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Definition
A rectocele occurs when the thin wall of fibrous tissue (fascia) separating the rectum from the vagina becomes weakened, allowing the front wall of the rectum to bulge into the vagina.
Childbirth and other processes that put pressure on the fascia can lead to a rectocele. A small rectocele may cause no signs or symptoms. If a rectocele is large, it may create a noticeable bulge of tissue through the vaginal opening. Though this bulge may be uncomfortable, it's rarely painful.
When treatment of a rectocele is necessary, self-care measures and other nonsurgical options are often effective. In severe cases, you may need surgical repair.
Symptoms
A small rectocele may cause no signs or symptoms. Otherwise, you may notice:
- A soft bulge of tissue in your vagina that may or may not protrude through the vaginal opening
- Difficulty having a bowel movement with the need to press your fingers on the bulge in your vagina to help push stool out during a bowel movement
- Sensation of rectal pressure or fullness
- A feeling that the rectum has not completely emptied after a bowel movement
- Sexual concerns, such as feeling embarrassed or sensing looseness in the tone of your vaginal tissue
Many women with a rectocele also experience related conditions, such as:
- Cystocele, when the bladder bulges into your vagina
- Enterocele, when the small intestine pushes down into your vagina
- Uterine prolapse, when the uterus descends into your vagina
When to see a doctor
When a rectocele is small, you don't need medical care. In fact, in mild cases, you may not even know you have a rectocele.
In moderate or severe cases, however, rectoceles can be bothersome, uncomfortable and, in a few cases, painful. Make an appointment with your doctor if you experience:
- A soft bulge of tissue that protrudes from within your vagina through your vaginal opening with straining
- A feeling of fullness or pressure in your rectum
- Difficulty emptying your rectum
- Chronic constipation
Causes
Pregnancy and childbirth
Pregnancy and childbirth are the most common causes of rectoceles. This is because the muscles, ligaments and fascia that hold and support your vagina become stretched and weakened during pregnancy, labor and delivery. As a result, the more pregnancies you have, the greater chance you have of developing a rectocele.
Not everyone who has delivered a baby develops a rectocele. Some women have very strong supporting muscles, ligaments and fascia in the pelvis and may never have a problem. Women who have only cesarean deliveries are less likely to develop a rectocele.
Increased pelvic floor pressure
Other conditions and activities that can put pressure on the pelvic floor and cause a rectocele include:
- Chronic constipation or straining with bowel movements
- Chronic cough or bronchitis
- Repeated heavy lifting
- Being overweight or obese
Risk factors
The following factors may increase your risk of experiencing a rectocele:
- Genetics. Some women are born with weaker connective tissues in their pelvic area, making them naturally more likely to develop a rectocele. Others are born with stronger connective tissues.
- Childbirth. If you have vaginally delivered multiple children, you have a higher risk of developing a rectocele. If you've had tears in the tissue between the vaginal opening and anus (perineal tears) and incisions that extend the opening of the vagina (episiotomies) during childbirth, you may also be at higher risk.
- Aging. Your risk of a rectocele increases as you age because you naturally lose muscle mass, elasticity and nerve function as you grow older, causing muscles to stretch or weaken.
- Obesity. Although the reasons aren't entirely clear, a high body mass index is linked to an increased risk of rectocele. This may be due to the chronic stress that excess body weight places on pelvic floor tissues.
Preparing for your appointment
To evaluate pelvic organ prolapse, your first appointment may be with your primary care provider. However, in some cases when you call to set up an appointment, you may be referred immediately to a doctor who specializes in conditions affecting the female reproductive tract (gynecologist).
Here's some information to help you prepare for your appointment and what to expect from your doctor.
What you can do
- Write down any symptoms you've had, and for how long.
- Make a list of your key medical information, including any other conditions for which you're being treated and the names of any medications, vitamins or supplements you're taking.
- Take a family member or friend along, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
- Write down questions to ask your doctor. Creating your list of questions in advance can help you make the most of your time with your doctor.
For rectocele, some basic questions to ask your doctor include:
- What is the most likely cause of my symptoms?
- Are there any other possible causes?
- Do I need any tests to confirm the diagnosis?
- What are the goals of treatment in my case?
- What treatment approach do you recommend?
- Am I at risk of complications from this condition?
- What is the risk that this problem will recur in the future?
- Do I need to follow any restrictions?
- Are there any self-care steps I can take?
- Should I see a specialist?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment if you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions, such as:
- What symptoms are you experiencing?
- When did you first notice these symptoms?
- Have your symptoms gotten worse over time?
- Do your symptoms include pain? If yes, how severe is the pain?
- Does anything in particular trigger your symptoms, such as coughing or heavy lifting?
- Do your signs and symptoms include urine leakage (urinary incontinence)?
- Have you had a chronic or severe cough?
- Does your work or daily activities involve heavy lifting?
- Do you strain during bowel movements?
- Are you currently being treated or have you recently been treated for any other medical conditions?
- What medications are you taking, including over-the-counter and prescription drugs as well as vitamins and supplements?
- Do any of your first-degree relatives — such as a parent or sibling — have a history of rectocele or any other pelvic problems?
- How many children have you delivered? Were your deliveries vaginal or cesarean?
- Do you plan to have children in the future?
- Do you have any other concerns?
Tests and diagnosis
In most cases, your doctor diagnoses a rectocele during a pelvic examination of your vagina and rectum.
Possible tests for rectocele include:
- Pelvic exam. During the exam, your doctor may ask you to bear down as if having a bowel movement. This may cause the rectocele to bulge, so your doctor can assess its size and location. To check the strength of your pelvic muscles, you may also be instructed to contract them, as if you are stopping the stream of urine. Your doctor may examine you while lying down and while standing up.
- Questionnaire. You may fill out a form that helps your doctor assess your degree of prolapse and how much it affects your quality of life. Information gathered also helps guide treatment decisions.
- Imaging tests. Imaging tests usually aren't needed to diagnose a rectocele. Rarely, your doctor may identify something during the physical exam that needs further evaluation. In that case, you may undergo an imaging test, such as magnetic resonance imaging (MRI) or an X-ray exam, to determine the size of the rectocele and how efficiently your rectum empties (defecography).
Treatments and drugs
Treatment depends on the severity of the rectocele. If your rectocele causes few or no obvious symptoms, you may need no treatment or find that simple self-care measures work well, such as performing exercises called Kegels to strengthen your pelvic muscles.
If these measures fail to help, your doctor may recommend:
- Pessary. A vaginal pessary is a plastic or rubber ring inserted in the vagina to support the bulging tissues. Several types of pessaries are available, including some you can remove to clean, and others your doctor must remove periodically to clean. Because they have a high "hassle factor," many women choose not to use this method.
- Surgery. If the rectocele protrudes outside your vagina and is especially bothersome, you may opt for surgery. More commonly, your doctor may suggest surgery if the rectocele accompanies another condition, such as a cystocele, an enterocele or uterine prolapse. In these cases, surgical repair for each condition can be completed at the same time.
Surgery usually consists of removing excess, stretched tissue that forms the rectocele. In most cases, this is done using a vaginal surgical approach. Occasionally, the surgical repair may involve using a mesh patch to support and strengthen the wall between the rectum and vagina.
Lifestyle and home remedies
Depending on the severity of the condition, self-care measures may provide the relief you need:
- Perform Kegel exercises.
- Avoid constipation by eating high-fiber foods and drinking plenty of fluids.
- Avoid heavy lifting.
- Try to control coughing.
- Lose weight if you're overweight or obese.
Kegel exercises
Kegel exercises, designed to strengthen your pelvic floor muscles, can help both prevent and ease symptoms of a rectocele. To perform Kegel exercises:
- Contract your pelvic floor muscles — the muscles you use to stop urinating.
- Hold them for a count of five and then relax for a count of five.
- Work up to 10 to 15 repetitions at a time.
- Repeat three times daily.
Kegel exercises may be most successful when they're taught by a therapist using biofeedback. Biofeedback uses information from a variety of (pain-free) monitoring devices to help teach you to control certain involuntary body responses, such as muscle tension. In this case, biofeedback can show whether you're contracting the correct muscles and using the right technique for the exercises to work to their best effect.
Prevention
You may be able to prevent a rectocele by:
- Doing Kegel exercises to strengthen your pelvic floor muscles. This is especially important after you have a baby.
- Treating and preventing constipation. The best approach is to drink plenty of fluids and eat high-fiber foods.
- Treating a chronic cough.
- Not smoking, because many smokers eventually develop a chronic cough.
- Maintaining a healthy weight. Talk to your doctor to determine your ideal weight.
Last Updated: 2010-03-16
