What is a rectocele? Symptoms, causes and when to see a doctor

The rectum and the vagina lie side by side. They are separated by a thin but strong layer of connective tissue called the rectovaginal septum. From below, the pelvic floor muscles hold them both up like a hammock.

When this layer weakens or tears, the pressure created during a bowel movement pushes the front wall of the rectum toward the vagina. At first, a small dip forms. As straining continues over the years, it grows and turns into a pocket that fills with stool. During a bowel movement, part of the stool goes into this pocket instead of toward the anus, the bowel doesn't empty completely, and the woman strains even harder. This creates a vicious circle.

A rectocele is not cancer and is not life-threatening. But it doesn't go away on its own, and if left untreated, it can grow over time. In everyday speech it is sometimes called a “rectal hernia” or a “bowel prolapse,” and you may also see the British spelling “rectocoele.”

Rectocele grades

A rectocele is divided into three grades according to its size and how far it has descended:

1. Grade I (small). The bulge is small and stays inside the vagina. It often causes no symptoms and is found by chance during an examination.
2. Grade II (moderate). The bulge reaches the vaginal opening. Straining, a feeling of incomplete emptying and the need to help with a finger appear.
3. Grade III (large). When you strain, the bulge comes out beyond the vaginal opening. The symptoms make daily life seriously difficult.

Defecography (an X-ray study taken while you empty your bowel) also measures the depth of the pocket: usually, up to 2 cm is considered a small rectocele, 2–4 cm a moderate one, and more than 4 cm a large one. But treatment decisions are based on symptoms, not only on size: a small rectocele that causes no complaints usually doesn't need surgery.

The main cause of a rectocele is vaginal childbirth. As the baby passes through the birth canal, the rectovaginal septum and the pelvic floor muscles are stretched to their limit. Sometimes tears that can't be seen with the naked eye remain in these tissues. Factors that increase the risk:

• a large baby and a long pushing stage;
• a vacuum or forceps delivery;
• a perineal tear or cut (episiotomy);
• several births, especially close together.

In the first months after childbirth, a feeling of heaviness in the perineum and mild discomfort on the toilet are often normal: these complaints ease as the pelvic floor gets stronger. If the symptoms persist or get worse as the months go by, that is a serious reason to get examined.

A rectocele often shows up not right after childbirth but years later, especially at menopause. As estrogen levels fall, the tissues become thinner, and the spot that was weakened during childbirth “opens up.” Chronic constipation, heavy lifting, a long-lasting cough and excess weight also speed up this process.

A rectocele can also occur in women who gave birth by C-section or have never given birth, but less often. In men, it is very rare. You can read about other changes after childbirth in our article 5 intimate problems after childbirth.

The following questions help you make sense of your symptoms and prepare for a conversation with your doctor:

• Do you have to strain hard on the toilet even when your stool is soft?
• After a bowel movement, do you feel that your bowel hasn't emptied completely, and do you need to go again soon afterward?
• Do you press with a finger on the vagina, the perineum or next to the anus to have a bowel movement?
• Do you feel fullness, pressure or a bulge in the vagina, and does it get worse toward evening?
• Do you have pain or discomfort during sex?
• Have you been using laxatives, suppositories or enemas for years without solving the problem?
• Do you notice slight soiling of your underwear after a bowel movement?

If you answer “yes” to several of these questions, it's a good idea to get examined. But this list is not meant for self-diagnosis: similar symptoms can also be caused by other types of constipation, hemorrhoids (piles), an anal fissure or poor coordination of the pelvic floor muscles. Only an examination can give you a definite answer.

Why does stool come out when you press with a finger?

When you press on the back wall of the vagina or on the perineum, the pocket closes temporarily. Stool no longer fills the pocket and is directed along the right path, toward the anus. Women often discover this trick on their own, without ever hearing about it from anyone. There is nothing shameful about it, and you are not the only one who does it. But it isn't normal: needing to help with a finger is the most typical sign of a rectocele and reason enough to get examined.

We often hear the same story at appointments: a woman has suffered from constipation for years and “gets by” with laxatives, suppositories and enemas. Some manage to have a bowel movement only with these helping maneuvers for 10–15 years. Meanwhile, the rectocele keeps growing. There are several reasons why it is recognized so late:

• The symptom looks very much like constipation. But there is a difference: with a rectocele, the stool is often soft; the problem is that it can't get out.
• Embarrassment. It is hard to talk about helping with a finger, so women don't mention it to the doctor. Yet this very symptom is the key to the diagnosis.
• The idea that “this is just what happens after childbirth.” Many women see these changes as an inevitable mark of giving birth and simply put up with them.
• Treatment without an examination. Constipation remedies are often bought at the pharmacy without seeing a doctor.

An untreated rectocele often doesn't stop at one problem. Prolonged straining can lead to hemorrhoids, and stool that hardens in the pocket can lead to an anal fissure. As a result, a woman comes to the doctor with not one but several problems. If laxatives don't help, the real cause of the constipation needs to be investigated.

Many women put off seeing a doctor because they are afraid of the examination. In fact, it is short and simple:

1. Conversation. We ask about your births, how long you have had constipation, how you help yourself on the toilet and which medicines you take. Speak openly: there are no embarrassing questions here.
2. Physical exam. In a private setting, while you lie down, the back wall of the vagina and the rectum are checked with a finger. You will be asked to strain for a moment so that the size of the bulge can be seen.
3. Anoscopy. The anal canal is examined with a small instrument to find out whether there are hemorrhoids, a fissure or a polyp.
4. Additional tests, if needed. Defecography shows how the rectum empties during a bowel movement. If there is bleeding, or if it is indicated because of your age, a colonoscopy is recommended.

The exam usually takes a few minutes and, in most cases, is painless. It is performed by a female doctor.

Usually no special preparation is needed. Bring a list of the medicines you use for constipation, the results of previous tests and any surgical discharge summaries. Write the questions you want to ask on your phone in advance so you don't forget them because of nerves.

Treatment is chosen according to your symptoms and the grade.

Non-surgical treatment. For a small rectocele, and in the time before surgery, a high-fiber diet, enough fluids, stool softeners prescribed by your doctor, good toilet habits and pelvic floor exercises can significantly reduce symptoms. In some cases, biofeedback therapy (exercises in which you watch your muscles working on a screen) or a pessary (a supportive ring placed in the vagina) is recommended. These measures don't get rid of the pocket, but they slow its growth.

Surgical treatment. For a moderate or large rectocele that causes symptoms, the main treatment is surgery (rectocele repair). Working through the vagina, with no incision on the abdomen, the surgeon repairs the weakened septum and strengthens the pelvic floor muscles (posterior colporrhaphy and anterior levatorplasty). If indicated, hemorrhoids or an anal fissure can be treated in the same session. You can read more about how the operation is done, how long it takes and what recovery involves on our rectocele repair page.

It isn't always possible to prevent a rectocele completely, but you can reduce the risk and slow the growth of an existing one:

• avoid constipation: eat vegetables, fruit and whole grains every day and drink enough water;
• don't strain on the toilet: take your time, put a small footstool under your feet and don't sit there for long with your phone;
• do pelvic floor exercises: during pregnancy, after childbirth and at menopause; the correct technique is explained on our aesthetic proctology page;
• don't put off your first bowel movement after childbirth: if needed, use a stool softener on your doctor's advice;
• lift heavy things correctly: bend your knees and don't hold your breath;
• treat a chronic cough and keep your weight under control.

You'll find more tips on diet and toilet habits in our article 5 golden rules against constipation.

See a proctologist if:

• you have to help with a finger to have a bowel movement;
• laxatives don't help, or you can't have a bowel movement without them;
• you see or feel a bulge in the vagina;
• anal pain, burning or bleeding has come on top of constipation;
• sex has become painful.

If you have bleeding from the anus, a sudden change in your bowel habits, unexplained weight loss or anemia, don't delay an examination: these are not symptoms of a rectocele, and other bowel diseases need to be ruled out.