and its effect on rectal function and the pelvic floor. A mild rectocele may not cause any noticeable symptoms.

1. Difficulty Passing Stool

Difficulty passing stool is one of the most common symptoms and may include:

• Needing to strain excessively to pass stool.

• Feeling that the rectum has not emptied completely.

• Needing to visit the bathroom repeatedly to complete a bowel movement.

• Feeling that some stool remains trapped despite attempts to pass it.

2. Feeling a Bulge or Lump in the Vagina

A woman may notice the following symptoms:

• Feeling a swelling or lump inside the vagina or near its opening.

• Noticing a bulge that becomes more prominent when standing or straining.

• Feeling pressure inside the vagina.

3. Pressure and Heaviness in the Pelvic Area

A woman may experience heaviness or pressure in the vagina or lower pelvis. This sensation may become more noticeable toward the end of the day or after standing for long periods.

4. Needing Manual Assistance During Bowel Movements

Some women may need to press their fingers against the posterior vaginal wall or the surrounding area to help pass stool. This may be necessary because stool collects in the pocket created by the rectocele.

5. Other Possible Symptoms

Additional symptoms may include:

• Discomfort or pain during sexual intercourse in some women.

• Constipation or increased difficulty passing stool.

• A feeling of pressure in the rectal area.

• A sensation of incomplete bowel emptying.

Does a Rectocele Cause Bleeding or Pain?

• Rectal bleeding: This is not a typical symptom of a rectocele. It may result from hemorrhoids, an anal fissure, or other causes that require medical evaluation.

• Severe pain: This is not a typical symptom of an uncomplicated rectocele, so it should be evaluated to identify another possible cause.

• Constipation: Constipation may occur alongside a rectocele, but it is not sufficient on its own to establish the diagnosis.

How Can You Distinguish Between a Rectocele and Hemorrhoids?

Comparison	Rectocele	Hemorrhoids
Nature of the condition	Bulging of the rectum toward the vagina	Swelling of blood vessels in the anal area or lower rectum
Location of the bulge	Inside the vagina or near its opening	At the anal opening or inside the anal canal
Common symptoms	Difficulty passing stool and a feeling of incomplete bowel emptying	Itching, pain, or rectal bleeding
Bleeding	Not a typical symptom	May occur, particularly during bowel movements
Diagnosis	Clinical examination, including examination of the vagina and pelvic floor	Examination of the anal area; a rectal examination may also be necessary

Diagnosis of Rectocele

Diagnosing a rectocele involves reviewing the patient's symptoms and medical history and performing a clinical examination to assess the posterior vaginal wall and the degree of bulging. In some cases, the doctor may recommend additional tests to determine how the rectocele affects bowel movements and to rule out other associated disorders.

First: Steps in Diagnosing a Rectocele

1. Reviewing Symptoms and Medical History

The doctor begins by asking questions about the patient's symptoms and medical and obstetric history. Important questions may include:

• Whether the patient has chronic constipation or difficulty emptying the bowels.

• Whether she feels that bowel emptying is incomplete after passing stool.

• Whether she feels a lump or bulge inside the vagina.

• Whether she needs to strain excessively or use her hand to help pass stool.

• Whether she has had previous vaginal deliveries or pelvic surgery.

• How much the symptoms affect her daily activities and quality of life.

This information helps the doctor assess the likelihood of a rectocele and determine which examinations may be appropriate.

2. Pelvic and Vaginal Examination

A clinical examination is one of the most important steps in diagnosis. The doctor examines the posterior vaginal wall to identify any bulging and assess its degree and location.

The patient may be asked to strain as though having a bowel movement so the doctor can observe the bulge more clearly and determine the extent of vaginal wall descent.

In many cases, a clinical examination is sufficient to diagnose a rectocele without additional tests.

3. Rectal Examination

The doctor may perform a digital rectal examination to assess the rectum and surrounding area and check for other problems that could cause similar symptoms.

In some cases, the doctor may combine a vaginal examination with a rectal examination to assess the tissue separating the rectum from the vagina and identify other disorders, such as hemorrhoids or pelvic floor muscle problems.

Second: Does a Rectocele Require Imaging or Laboratory Tests?

Not all cases of rectocele require imaging or laboratory tests, as many can be diagnosed through medical history and clinical examination alone. However, the doctor may request additional tests when symptoms are unclear, the examination findings do not match the reported symptoms, or surgery is being considered.

Examination	When Is It Used?
Defecography	To assess the shape of the rectum during bowel movements, the degree of bulging, and how completely the bowel empties.
Dynamic Pelvic MRI	To evaluate the movement of pelvic organs and supporting tissues, especially in complex cases or when more than one type of prolapse is suspected.
Anorectal Manometry	When dysfunction of the anal or rectal muscles, or poor coordination of the muscles during bowel movements, is suspected.
Colonoscopy	When medically indicated, such as in cases of rectal bleeding or persistent changes in bowel habits. It is not used solely to diagnose a rectocele.

The doctor may recommend other tests depending on the patient's symptoms and clinical findings.

Third: Which Doctor Is Best Qualified to Diagnose a Rectocele?

The choice of doctor depends on the patient's main symptoms:

• A gynecologist specializing in pelvic organ prolapse: If the main symptom is a bulge inside the vagina or a feeling of pelvic pressure and heaviness.

• A colorectal surgeon: If the main problem is difficulty passing stool, anal symptoms, or disorders affecting rectal emptying.

• A pelvic floor dysfunction specialist: May be involved in the assessment and treatment if there are problems with bowel movement coordination or weakness of the pelvic floor muscles.

Rectocele Surgery: When Is It Performed, and What Are the Types?

First: When Is Rectocele Surgery Recommended?

Surgery is not recommended simply because a rectocele has been identified during a clinical examination or on imaging. Instead, it may be considered when the condition causes bothersome symptoms that affect daily life and do not improve sufficiently after appropriate conservative treatment.

The following situations may warrant consideration of surgery:

• A noticeable vaginal bulge that causes discomfort or interferes with daily activities.

• Persistent difficulty passing stool or a feeling that the rectum does not empty completely.

• Repeatedly needing to use the hand to help remove stool.

• Persistent symptoms despite treatment for constipation and changes in daily habits.

• Associated pelvic organ prolapse that requires surgical intervention.

Before deciding on surgery, it is important to assess pelvic floor muscle function, rule out defecatory muscle coordination disorders, and confirm that the rectocele is the primary cause of the symptoms. Repairing the rectocele alone may not provide sufficient improvement if another underlying problem is present.

There is no single operation that is suitable for every case. The choice of surgical technique depends on the location of the rectocele, the degree of bulging, associated symptoms, and whether other pelvic organs are also prolapsed.

Second: Types of Rectocele Surgery

1. Transvaginal Repair

This is one of the commonly used approaches.

The procedure is often known as posterior colporrhaphy and aims to strengthen the tissues separating the rectum from the vagina.

How is the procedure performed?

1. The patient receives general or spinal anesthesia, depending on the case.

2. An incision is made in the posterior vaginal wall.

3. The vaginal tissues are separated from the rectum to access the weakened area.

4. The supporting tissues are brought together and sutured to strengthen the barrier between the rectum and vagina.

5. Excess vaginal lining may be removed if necessary, and the surgical incision is then closed.

When is it used?

It is used when a vaginal bulge and weakness of the posterior vaginal wall are the main problems requiring repair.

What are the potential risks?

• Recurrence of the rectocele or persistence of some symptoms.

• Bleeding or infection.

• Pain during sexual intercourse.

• Rectal injury in rare cases.

2. Transperineal Repair

The perineum is the area between the vaginal opening and the anus.

How is the procedure performed?

1. A surgical incision is made in the perineal area.

2. The weakened tissues between the rectum and vagina are accessed.

3. The tissues are brought together and sutured to strengthen the supporting area.

4. Perineal weakness or certain associated injuries to the anal sphincter may also be repaired if present and requiring treatment.

When is it used?

It may be used in selected cases, particularly when the rectocele is associated with perineal weakness or a previous injury to the tissues and muscles surrounding the anus.

What are the potential risks?

• Pain in the perineal area.

• Infection or problems with wound healing.

• Pain during sexual intercourse.

• Recurrence of the bulge or persistent difficulty passing stool.

3. Transanal Repair

This operation is performed through the anus and aims to reduce the pocket created by the bulging anterior wall of the rectum.

How is the procedure performed?

1. The weakened area is accessed from inside the rectum.

2. The weakened tissues are folded and sutured to reduce the bulge.

3. In some techniques, a portion of excess mucosal tissue may be removed, depending on the nature of the condition.

When is it used?

It may be considered in selected cases when difficulty passing stool or impaired rectal emptying are the main symptoms. Its suitability depends on the specific anatomy of the condition and the presence of other associated disorders.

What are the potential risks?

• Persistent constipation or difficulty passing stool.

• A feeling of urgency or a sudden, compelling need to have a bowel movement.

• Recurrence of the rectocele.

• Bowel control problems in some patients.

This approach may not be suitable for some patients who already have fecal incontinence.

4. Abdominal Repair

Surgery may be performed through the abdomen using laparoscopy or robotic assistance, and sometimes through open surgery.

One procedure used in selected cases is ventral rectopexy, which involves fixing the rectum from the front.

How is the procedure performed?

1. When minimally invasive surgery is used, the surgeon accesses the pelvis through small abdominal incisions.

2. The tissues surrounding the anterior part of the rectum are mobilized as needed.

3. The rectum is lifted and fixed in place to support its anatomical position, using sutures or a supportive material in some techniques.

4. Associated prolapse may also be treated if intervention is necessary.

When is it used?

This approach may be considered when there is internal rectal prolapse or other pelvic disorders, or in selected cases that require rectal fixation. It is not the standard option for every isolated rectocele.

What are the potential risks?

• Bleeding or injury to the bowel and nearby organs.

• Abdominal adhesions.

• Recurrence or persistence of symptoms.

• Complications associated with supportive material, if used, such as infection, erosion, or fistula formation in rare cases.

5. Stapled Transanal Rectal Resection (STARR)

The full name is Stapled TransAnal Rectal Resection.

This technique uses a surgical stapling device to remove a specific portion of excess rectal tissue.

How is the procedure performed?

1. A surgical stapling device is inserted through the anus.

2. The targeted portion of tissue is removed, and the edges of the remaining tissue are stapled together.

When is it used?

It may be considered in selected cases of defecatory disorders associated with internal rectal prolapse or excess tissue suitable for this technique.

Important note: This procedure is not a routine treatment for all cases of rectocele and should not be selected automatically simply because a rectocele is present. It carries potential risks, including bleeding, pain, fecal urgency, rectal injury, and fistula formation. Its suitability should be carefully assessed by an experienced specialist.

Third: Additional Techniques That May Be Used During Surgery

These techniques are not necessarily separate operations. Instead, the surgeon may add them to the primary procedure depending on the location of the weakness and the examination findings.

Technique	Purpose
Tissue Plication	Bringing the supporting tissues together and suturing them to strengthen the barrier between the rectum and vagina.
Site-Specific Repair	Repairing a specific area of tearing or weakness in the supporting tissues.
Perineorrhaphy	Strengthening the perineal area when associated weakness or widening is present.
Levatorplasty	Bringing certain pelvic floor muscles closer together in selected cases, while considering the potential risk of increased pain during sexual intercourse.
Repair of Associated Pelvic Organ Prolapse	Treating a bladder prolapse, uterine prolapse, or enterocele if the condition warrants intervention.

Is Surgical Mesh Used to Repair a Rectocele?

The use of supportive materials depends on the type of operation and the location where the material would be placed.

• In transvaginal repair: Synthetic mesh is generally not recommended for routine rectocele repair because of potential risks such as tissue erosion, chronic pain, infection, and fistula formation.

• In some abdominal rectal fixation procedures: A supportive material may be used depending on the technique and the patient's medical condition. The potential benefits and risks should be discussed with the surgeon.

Using mesh does not necessarily lead to better outcomes for every patient. The decision should therefore be based on specialist assessment and a discussion of the available alternatives.

Fifth: How Is the Most Appropriate Surgical Technique Chosen?

The choice depends on several factors, including:

• The degree and location of the rectocele.

• The extent to which it affects bowel movements and daily life.

• The presence of prolapse affecting other pelvic organs.

• The condition of the perineal muscles and anal sphincter.

• The presence of defecatory muscle coordination disorders.

• The patient's surgical history and general health.

Tips for Managing a Rectocele

1. Daily Tips to Make Bowel Movements Easier

Gradually increase your fiber intake

Include vegetables and fruits, such as kiwi and pears, as well as oats and whole grains. Increase your fiber intake gradually to reduce the likelihood of gas and bloating.

Drink enough water

Drinking water regularly helps soften stool, especially when increasing fiber intake. Fluid requirements vary depending on your health and physical activity. If you have heart or kidney disease that requires fluid restriction, follow your doctor's advice.

Adjust your position on the toilet

Place your feet on a low footstool so that your knees are slightly higher than your hips. Lean your torso forward, relax your abdomen, and breathe calmly. Avoid excessive straining and holding your breath while having a bowel movement.

Walk regularly

Moderate physical activity, such as walking, can help improve bowel movement and reduce constipation. Choose an activity that suits your ability.