An enterocele is a type of pelvic organ prolapse where the small intestine pushes down into the space between the vagina and rectum, creating a bulge in the upper back wall of the vagina. It happens when the tissue and muscles that normally hold the pelvic organs in place weaken enough to let the bowel slip out of position. While mild cases may cause no symptoms at all, more advanced enteroceles can produce noticeable pressure, pain, and a visible or palpable bulge.
How an Enterocele Forms
The pelvis contains a natural pocket of space between the back wall of the vagina and the front wall of the rectum. In most women, this space is shallow and held in place by connective tissue and pelvic floor muscles. In women who develop an enterocele, this pocket deepens significantly, sometimes extending more than halfway down the length of the vagina. When that happens, loops of small intestine (and sometimes the sigmoid colon or its surrounding fat) can slide down into the expanded space, especially during straining or standing.
Anatomical studies have found that women with enteroceles tend to have a rectovaginal pouch that covers more than half the vaginal length, along with differences in how the sigmoid colon sits in the pelvis. These structural features make the condition distinct from a rectocele, where the rectum itself bulges into the vagina, rather than the small bowel descending from above.
Who Is at Risk
The biggest risk factors are age, childbirth history, and menopause. Women over 70 have roughly 16 times the risk compared to women under 50, and having more than three vaginal deliveries raises the odds more than fivefold. Menopause independently increases risk by nearly eight times, largely because declining estrogen weakens the connective tissue that supports pelvic organs.
Body weight plays a role too. Being overweight raises the risk by about 36%, and obesity increases it by 47%, because extra abdominal weight puts continuous downward pressure on the pelvic floor. Other contributors include chronic constipation, chronic coughing, repetitive heavy lifting, smoking, prior pelvic surgery, and genetic differences in connective tissue strength. Any condition that regularly increases pressure inside the abdomen can accelerate the weakening process over time.
What It Feels Like
Many small enteroceles produce no symptoms. When the prolapse becomes more significant, the most common sensation is a pulling or dragging feeling deep in the pelvis that eases when you lie down. You may also notice:
- A feeling of fullness, pressure, or aching in the pelvis
- Low back pain that improves with rest
- A soft bulge of tissue at or near the vaginal opening
- Discomfort or pain during intercourse
Symptoms tend to worsen as the day goes on or after long periods of standing, and they typically improve overnight. Some women describe the sensation as feeling like something is “falling out.” Because the small bowel is involved, some people also experience vague abdominal discomfort or changes in bowel habits, though this varies.
How It’s Diagnosed
A pelvic exam is usually the first step. Your doctor will ask you to bear down or strain while they observe and feel for any bulging in the vaginal walls. This can often distinguish an enterocele from other types of prolapse, but not always, because the bulge can look similar to a rectocele on physical exam alone.
When the diagnosis is unclear, or before planning surgery, imaging can help. Dynamic MRI defecography is one of the most precise tools available. During this test, you’re asked to bear down or simulate a bowel movement inside an MRI scanner, which lets doctors watch the pelvic organs move in real time. An enterocele is identified when the small bowel or its surrounding tissue descends below a specific pelvic landmark during straining. This is different from a rectocele, which shows up as a forward bulge of the rectal wall greater than 20 to 30 millimeters.
Stages of Prolapse
Doctors grade the severity of an enterocele using a standardized system that measures how far the prolapse has descended relative to the vaginal opening (the hymen). There are four stages:
- Stage 1: The lowest point of the prolapse sits more than 1 cm above the vaginal opening. Often produces no symptoms.
- Stage 2: The prolapse reaches within 1 cm above or below the opening. This is where most women start noticing symptoms.
- Stage 3: The prolapse extends more than 1 cm beyond the opening but hasn’t fully descended.
- Stage 4: The vaginal wall has essentially turned inside out completely, with the bowel herniating through it.
Stage doesn’t always correlate perfectly with symptoms. Some women with stage 2 prolapse feel significant discomfort, while others with stage 3 manage well with conservative treatment.
Non-Surgical Treatment
For mild to moderate enteroceles, a vaginal pessary is often the first option. A pessary is a removable device inserted into the vagina to physically support the prolapsed tissue and push it back into place. Not all pessary shapes work equally well for enteroceles. Because the bulge comes from above and behind, most women need a more supportive design, such as a Gellhorn, donut, inflatable, or cube pessary, rather than the simpler ring-style devices used for other types of prolapse.
Pelvic floor exercises (Kegels) can help strengthen the surrounding muscles and may slow progression, though they’re unlikely to reverse an established enterocele on their own. Managing contributing factors also matters: treating chronic constipation, addressing a persistent cough, losing weight if applicable, and avoiding heavy lifting when possible. These changes won’t fix the prolapse, but they reduce the forces that make it worse.
Surgical Repair
When symptoms interfere with daily life and conservative measures aren’t enough, surgery becomes an option. The two main approaches are vaginal repair and abdominal repair, and each has trade-offs.
Vaginal native tissue repair involves stitching the weakened tissue back together through the vagina, without synthetic materials. It’s less invasive and has a shorter operating time, with recurrence rates around 8% in published studies. The recovery is generally faster, with a hospital stay of one to three days.
Sacrocolpopexy is the abdominal approach and is widely considered the gold-standard procedure for more severe or recurrent prolapse. A surgeon attaches a small piece of synthetic mesh to the vaginal walls and anchors it to a ligament on the front of the sacrum (the bone at the base of the spine), creating a permanent internal support structure. This can be done through traditional open surgery, laparoscopy, or with robotic assistance. Recurrence rates range from about 3% to 12% depending on the study and follow-up period, with most large studies reporting rates under 10%.
Women who had stage 4 prolapse before surgery and those who waited years before seeking treatment tend to have higher recurrence rates. In one study, the patients whose prolapse returned after sacrocolpopexy had all started with stage 4 disease and waited an average of five years from symptom onset to surgery.
What Recovery Looks Like
After surgical repair, most women stay in the hospital for one to three days. In the first few days at home, fatigue is common, and you’ll need someone to drive you. Walking and climbing stairs are safe immediately and won’t damage the repair.
You’ll likely be advised to avoid sex for several weeks, take stool softeners to prevent straining, and gradually increase your activity level based on how you feel. Higher-impact activities like running, heavy lifting, and abdominal exercises can typically resume once you feel strong enough, though your surgeon will give specific guidance based on the procedure performed. Some vaginal discharge and light bleeding during recovery is normal. Most women return to their full routine within four to six weeks, though individual timelines vary based on the type of surgery and overall health.