A rectocele is a type of pelvic organ prolapse that occurs when the rectovaginal septum, the wall of fibrous tissue separating the rectum from the vagina, weakens. This allows the front wall of the rectum to bulge into the back wall of the vagina. The severity of a rectocele can range from a small, unnoticeable bulge to a more significant protrusion.
Visual Signs and Physical Symptoms of a Rectocele
The symptoms of a rectocele vary depending on the severity of the prolapse, and some individuals may not experience any. For those who do, a direct sign is a soft, fleshy bulge of tissue that can be felt or seen in the vagina. This bulge may become more prominent when bearing down, such as during a bowel movement, or after prolonged standing. In advanced cases, the tissue may protrude through the vaginal opening.
A rectocele can also cause a feeling of pressure or fullness in the pelvic and rectal areas. This is often accompanied by a persistent feeling that the rectum has not been completely emptied after a bowel movement. This sensation occurs because stool can become trapped in the pocket created by the rectocele, preventing complete evacuation.
To address this, some individuals need to manually press on the bulge within the vagina or on the skin between the vagina and anus to help pass stool, an action known as splinting. Other symptoms can include constipation, discomfort during sexual intercourse, and low back pain.
Underlying Causes and Risk Factors
A rectocele develops from the weakening of the pelvic floor muscles and the rectovaginal septum, often due to sustained pressure. Childbirth, particularly vaginal delivery, is a primary contributing factor. The process can stretch and tear supportive tissues, especially with multiple births, difficult labor, or the use of forceps or vacuum assistance.
Chronic pressure from other sources also increases risk. Long-term constipation with associated straining, a chronic cough, or frequent heavy lifting can all weaken these supportive structures over time.
Hormonal shifts and age-related changes also contribute. The decrease in estrogen during and after menopause can lead to thinner, weaker pelvic tissues. Other risk factors include a history of pelvic surgery, such as a hysterectomy, and being overweight, which adds extra pressure to the pelvic region.
The Diagnostic Process
A rectocele diagnosis begins with a physical pelvic examination. During the exam, a healthcare provider will inspect the vaginal canal, sometimes using a speculum, to identify a bulge along the back wall of the vagina.
To assess the severity of the prolapse, the provider may ask you to cough or bear down as if having a bowel movement. These actions increase pressure within the pelvis, making the bulge more visible and helping determine its size. The provider may also assess the strength of the pelvic floor muscles by asking you to squeeze them.
If symptoms are complex or the diagnosis is uncertain, imaging tests may be ordered. A specialized test called defecography uses X-ray or MRI to capture the movement of the rectum during a simulated bowel movement. This provides detailed information about the size of the rectocele and how effectively the rectum empties.
Management and Treatment Approaches
Managing a rectocele depends on the severity of the symptoms, and treatment may not be necessary for mild cases. Non-surgical management is the first line of defense and focuses on lifestyle changes. This includes dietary adjustments, such as increasing fiber and fluid intake, to prevent constipation and avoid straining.
Pelvic floor muscle exercises, known as Kegels, can strengthen the muscles that support the pelvic organs. Another non-surgical option is a pessary, a small silicone device inserted into the vagina. A pessary provides structural support to the vaginal walls, helping to hold the prolapsed tissue in place.
Surgery may be considered for rectoceles that cause significant discomfort or interfere with daily life, especially if conservative treatments fail. The most common procedure is a posterior colporrhaphy, where a surgeon makes an incision in the back wall of the vagina. Stitches are then used to repair and strengthen the rectovaginal septum.