A rectocele develops when the layer of connective tissue separating the rectum from the vagina weakens or tears, allowing the front wall of the rectum to bulge into the back wall of the vagina. Estimates suggest anywhere from 20% to 80% of adult women are affected to some degree, though most cases appear in older women who have had multiple vaginal deliveries. The causes range from acute physical trauma during childbirth to slow, cumulative damage from aging, hormonal changes, and chronic pressure on the pelvic floor.
The Tissue That Holds Everything in Place
The rectovaginal septum is a thin sheet of connective tissue fascia that sits between the vagina and the rectum, acting as a structural wall between the two. It attaches more firmly to the vaginal side than the rectal side, and it works alongside pelvic floor muscles and ligaments to keep both organs in their normal position.
When this fascia stretches, thins, or tears, the rectum loses its barrier. Without that support, the front wall of the rectum sags and pushes into the vagina. In severe cases, the bulge can extend all the way to the vaginal opening. Damage to this area is considered the primary cause of posterior pelvic organ prolapse.
Vaginal Childbirth Is the Leading Cause
Labor and delivery place enormous strain on pelvic tissues, and vaginal birth is the single biggest risk factor for rectocele. The second stage of labor, when you’re actively pushing, is especially demanding on the rectovaginal septum and the surrounding muscles. A prolonged second stage, delivering a large baby, and perineal tearing all contribute to the cumulative damage.
Forceps-assisted delivery appears to raise the risk as well. In one large study of over 6,500 postpartum women, 81% of those who had forceps deliveries showed some degree of pelvic organ prolapse, compared to 74% of those who delivered without forceps. The effect of each individual delivery compounds over time, which is why women who have had three or more vaginal births are at substantially higher risk than those who have had one.
Not every rectocele shows up right after delivery. Some women develop symptoms months or years later, as the tissue that was weakened during childbirth gradually gives way under the normal stresses of daily life.
Chronic Pressure on the Pelvic Floor
Any activity that repeatedly pushes downward on pelvic tissues can contribute to a rectocele over time. Chronic constipation is one of the most common culprits. Years of straining during bowel movements creates a cycle: the straining weakens the rectovaginal septum, which can make it harder to empty the rectum fully, which leads to more straining.
Chronic coughing from conditions like asthma, bronchitis, or long-term smoking produces similar repetitive pressure. So does heavy lifting, whether occupational or recreational, if it consistently raises intra-abdominal pressure without adequate pelvic floor support. The damage from these forces is gradual. No single episode of straining causes a rectocele, but thousands of episodes over years can.
Estrogen Loss After Menopause
The connective tissue that supports pelvic organs depends on collagen to maintain its strength, and collagen production is influenced by estrogen. After menopause, the drop in estrogen triggers measurable changes in pelvic tissue composition. Research published in the American Journal of Obstetrics and Gynecology found a 75% decrease in type I collagen (the type responsible for tensile strength) in the pelvic support structures of postmenopausal women not using hormone therapy, compared to premenopausal women.
This shift in collagen changes the ratio of strong, load-bearing fibers to more flexible ones, effectively making the tissue weaker and more prone to stretching. Notably, the study found that postmenopausal women on hormone therapy did not show the same collagen loss, suggesting estrogen plays a direct protective role in maintaining pelvic tissue integrity. This is a major reason why rectoceles become more common with age, even in women who never had a vaginal delivery.
Carrying Extra Weight
Higher body weight places constant additional pressure on pelvic floor structures. A systematic review and meta-analysis of 70 studies found that overweight women (BMI 25 to 30) had a 36% higher risk of pelvic organ prolapse compared to normal-weight women. For obese women (BMI over 30), the risk was 47% higher. These numbers reflect all types of pelvic organ prolapse, including rectocele. The effect was even stronger when prolapse was measured by a clinician during an exam rather than self-reported by patients.
Connective Tissue Disorders
Some women are born with tissue that is structurally more vulnerable. Ehlers-Danlos syndrome, a hereditary condition affecting collagen production, significantly raises the risk of pelvic organ prolapse. Women with this and similar connective tissue disorders can develop prolapse as early as their late 20s, without the usual triggers of pregnancy or menopause. For these women, the underlying collagen defect means their pelvic support structures were never as strong as typical tissue, making them susceptible much earlier in life.
Previous Pelvic Surgery
Hysterectomy can alter the structural support of the pelvic floor, and prolapse is a recognized long-term complication regardless of how the surgery is performed. A study tracking over 2,100 women for up to 17 years after hysterectomy found that the route of surgery (open, vaginal, or laparoscopic) made no significant difference in prolapse risk once other factors were accounted for. What did matter was the reason for the surgery: women who had a hysterectomy because of existing prolapse were at the highest risk for recurrence.
The time between surgery and prolapse development varied, from a median of 27 months after vaginal hysterectomy to 71 months after laparoscopic procedures. But the overall rates converged over the long term, suggesting the disruption to pelvic anatomy matters more than the surgical approach.
How These Causes Overlap
In practice, a rectocele rarely has a single cause. The more common scenario is a combination of factors building on each other. A woman might sustain mild pelvic floor damage during childbirth in her 30s, then experience collagen loss from menopause in her 50s, while also dealing with chronic constipation and weight gain. Each factor alone might not be enough, but together they gradually overwhelm the tissue’s ability to hold.
Severity is measured on a four-stage scale. Stage I means the bulge stays well inside the vaginal canal. Stage II means it reaches near the vaginal opening. Stage III means it extends beyond the opening, and stage IV represents complete eversion. Many women have a mild rectocele that never causes symptoms and is only discovered during a routine pelvic exam. Symptoms like difficulty emptying the bowels, a sensation of pressure, or a visible bulge typically correspond to stage II or higher.