What Is a Rectocele? Symptoms, Causes and Non-Surgical Treatment

If you have been diagnosed with a rectocele, or you are dealing with pressure, fullness in the vagina and difficulty having a bowel movement, it is completely normal to feel worried. Many women only learn what a rectocele is when they face this problem themselves. Yet a rectocele is a common pelvic floor problem that can be managed in different ways depending on your symptoms.

The aim of rectocele treatment is not only to correct the bulge seen during an examination. The real goal is to make bowel movements easier, reduce the feeling of pressure in the vagina and make everyday life and your sex life more comfortable.

What is a rectocele?

A rectocele is a bulging of the rectum into the back wall of the vagina, caused by weakening or stretching of the supporting tissue between the rectum and the vagina. That is why it is also called posterior vaginal wall prolapse.

The bladder sits in front of the vagina and the rectum behind it. The connective tissue and pelvic floor muscles between the rectum and the vagina support this area. When these support structures weaken, the rectum can push forward into the vagina.

A rectocele is not the same as rectal prolapse, in which the rectum protrudes out through the anus. Because the symptoms can be similar, the correct diagnosis should be made through an examination.

What are the symptoms of a rectocele?

Small rectoceles may cause no symptoms at all and may be noticed during a routine gynecological exam. When symptoms do occur, the most common are:

• A feeling of pressure, heaviness or fullness in the vagina

• A feeling that something is coming out of the vagina or that a tampon is slipping down

• A soft bulge you can feel at the vaginal opening

• Constipation and straining during bowel movements

• A feeling that the bowel has not emptied completely

• Spending a long time on the toilet and needing to strain a lot

• Needing to support the back wall of the vagina or the perineum with your fingers to finish a bowel movement

• Wanting to go to the toilet again after a bowel movement

• Difficulty controlling gas or stool

• Discomfort or pain during intercourse

• Pelvic pressure that gets worse later in the day or after standing for a long time

The grade of a rectocele on examination does not always match the symptoms a person experiences. A noticeable rectocele may cause few symptoms, while a smaller one can affect daily life more because of accompanying constipation or a coordination problem in the pelvic floor muscles.

What causes a rectocele?

There is usually no single cause of a rectocele. The load placed on the pelvic floor over the years combines with changes in the supporting tissues. Factors that can increase the risk include:

• Vaginal birth, especially a history of difficult or assisted delivery

• Long-term constipation and frequent straining

• Repeated heavy lifting and poorly managed pressure

• Chronic cough

• Tissue changes that come with menopause

• Aging

• A genetic predisposition related to connective tissue

• Previous pelvic surgery

Having one of these factors does not mean you will definitely develop a rectocele. An assessment should look not only at your birth history but also at your bowel habits, breathing, how you manage intra-abdominal pressure and how your pelvic floor muscles work.

Does a rectocele cause constipation?

A rectocele can make emptying harder by causing stool to collect in the rectum or in the pocket that forms. As a result, you may feel that you have not emptied completely, strain again and again, or need to use your hand for support to finish a bowel movement.

But the relationship works both ways. Long-term constipation and chronic straining also increase pressure on the pelvic floor and can contribute to a rectocele forming or to existing symptoms getting worse. That is why treatment should address not only muscle exercises but also stool consistency and toilet habits.

How is a rectocele diagnosed?

The diagnosis is usually made by an obstetrician-gynecologist or a urogynecologist during a pelvic exam. During the exam you may be asked to cough or bear down so the bulge in the back wall of the vagina can be assessed.

In some cases where difficulty with bowel movements is significant, defecography, dynamic pelvic MRI or other bowel function tests may be needed. This is because the bowel problem may not be due to the rectocele alone; there may also be accompanying functional problems, such as the pelvic floor muscles failing to relax during bowel movements.

Can a rectocele be treated without surgery?

Yes. Non-surgical methods are usually considered first, especially for mild to moderate rectoceles or when symptoms do not seriously limit daily life. Treatment is planned individually and may include the following options:

Pelvic floor physiotherapy

The aim of pelvic floor physiotherapy is not only to strengthen the muscles. First, the strength, endurance, ability to relax and coordination of the muscles with the abdominal muscles are assessed.

In some people the pelvic floor muscles are weak; in others the muscles are overly tense and cannot relax enough during bowel movements. That is why it is not right to give Kegel exercises straight away to every patient with a rectocele. Unnecessary or incorrectly performed squeezing exercises can worsen difficulty with bowel movements and tension in the pelvic area.

A personalized program may include:

• Training to contract and relax the pelvic floor muscles correctly

• Coordinating diaphragmatic breathing with the pelvic floor

• Training to relax and push correctly during bowel movements

• Managing intra-abdominal pressure

• Deep abdominal muscle and trunk control work

• Biofeedback

• Manual therapy when needed

• Correct movement strategies for daily life, exercise and lifting

Physiotherapy may not always eliminate the anatomical bulge completely, but it helps reduce symptoms such as difficulty with bowel movements, a feeling of pressure and strain in daily life.

Managing constipation and toilet habits

In rectocele treatment it is important for stool to be soft and well formed and to reduce unnecessary straining. Drinking enough fluids, getting the right amount of fiber, a toilet routine that suits you and a good position achieved by placing a small step under your feet can make bowel movements easier.

If constipation has lasted a long time, or if there is blood in the stool, unexplained weight loss or a marked change in bowel habits, an assessment by a gastroenterologist is also needed.

Using a pessary

A pessary is a medical device inserted into the vagina to support prolapsed tissue. The right type and size are determined by a physician. It can reduce symptoms, especially when standing for long periods, during exercise, or for people who do not want surgery.

Surgical treatment

Surgery may be considered when symptoms are severe, daily life is significantly affected, or non-surgical treatments have not provided enough relief. The decision to operate should not be based on the grade of the rectocele alone, but should take into account your symptoms, bowel function, whether other pelvic organs are also prolapsed and your expectations for daily life.

Before and after surgery, pelvic floor physiotherapy can be supportive in terms of correct breathing, pressure management, preventing constipation and a safe return to daily activities.

Does a rectocele get worse over time?

The course of a rectocele varies from person to person. Not every rectocele gets worse. Constipation, chronic cough, frequent heavy lifting and repeated straining can increase the load on the pelvic floor. Bringing these factors under control and improving muscle function helps manage symptoms.

What should you watch out for if you have a rectocele?

• Try not to sit on the toilet for a long time or strain while holding your breath.

• Don't treat constipation as a temporary problem; keep track of your stool consistency and bowel routine.

• When lifting something heavy, learn to breathe out with the effort instead of holding your breath.

• Don't follow every Kegel program you find online.

• Rather than giving up exercise completely, find out which movements and load levels are right for you.

• See a doctor if you have a noticeable bulge in the vagina, bleeding, a sore or new severe pain.

Frequently asked questions

Does a rectocele go away on its own?

The change in the supporting tissue usually does not disappear completely on its own. Even so, with the right treatment, pressure, difficulty with bowel movements and the feeling of incomplete emptying can be reduced considerably.

Should you do Kegel exercises for a rectocele?

For some people, pelvic floor muscle exercises done with the correct technique can be helpful. But if the muscles are overly tense or cannot relax during bowel movements, Kegels may not be suitable. Pelvic floor function should be assessed first.

Does a rectocele affect sex?

Some women experience pressure, discomfort or pain during intercourse, while others have no sexual complaints at all. If there is pain, not only the degree of prolapse but also muscle tension and the condition of the tissues should be assessed.

Is surgery necessary for a rectocele?

No. Rectoceles that cause no symptoms or only mild symptoms may not need surgery. Pelvic floor physiotherapy, constipation management and, if needed, a pessary may be among the first options.

Which doctor should you see for a rectocele?

For diagnosis and medical evaluation, you can see an obstetrician-gynecologist or a urogynecologist. If difficulty with bowel movements is the main problem, an assessment by a gastroenterologist or colorectal surgeon may also be needed. To have your pelvic floor muscles and bowel coordination assessed, you can see a pelvic floor physiotherapist.

What does pelvic floor physiotherapy involve?

For rectocele symptoms, the first session includes a detailed assessment of your birth and surgical history, constipation, bowel habits, bladder symptoms, sexual function and situations in daily life that make your symptoms worse. The pelvic floor muscles are assessed not only for strength but also for their ability to relax and coordinate.

Based on the assessment, a personalized program is created. The aim is not to give everyone the same exercises, but to identify the factors keeping your symptoms going, make bowel movements easier, reduce unnecessary load on the pelvic floor and help you return to daily life more safely.

If you are dealing with a rectocele, constipation or a feeling of incomplete emptying, you can contact us for an in-person assessment at our clinic on Bağdat Caddesi in Istanbul or, where appropriate, an online pelvic floor physiotherapy assessment.

References

• Brown HW, et al. International Urogynecology Consultation: Epidemiology of Pelvic Organ Prolapse. International Urogynecology Journal. 2022.

• Deprest JA, et al. Pathophysiology of Pelvic Organ Prolapse. International Urogynecology Journal. 2022.

• Madhu C, et al. The Aetiology, Risk Factors and Management of Pelvic Organ Prolapse. The Obstetrician & Gynaecologist. 2022.

• Ladd M, Tuma F. Rectocele. StatPearls. 2023.