Rectocele

What is a rectocele (posterior vaginal wall prolapse)?

A rectocele is a condition where the tissue between your rectum and vagina weakens, causing your rectum to bulge onto your vagina's back wall. Your rectum is the bottom part of your colon (large intestine). Both your rectum and vagina stay in position because the muscles and ligaments in your pelvis, called your pelvic floor, hold them in place. When your pelvic floor weakens, these organs can shift and even fall onto each other.

Rectocele is one form of pelvic organ prolapse (POP), a condition where organs droop because of a weak pelvic floor. Often, rectocele happens with other forms of pelvic organ prolapse, where organs like your uterus or bladder shift out of place, too.

Rectocele is also called posterior vaginal wall prolapse.

Who do rectoceles affect?

Rectoceles are most commonly diagnosed in females who are over 60. Still, you can get a rectocele no matter your age or sex.

How common are rectoceles?

Rectoceles are common, probably even more than we know. Minor rectoceles often don't cause symptoms, which means that many people likely never visit their providers for this complaint or receive a diagnosis.

What are the symptoms of a rectocele?

Rectoceles don't always cause symptoms. When they do, they're usually more unpleasant or uncomfortable than painful.

Signs of a rectocele include:

• A sensation of pressure or fullness in your rectum or vagina.
• A soft bulge of tissue that may or may not poke through your vagina.
• Feeling that your rectum hasn't completely emptied after pooping.
• Having the urge to poop several times a day.
• Experiencing discomfort during intercourse (dyspareunia).
• Sensing a feeling of looseness or loss of muscle tone in your vagina.
• Having to press your fingers on the bulge in your vagina to push out a stool during a bowel movement ("splinting").

If you have a rectocele along with another form of prolapse where your bladder sags, you may also experience urinary incontinence. You may feel the urge to pee frequently, or you may dribble.

What causes a rectocele?

A rectocele occurs when your pelvic floor weakens. Several factors can contribute:

• Pregnancy and childbirth: Vaginal childbirth, especially multiple births, can damage or weaken your pelvic floor. Prolonged labor and large newborns can stretch your pelvic floor muscles, leading to weakened support for your vagina.
• Aging: Your pelvic floor can weaken over time. Menopause causes many changes in your body, which can lead to decreased muscle tone in your pelvic region.
• Chronic cough or bronchitis: Prolonged coughing associated with asthma, smoking and respiratory disease can also strain your pelvic floor over time, making you more susceptible to rectocele.
• Chronic constipation: Bearing down or straining too hard to poop can weaken your pelvic muscles over time.
• Repeated heavy lifting. Having a job that involves frequent heavy lifting can place too much strain on your pelvic floor muscles, causing them to stretch and weaken.
• Having a heavier body: Having obesity can increase your risk of rectocele.
• Previous surgery: Surgeries involving your pelvic organs (like a hysterectomy) may damage the tissue in your pelvic floor.

How is a rectocele diagnosed?

Gynecologists can often diagnose a rectocele with a thorough medical history and physical exam.

Diagnosis may include:

• Pelvic exam: In addition to examining your vaginal canal for signs of prolapse, your provider may test your pelvic floor strength during the exam. They may ask you to squeeze and relax your pelvic floor muscles as if you were stopping a stream of pee. They may also ask that you apply pressure to your gut or strain as if you were pooping. Doing this makes your prolapse more visible.
• Imaging: Imaging isn't often used for rectocele diagnosis. In rare instances, your provider may order a transvaginal ultrasound to check if your small intestine has prolapsed (enterocele). They may order a special X-ray called a defecography. A defecography shows the changes in your rectum when you poop. It can show how severe a rectocele is.

How is rectocele treated?

Mild rectoceles may be managed with pelvic floor exercises to strengthen your pelvic floor muscles. Your healthcare provider may also recommend a pessary. A vaginal pessary is a removable device inserted into your vagina to support prolapsed organs.

With moderate to more severe prolapse, your healthcare provider may recommend surgery to repair the rectocele. You may discuss the following with your provider to determine the right procedure:

• Your age and general health.
• The degree of your prolapse.
• Your desire for future pregnancies.
• Your wish to continue having intercourse (one surgery for POP called colpocleisis seals your vaginal opening).

A surgical procedure called posterior colporrhaphy is commonly used to repair rectoceles. During the procedure, your provider removes damaged tissue that's no longer supporting your pelvic organs and sutures the healthy tissue together for added support.

Often, your provider performs rectocele surgeries through your vagina, an approach that leaves no scars.

Can rectocele be prevented?

You can't prevent a rectocele or pelvic organ prolapse. Still, you can put good practices into place that can strengthen your pelvic floor. Many of the same strategies used to manage mild cases of rectocele can be used to reduce your risk of prolapse.

• Perform Kegel exercises regularly. Kegel's can strengthen your pelvic floor muscles, which is especially important after childbirth. Ask your healthcare provider about when it's safe to perform Kegel's after you've had your baby.
• Treat and prevent constipation. Drink plenty of fluids and eat high-fiber foods, such as fruits, vegetables, beans and whole-grain cereals. Aim for 25 to 35 grams of fiber daily and eight glasses of water. Use stool softeners if you need them.
• Avoid heavy lifting and lift correctly. When lifting, use your legs instead of your waist or back. Get help when lifting heavier objects.
• Manage a cough. Get treatment for a chronic cough or bronchitis and don't smoke.
• Maintain a healthy weight. Talk with your doctor to determine your ideal weight and get advice on weight-loss strategies if you need them.

What can I expect if I have this condition?

Your outlook depends on your symptoms and how severe your prolapse is. Most people who receive surgery for rectocele experience symptom relief after their procedure.

Speak with your provider about the outlook for your rectocele based on the treatments they recommend for you.

Can rectocele go away on its own?

No. A rectocele occurs because of injury or long-term weakening of your pelvic floor. It doesn't heal on its own without treatment.

What happens if a rectocele goes untreated?

Rectocele can worsen without treatment. Not every rectocele requires surgery. Still, depending on the severity of your rectocele, you may need to increase your fiber intake, perform daily Kegel's, use a pessary, etc. Follow the treatment plan that you and your provider decide works best.

How do you poop with a rectocele?

With severe prolapse, you may need to use your fingers to hold your vaginal wall up so that you can poop. This process is called "splinting." You may have to use a finger to nudge the poop out. Ensure that your finger is clean (bacteria-free) before inserting it into your vagina. Wash with mild soap and water.

When prolapse is this severe, it's a good idea to speak to your provider about treatment options.

What questions should I ask my doctor?

• What lifestyle changes may ease my symptoms?
• How can I prevent my rectocele from getting worse?
• How can I prevent other forms of pelvic organ prolapse?
• Would you recommend surgery? If so, what are the risks?
• What are the success rates for the type of surgery you'd recommend?
• Will treatment negatively impact my sex life in any way? My chances of pregnancy?

Can poop get stuck in a rectocele?

Yes. With severe prolapse, stool can become trapped in the pocket formed by the rectocele, preventing stools from passing easily. In this case, you may have to try splinting to pass a stool. Talk to your provider about treatment options if you have to use your fingers to have a bowel movement.

What does a rectocele feel like to touch?

Your rectocele may be so slight that you can't feel it. If the prolapse is more pronounced, it may feel like a bulge or lump in the back wall of your vagina. You can insert a (clean) finger or two to feel for a rectocele. Place pressure on the back part of your vaginal wall so that you're pressing the tissue closest to your rectum. Bulging tissue in this area is a sign of a rectocele.

What is the difference between a rectocele and a cystocele?

Both rectocele and cystocele are conditions that involve pelvic organs shifting out of place because of a weakened pelvic floor. With a rectocele, weaknesses in the pelvic floor cause the rectum to bulge onto your back vaginal wall. With a cystocele, weaknesses cause your bladder to bulge onto the front vaginal wall. These types of prolapse sometimes happen together, along with other forms of pelvic organ prolapse.