A rectocele, also known as a posterior vaginal wall prolapse, is a common type of pelvic organ prolapse. This condition occurs when the supportive tissues separating the rectum from the vagina weaken, allowing the rectum to push forward and create a bulge into the vaginal canal. It is an anatomical change that often affects a person’s quality of life, particularly concerning bowel function and pelvic comfort. The physical appearance of a rectocele varies significantly depending on its size and the degree of protrusion. The experience of this condition is often characterized more by internal sensations than by outward visibility.
Understanding the Anatomy and Mechanism of a Rectocele
The pelvic floor is a complex network of muscles and connective tissues that acts like a sling to support the organs above it. A thin, fibrous sheet called the rectovaginal septum separates the anterior wall of the rectum from the posterior wall of the vagina. This septum is the primary support structure in the posterior compartment of the pelvis.
A rectocele forms when the rectovaginal septum loses its strength or integrity, often due to stretching or tearing. Pressure within the rectum, especially during a bowel movement, causes the rectal wall to herniate or pouch into the vaginal space. This creates a pocket where stool can become trapped, leading to many of the condition’s most bothersome symptoms.
Primary Causes and Contributing Risk Factors
The most significant factor contributing to rectocele formation is the trauma associated with vaginal childbirth. The intense pressure and stretching forces of labor can damage the muscles and connective tissue of the pelvic floor and the rectovaginal septum. This risk increases with multiple vaginal deliveries, prolonged pushing during labor, or the use of forceps and vacuum devices.
Chronic increases in intra-abdominal pressure also exert a constant strain on the pelvic support system, gradually weakening the tissue over time. Frequent straining due to chronic constipation is a major contributor, as is persistent heavy lifting or a chronic cough.
Natural changes after menopause also play a role. The loss of estrogen can lead to a thinning and loss of elasticity in the supportive tissues throughout the pelvis. This tissue degradation makes the rectovaginal septum more susceptible to stretching and tearing. Some individuals may also have a congenital predisposition due to inherited variations in the strength of their connective tissue.
Clinical Signs and Physical Manifestations
The physical manifestation of a rectocele is a noticeable sensation of pressure or a soft bulge felt in the vagina. This feeling is often described as heaviness or a sensation that something is falling out, and it typically worsens with standing, lifting, or toward the end of the day. The visible bulge, which is the rectal wall pushing into the vaginal canal, can be felt or seen protruding from the vaginal opening in more severe cases.
The most specific symptoms relate to bowel function, particularly difficulty with evacuation. When attempting to pass stool, feces can push into the prolapsed pouch instead of moving out through the anus, leading to a feeling of incomplete emptying. This obstructive defecation can necessitate manual assistance, a process known as “splinting.”
Splinting involves pressing on the vaginal bulge or the area between the vagina and anus (perineum) to push the stool out of the pocket and facilitate a complete bowel movement. Additionally, some people report discomfort during sexual intercourse. Small rectoceles, however, may exist without any noticeable symptoms at all.
Diagnostic Confirmation and Severity Grading
A healthcare provider typically diagnoses a rectocele through a physical examination and medical history. During a pelvic exam, the clinician inspects the vaginal wall and asks the patient to perform a Valsalva maneuver (bearing down). This action increases intra-abdominal pressure and makes the prolapse more visible and palpable.
To document the extent of the prolapse, physicians use standardized severity scales like the Pelvic Organ Prolapse Quantification (POP-Q) system. This system provides a precise, objective measurement of the prolapse relative to the hymen. Rectoceles are often categorized by the extent of their protrusion: small (less than two centimeters), medium (two to four centimeters), and large (extending beyond four centimeters or protruding past the vaginal opening).
For complex symptoms or surgical planning, specialized imaging tests may be performed. Defecography is a dynamic X-ray or MRI study where contrast material is placed into the rectum. Images are taken while the patient attempts to empty their bowels, providing a functional view that shows exactly how the rectal wall bulges and whether stool is trapped within the rectocele, helping to confirm its role in obstructive symptoms.
Management Options: From Lifestyle Adjustments to Surgical Repair
Treatment for a rectocele is tailored to the severity of the prolapse and its impact on daily life. For mild cases, conservative, non-surgical management focuses on minimizing strain and strengthening pelvic support. Lifestyle adjustments include dietary modifications, such as increasing fiber intake and fluid consumption, to ensure soft, regular bowel movements without excessive straining.
Pelvic floor physical therapy, which includes targeted exercises like Kegels, can help strengthen the surrounding muscles, offering better support to the pelvic organs. If conservative measures are insufficient, a vaginal pessary, a removable silicone device, can be fitted to mechanically hold the bulging tissues in place. Pessaries provide effective non-surgical support and often offer immediate relief from symptoms of pressure and prolapse.
For larger rectoceles causing significant functional issues, surgical correction may be recommended. The most common procedure is a posterior colporrhaphy, where the surgeon accesses the area through the vagina. The goal of this surgery is to reinforce the rectovaginal septum, often by suturing the weakened tissue together in a technique called plication. The repair restores the normal anatomy, creating a stronger barrier between the rectum and the vagina. In some instances, the surgeon may use a biocompatible graft or mesh material to further reinforce the repair, although the use of mesh is determined on a case-by-case basis. Surgical intervention aims to resolve the obstructive defecation symptoms and eliminate the vaginal bulge.