A cystocele is a condition where the bladder pushes into the front wall of the vagina, and a rectocele is where the rectum pushes into the back wall of the vagina. Both are types of pelvic organ prolapse, meaning the muscles and connective tissues that normally hold pelvic organs in place have weakened enough that those organs shift out of position. Prolapse has been found in 25 to 50% of postmenopausal women in clinical exams, making these conditions far more common than most people realize.
How Pelvic Support Normally Works
Your pelvic organs, including the bladder, uterus, and rectum, are held in place by a hammock-like system of muscles and connective tissue. The main muscle group involved is the levator ani, a broad sheet of muscle that forms the floor of the pelvis. This muscle works together with ligaments and layers of connective tissue that attach the vagina and uterus to the pelvic sidewalls.
Support can be thought of in three zones. At the top, the cervix and upper vagina are suspended by ligament-like structures that anchor toward the sacrum and pelvic walls. In the middle, the vaginal walls are attached to the sides of the pelvis by bands of connective tissue. At the bottom, the vagina is fused directly to the surrounding muscles and the perineal body (the tissue between the vaginal opening and the anus). When any part of this system weakens, the organs behind it can start to sag.
Cystocele: Bladder Drops Into the Vaginal Wall
A cystocele, sometimes called anterior prolapse, happens when the connective tissue between the bladder and the front vaginal wall stretches or tears. The bladder then bulges downward into the vagina. Research shows a strong relationship between descent of the upper vagina and cystocele size, meaning the problem often involves weakening at multiple levels of support rather than one isolated spot. When the levator ani muscle is impaired, the opening in the pelvic floor widens, exposing more of the vaginal wall to downward pressure and allowing a larger bulge to develop.
Rectocele: Rectum Pushes Into the Vaginal Wall
A rectocele, or posterior prolapse, occurs when the tissue separating the rectum from the back wall of the vagina weakens. The rectum then presses forward into the vagina, creating a bulge. In some cases, stool can get trapped in the bulging pocket, making bowel movements difficult or requiring you to press against the vaginal wall to fully empty.
What Symptoms Feel Like
The hallmark symptom of both conditions is a feeling of fullness, pressure, or a noticeable bulge at or near the vaginal opening. Many women describe it as feeling like something is “falling out.” Interestingly, research comparing women with cystocele versus rectocele found that the sensation of vaginal bulging was equally common in both groups. Most pelvic floor symptoms traditionally attributed to one type of prolapse actually reflect the presence of any bulge, rather than being specific to the front or back wall.
There are some differences. Women with anterior prolapse (cystocele) tend to score higher on measures of urinary distress, including symptoms like difficulty emptying the bladder, urinary urgency, or stress incontinence when coughing or sneezing. Women with posterior prolapse (rectocele) report more colorectal and bowel symptoms, such as constipation, incomplete emptying, and the need to splint (press on the vaginal wall) during a bowel movement. That said, the differences between groups are modest, and overlap is the rule rather than the exception.
What Causes These Conditions
Prolapse results from a combination of anatomical, genetic, lifestyle, and reproductive factors interacting across a woman’s lifetime. The most consistently identified risk factors are the number of pregnancies, vaginal delivery, age, and higher body mass index. Each vaginal delivery stretches and can injure the pelvic floor muscles and connective tissue, and the cumulative effect of multiple deliveries increases risk further.
Age plays a major role. The estimated probability of developing prolapse increases roughly 4% per decade, rising from about 2% at age 45 to 10% by age 65. Ethnicity also influences risk: one large study found that at age 65, the probability ranged from about 4% in Japanese and Chinese women to nearly 34% in Hispanic women, even after accounting for other factors. Anything that chronically increases pressure in the abdomen, such as obesity, chronic coughing, or heavy repeated lifting, can accelerate the weakening of pelvic support over time.
How Prolapse Is Measured
Doctors grade prolapse severity using a standardized system called POP-Q, which measures how far the vaginal walls have descended relative to the hymen (the tissue at the vaginal opening). The scale runs from Stage 0 to Stage 4:
- Stage 0: No prolapse detected.
- Stage 1: The lowest point of the bulge is still more than 1 cm above the hymen.
- Stage 2: The bulge reaches within 1 cm above or below the hymen.
- Stage 3: The bulge extends more than 1 cm past the hymen, but the vagina has not completely turned inside out.
- Stage 4: The vaginal wall has essentially everted completely.
A physical exam during bearing down is usually all that’s needed to diagnose and stage prolapse. Many women have Stage 1 or 2 prolapse without any symptoms and never need treatment.
Pelvic Floor Exercises as First-Line Treatment
Pelvic floor muscle training is recommended as the first treatment option because it is safe, effective, and noninvasive. A systematic review of the evidence found that structured training programs significantly improved prolapse symptoms, urinary complaints, bowel symptoms, and quality of life at 6, 12, and even 24 months.
The exercise protocols studied vary quite a bit. Some programs use slow, sustained contractions, others use quick contractions, and many combine both. Session lengths range from 24 to 180 repetitions, and programs last anywhere from 6 weeks to 2 years. The consistent finding is that pelvic floor training helps regardless of the specific protocol, though longer and more intensive programs tend to produce better results. A pelvic floor physical therapist can assess your muscle function and build a program tailored to your needs, which is more effective than trying to learn from instructions alone.
Pessaries: A Non-Surgical Device Option
A pessary is a removable silicone device inserted into the vagina to physically support the prolapsing organs. It doesn’t fix the underlying weakness but holds everything in place, often relieving symptoms entirely. Ring pessaries are typically tried first because they’re easy to insert and remove. For more advanced prolapse, options include the Gellhorn (a disc-shaped device better suited for women who are not sexually active), the donut pessary, and the cube pessary for Stage 3 or 4 prolapse.
For prolapse that involves a prominent cystocele or rectocele alongside uterine descent, a Gehrung pessary, which sits along the front vaginal wall like a bridge, can be particularly helpful. Fitting involves trying different sizes and shapes while you stand, sit, walk, and bear down so both you and your clinician can confirm it stays in place and feels comfortable. The goal is the largest size that fits without causing pressure or pain.
When Surgery Is Considered
Surgery is generally reserved for women whose symptoms significantly affect daily life and who haven’t found adequate relief from exercises or pessaries. The most common procedures are anterior colporrhaphy (for cystocele) and posterior colporrhaphy (for rectocele), which involve tightening and reinforcing the weakened vaginal wall tissue from the inside.
One study following 158 women after surgical repair found a recurrence rate of 8.2%, with recurrences appearing on average about 10 months after surgery. Other research reports that long-term recurrence can reach up to 30%, depending on the study and follow-up period. Women who develop prolapse at a younger age may face higher recurrence risk, possibly due to underlying connective tissue weakness that persists after repair.
Transvaginal mesh, once widely used to reinforce surgical repairs, is no longer available in the United States for prolapse. In 2019, the FDA ordered all manufacturers to stop selling these devices after determining they had not demonstrated a reasonable balance of safety and effectiveness. There are currently no FDA-approved mesh products for transvaginal prolapse repair on the U.S. market. Women who already have mesh implants and are not experiencing complications do not need additional intervention but should let their healthcare provider know about the mesh before any future procedures.
Recovery After Prolapse Surgery
Recovery timelines depend on the type of procedure. After vaginal or minimally invasive surgery, some guidelines suggest returning to normal activity within 1 to 2 weeks, though many surgeons are more conservative. About 60% of gynecologic surgeons recommend lifting restrictions for at least 6 weeks, and half of those recommend keeping the limit at roughly 10 pounds, which is about the weight of a gallon of milk. In practice, there is no strong consensus: after minimally invasive procedures, 34% of surgeons restrict activity for 2 weeks, 24% for 4 weeks, and 16% for 6 weeks, while 12% recommend no formal restrictions at all. Your surgeon’s specific instructions will depend on the extent of the repair and your individual healing.