A rectocele is a type of pelvic organ prolapse where the rectum pushes forward into the back wall of the vagina, creating a noticeable bulge. It happens when the layer of tissue separating the vagina from the rectum weakens and can no longer hold the rectum in place. Rectoceles range from small and barely noticeable to large enough to interfere with bowel movements and daily comfort. Some degree of posterior vaginal wall bulging is extremely common, with small outpouchings detected on imaging in 78 to 99% of women who have given birth.
How a Rectocele Forms
The vagina and rectum sit right next to each other, separated by a thin but sturdy wall of connective tissue called the rectovaginal septum. This septum connects to a broader network of supportive structures: ligaments at the top, pelvic floor muscles in the middle, and a band of tissue called the endopelvic fascia lower down. Together, these layers keep the pelvic organs where they belong.
When the rectovaginal septum loses its structural integrity, the front wall of the rectum has nothing firm to push against. It herniates forward into the vaginal space, forming a pocket or bulge along the back vaginal wall. This bulge becomes more obvious when you bear down or strain, because the increased abdominal pressure pushes rectal tissue further into the weakened area.
Common Causes and Risk Factors
Vaginal childbirth is the single biggest risk factor. Pregnancy, labor, and delivery stretch and sometimes tear the muscles, ligaments, and connective tissue that support the vagina. The more vaginal deliveries you’ve had, the higher your risk. Perineal tears, episiotomies, and forceps-assisted deliveries cause additional damage to the tissue between the vagina and rectum, raising the likelihood further.
Beyond childbirth, anything that puts repeated pressure on your pelvic floor can contribute. Chronic constipation and straining during bowel movements push downward on an already vulnerable septum. A long-lasting cough, repeated heavy lifting, and carrying excess body weight all do the same. Aging plays a role too, as muscle mass, elasticity, and nerve function naturally decline over time, allowing the pelvic floor to weaken. Some people are also born with naturally weaker connective tissue in the pelvic area, which makes them more susceptible regardless of other factors.
What a Rectocele Feels Like
Many small rectoceles cause no symptoms at all and are only discovered during a routine pelvic exam. When a rectocele does cause problems, the hallmark symptom is difficulty with bowel movements. The rectal pocket traps stool instead of letting it pass normally, leading to a persistent feeling of incomplete emptying. You might feel like you need to go but can’t fully evacuate, no matter how long you sit.
Some women find that pressing a finger against the back wall of the vagina, the perineum, or around the vagina helps push stool out of the pocket and through the rectum. This maneuver is called splinting, and needing to do it regularly is a strong indicator of a significant rectocele. Other symptoms include a sensation of pressure or fullness in the pelvis, a visible or palpable bulge at the vaginal opening, vaginal discomfort, and pain around the anus. In more advanced cases, the bulge may protrude beyond the vaginal opening, especially after standing for long periods.
How Rectoceles Are Graded
Doctors classify rectoceles by how far the tissue has descended. Two grading systems are commonly used. The Baden-Walker system is straightforward: Grade 1 means the bulge extends halfway to the vaginal opening, Grade 2 reaches the vaginal opening, Grade 3 extends halfway past it, and Grade 4 represents maximum descent. The POP-Q system uses more precise measurements relative to the hymen, staging prolapse from Stage 0 (no prolapse) through Stage 4 (essentially complete vaginal eversion).
On imaging, rectoceles are also measured by how far the rectal wall bulges forward. An outpouching up to 2 centimeters is considered Grade I and is so common in women who’ve given birth that it’s generally not considered clinically significant. A bulge between 2 and 4 centimeters is Grade II, and anything 4 centimeters or larger is Grade III. Grades II and III are more likely to trap stool and cause symptoms.
How a Rectocele Is Diagnosed
A physical exam is usually the first step. Your doctor will look at the vaginal walls while you bear down, which makes the bulge more prominent and easier to assess. This alone is often enough to confirm the diagnosis and estimate its severity.
When the clinical picture is unclear, or when surgery is being considered, imaging can provide more detail. A defecography, which uses X-ray or MRI to watch the pelvic floor in real time while you simulate a bowel movement, shows exactly where the rectum is bulging, how large the pocket is, and whether stool is getting trapped in it. MRI-based versions can also reveal other pelvic floor problems that might be contributing to symptoms, since rectoceles sometimes occur alongside bladder prolapse or uterine descent.
Non-Surgical Treatment
Most rectoceles, particularly mild to moderate ones, are managed without surgery. The two main options are pelvic floor exercises and vaginal pessaries.
Pelvic floor exercises (often called Kegels) strengthen the muscles at the base of the pelvis that support the vagina, bladder, and rectum. A typical routine involves several minutes of controlled muscle contractions repeated one to three times per day. Studies show these exercises can improve symptoms in Stage 1 through Stage 3 prolapse and sometimes prevent the prolapse from getting worse. The commitment required is modest, and the payoff is real: in studies tracking women who did pelvic floor exercises, only 3 to 10 out of 100 eventually chose to have surgery.
If exercises alone aren’t enough, a vaginal pessary can help. These are small devices made of silicone or rubber, shaped as rings, cubes, or saucers, that fit inside the vagina and prop up the prolapsing tissue. They don’t fix the underlying weakness, but they hold things in place so symptoms improve. About half of women who try a pessary find it comfortable and effective enough to use for years. Pessaries are a particularly good option if you want to avoid or delay surgery, or if health conditions make surgery risky.
Managing constipation is also important. Increasing fiber intake, staying hydrated, and avoiding prolonged straining reduce the downward pressure that worsens a rectocele over time.
Surgical Repair
Surgery is typically reserved for rectoceles that cause significant symptoms despite conservative treatment. Several approaches exist, including repairs done through the vagina, through the anus, through the perineum, and laparoscopic procedures. The most common vaginal approach is a posterior colporrhaphy, which tightens and reinforces the weakened wall between the vagina and rectum.
Outcomes after surgical repair are generally favorable. In one study of vaginal repair, the sensation of a vaginal bulge disappeared completely in about 91% of patients. Difficulty with bowel movements improved or resolved entirely in 100% of patients, and all women who had been splinting to empty their bowels stopped needing to after surgery. Defecography after the procedure showed complete disappearance of the rectocele in about two-thirds of patients, with measurable improvement in the remaining third.
Earlier surgical techniques sometimes used synthetic mesh to reinforce the repair, but mesh has fallen out of favor for posterior wall prolapse due to complications including erosion through tissue, chronic pain, pain during intercourse, infection, and fistula formation. Most surgeons now prefer mesh-free techniques that restore the septum using the body’s own tissue or the surrounding muscles, which avoids these risks while still achieving durable results.
Living With a Rectocele
A rectocele is not dangerous, but it can significantly affect quality of life when symptoms are present. The good news is that many women manage effectively with exercises and lifestyle changes alone, and those who do need more intervention have a range of reliable options. Pelvic floor physical therapists can tailor an exercise program to your specific situation, and a gynecologist or urogynecologist can fit a pessary or discuss surgical options if conservative measures fall short. Because rectoceles sometimes accompany other types of prolapse, a thorough evaluation of the entire pelvic floor ensures nothing gets overlooked.