A rectocele repair is a surgical procedure that corrects a bulge where the rectum pushes into the back wall of the vagina. This bulge, called a rectocele, happens when the tissue separating the vagina from the rectum weakens, often after childbirth, chronic straining, or aging. The repair reinforces that wall so the rectum stays in its normal position, relieving symptoms like difficulty emptying the bowels, pelvic pressure, and a feeling of something bulging out of the vagina.
Why the Repair Is Done
Not every rectocele needs surgery. Small ones often cause no symptoms at all, and asymptomatic prolapse does not require treatment. Surgery is considered when symptoms are severe enough to affect daily life and haven’t improved with conservative options like pelvic floor physical therapy or a pessary (a removable device inserted into the vagina to hold tissues in place).
There is no single prolapse stage that automatically qualifies someone for surgery. The decision is individualized, based on your symptoms, overall health, age, and personal preference. Pelvic floor therapy and pessaries are typically tried first, with surgery reserved for cases where those approaches fall short.
How the Surgery Works
The most common version of this procedure is called a posterior colporrhaphy, performed entirely through the vagina with no external incisions on the abdomen. The surgeon makes an incision along the back wall of the vagina, then separates the vaginal lining from the weakened connective tissue underneath. That connective tissue layer, which sits between the vagina and rectum, is then folded over itself and stitched together in the midline to create a stronger barrier.
In many cases, the pelvic floor muscles on either side are also brought closer together with stitches, adding structural support. The surgeon then trims any excess vaginal tissue, closes the vaginal wall, and reconstructs the perineal body (the tissue between the vaginal opening and the anus). This last step, sometimes called a perineorrhaphy, reinforces the bottom of the repair and restores the opening to a more normal size. All the sutures used are absorbable, meaning they dissolve on their own over the following weeks.
The entire procedure typically takes under an hour and can be performed under general anesthesia or regional anesthesia (a spinal or epidural block). Most women go home the same day or after one night in the hospital.
Native Tissue vs. Mesh Repair
The standard approach uses your own tissue to rebuild the vaginal wall. In the past, synthetic mesh was sometimes placed through the vagina to reinforce the repair. While vaginal mesh does lower the chance of feeling the prolapse come back and reduces the rate of repeat surgery for prolapse specifically, it introduces significant risks of its own.
A large Cochrane review found that about 12% of women who received permanent transvaginal mesh experienced mesh exposure, where the material erodes through the vaginal wall. Roughly 6% needed additional surgery just to address the mesh complication. Mesh was also linked to higher rates of new stress incontinence and bladder injury. When all repeat surgeries were combined (for prolapse, incontinence, or mesh problems), women in the mesh group actually needed more total reoperations than those who had native tissue repair alone.
Absorbable meshes and biological grafts have also been studied, but neither showed a clear advantage over native tissue repair. Given this risk-benefit profile, current guidelines recommend that permanent transvaginal mesh has limited use in primary prolapse surgery. For most women undergoing a rectocele repair, native tissue is the preferred approach.
Pessary vs. Surgery
If you’re weighing whether to try a pessary first, a Mayo Clinic trial offers some perspective. Of 40 women who tried both a pessary and surgery, 33 preferred the surgical outcome, five felt the results were equal, and only two felt the pessary worked better. That said, about 19% of participants who tried a pessary decided it controlled their symptoms well enough and chose not to have surgery at all. A pessary is a reasonable first step, especially if you want to avoid or delay an operation.
Risks and Complications
Rectocele repair is generally safe, but like any surgery it carries risks. The most common concerns include:
- Pain during sex (dyspareunia). New onset pain with intercourse occurs in roughly 2 to 3% of women after pelvic prolapse surgery. Having had a previous posterior repair or experiencing pain before surgery increases that risk.
- Recurrence. The prolapse can return over time. One 10-year retrospective study found that recurrence happened in nearly one-third of cases, though the vast majority did not need a second operation. The actual reoperation rate was under 6%.
- Bleeding and infection. These are standard surgical risks, typically mild and manageable.
- Urinary issues. Some women experience temporary difficulty urinating in the first days after surgery.
Younger age, lower body weight, and having a less advanced prolapse at baseline have all been identified as factors that may increase the risk of postoperative pain with intercourse, possibly because these patients have tighter tissues to begin with.
Recovery Timeline
Full recovery takes three to six weeks. During the first week or two, expect soreness, swelling, and some vaginal discharge. Most women with desk jobs return to work within two to three weeks, while those with physically demanding jobs may need up to six weeks off.
You can resume activities like lifting, running, and high-impact exercise when you feel strong enough, though most surgeons recommend easing back in gradually. Sexual intercourse is restricted for a period after surgery to allow the vaginal incision to heal. Your surgeon will give you a specific timeline, but six to eight weeks is common. Driving is usually fine once you’re off pain medication and can brake comfortably, which for many women is about one to two weeks.
What Results to Expect
Most women notice significant improvement in their bowel symptoms, pelvic pressure, and the sensation of vaginal bulging. The repair physically restores the wall between the vagina and rectum, so the mechanical cause of symptoms is directly addressed. Patient satisfaction is generally high, and the majority of women who have the surgery would choose it again over a pessary alone.
That said, about one in three women will see some degree of recurrence on examination over the following decade. Recurrence on exam doesn’t always mean symptoms come back, which is why the reoperation rate stays much lower than the anatomical recurrence rate. Maintaining pelvic floor strength through exercises, managing chronic constipation, and avoiding heavy straining can all help protect the repair long-term.