Rectocele treatment and repair: symptoms, diagnosis and surgery

The rectum and the vagina lie side by side. They are separated by a thin but strong layer of connective tissue, the rectovaginal septum. When childbirth, years of straining and age weaken this layer, the front wall of the rectum bulges into the back wall of the vagina and forms a “pocket.” In everyday speech it is also called a “rectal hernia” or a “sagging bowel.”

During a bowel movement, instead of going straight toward the anus, stool fills this pocket. The more a woman strains, the bigger the pocket gets, and the bowel does not empty completely. A rectocele is not cancer and is not life-threatening, but over time it can seriously affect quality of life and lead to other proctological conditions. You can read a detailed plain-language explanation in our article What is a rectocele?

A small rectocele may cause no symptoms at all. As it grows, the following symptoms appear:

• heavy, prolonged straining on the toilet; stool is hard to pass even when it is soft;
• a feeling of incomplete emptying and needing to go again shortly afterward;
• needing to press on the vagina, the perineum or next to the anus with a finger to pass stool;
• a feeling of bulging, fullness or pressure in the vagina, with heaviness that gets worse toward evening;
• pain and discomfort during sex;
• sometimes slight soiling of underwear after a bowel movement.

We want to say a separate word about helping with a finger. You are not the only one who does this, and there is nothing shameful about it. Pressing on the back wall of the vagina closes the pocket and directs the stool the right way. Your body finds its own way out, but this is not normal: it is the most typical sign of a rectocele and needs treatment.

These symptoms are easily mistaken for “ordinary constipation,” so women sometimes receive the wrong treatment for years. Bleeding from the anus, a sudden change in bowel habits and unexplained weight loss, however, are not signs of a rectocele: if you have them, do not delay an examination, because other bowel diseases need to be ruled out.

A rectocele occurs mainly in women and develops from a combination of several factors:

• Vaginal childbirth. Especially a large baby, a long pushing stage, an instrumental delivery, or a perineal tear or cut. The more births, the higher the risk.
• Chronic constipation. Years of straining gradually weaken the septum. Constipation is both a cause and a result: as the rectocele grows, constipation gets worse.
• Heavy lifting, chronic cough, excess weight. These constantly raise the pressure inside the abdomen.
• Menopause. As estrogen levels fall, tissues become thinner and lose their elasticity.
• Congenital weakness of connective tissue and previous pelvic surgery.

In men, a rectocele is very rare. You can read about other causes of constipation on our constipation and digestive problems page.

Defecography also measures the depth of the pocket: a bulge of up to 2 cm is usually considered a small rectocele, 2–4 cm a moderate one, and more than 4 cm a large one. But the treatment decision is based on symptoms, not size.

When the bowel does not empty completely, a woman sits on the toilet for a long time and strains again and again. This causes blood to pool in the veins of the anal area, and hemorrhoids can develop or get worse. Stool left in the pocket hardens and can tear the lining of the anal canal on its way out: this is how an anal fissure forms.

That is why we often see a rectocele together with hemorrhoids or a chronic anal fissure. You can “get by” with laxatives and enemas for years, but in that time one problem can turn into several diseases.

A rectocele is often diagnosed at the first visit. First we ask about your symptoms, your childbirths, how long you have had constipation and how you help yourself on the toilet. Open answers to these questions make the diagnosis much more accurate.

The examination is done lying down, in private, and takes a few minutes. We check the back wall of the vagina and the rectum with a finger and ask you to strain for a moment so that the size of the bulge can be seen. With anoscopy (a look into the anal canal with a small instrument), we check for hemorrhoids, an anal fissure or polyps.

If needed, additional tests are ordered:

• defecography: a contrast X-ray or MRI study that shows how the rectum empties during a bowel movement; it shows the size of the pocket and whether stool stays in it;
• colonoscopy: if there is bleeding, if it is recommended for your age, or if another bowel disease is suspected.

Sometimes the cause of constipation is not a rectocele but pelvic floor muscles that tighten instead of relaxing during a bowel movement. In that case surgery does not help; exercises and biofeedback are needed first. That is why we do not rush the diagnosis.

Treatment is chosen based on the symptoms and the grade. A small rectocele that causes no symptoms often needs only monitoring and prevention of constipation.

Non-surgical (conservative) treatment

In mild cases, and until surgery, these measures can significantly reduce symptoms:

• high-fiber food and enough water: vegetables, fruit, bran, whole grains; soft stool gets stuck in the pocket less often;
• stool softeners: as prescribed by your doctor, so you can have a bowel movement without straining;
• good toilet habits: putting a small stool under your feet, not rushing, not sitting on the toilet for long with your phone;
• pelvic floor exercises and biofeedback: these teach you to tighten and relax the muscles correctly; we explain the exercises step by step on the aesthetic proctology page;
• pessary: a supportive ring placed in the vagina; it can be an option for some women who do not want surgery or are not ready for it yet.

These measures do not get rid of the pocket, but they slow its growth and make bowel movements easier.

Surgical treatment: rectocele repair

If conservative measures do not help and the rectocele makes your life difficult, surgery is the main treatment. We repair a rectocele through the vagina in one operation made up of two parts, with no incision on the abdomen:

• posterior colporrhaphy: an incision is made in the back wall of the vagina, the weakened rectovaginal septum is repaired with stitches, and the rectal wall is returned to its place;
• anterior levatorplasty: the edges of the levator muscles, the main muscles of the pelvic floor, are brought together in front of the rectum and stitched, which strengthens the perineum and gives the rectum support again.

The operation is performed under anesthesia, and we choose the type (spinal or general) together with the anesthesiologist. With spinal anesthesia, you stay awake while the lower half of your body is numb. Depending on its extent, the operation usually takes 30–60 minutes; the exact duration is given after the examination. The stitches dissolve on their own.

When indicated, rectocele repair can be combined in the same session with surgery for hemorrhoids or an anal fissure, vaginoplasty, or a TOT (sling) procedure for stress urinary incontinence. This is called combined (“bouquet”) surgery.

Like any operation, this one has risks: bleeding, wound infection, difficulty passing urine in the first days, and discomfort during sex in some women. If constipation and heavy lifting continue, a rectocele can come back years later. We discuss these risks openly with you before surgery.

Recovery depends on the extent of the operation. The table shows what to expect on average; your exact timeline is given after the examination.

It is natural to be afraid of the first bowel movement. When the stool is soft, it is often easier than expected. The main rule: do not strain and do not put off going to the toilet.

1. Prevent constipation. Drink about 1.5–2 liters of water a day and eat vegetables, fruit and whole grains every day. More: 5 golden rules against constipation.
2. Don't strain. Don't rush on the toilet, put a small stool under your feet and don't sit there for long with your phone.
3. Strengthen your pelvic floor muscles. Do Kegel exercises regularly after childbirth and during menopause.
4. Lift correctly. Lift loads by bending your knees, without holding your breath, and leave very heavy loads to someone else.
5. Don't delay seeing a doctor. If you have started needing to help with a finger, get examined: at an early stage, there is a better chance of managing a rectocele without surgery.

Our patient had suffered from both a rectocele and hemorrhoids for a long time. After the examination, we treated both problems surgically in the same session, under one anesthetic. When she came for her follow-up visit on the sixth day, she said she had already started to comfortably return to her daily life. Every patient's situation is individual.