Posterior colporrhaphy is a surgical repair of the back wall of the vagina, performed to correct a condition called a rectocele, where the rectum pushes forward into the vaginal wall. The surgeon strengthens the weakened tissue layer separating the vagina from the rectum by folding and stitching it back together, then closes the incision with dissolvable sutures. It’s one of the most common pelvic floor surgeries, and about 78% of women who undergo it report being satisfied with the outcome.
Why the Back Wall Weakens
The vagina and rectum are separated by a thin but tough layer of connective tissue. Over time, this layer can stretch and weaken, allowing the rectum to bulge into the vaginal space. Childbirth is the most common cause, but chronic straining from constipation, heavy lifting, aging, and hormonal changes after menopause all contribute. The result is a noticeable bulge inside the vagina, sometimes visible at the opening.
Doctors grade the severity of this prolapse using a standardized system called POP-Q, which measures how far the tissue has descended relative to the hymen. An older but still widely used system, the Baden-Walker scale, assigns grades from 0 (no prolapse) to 4 (maximum descent past the vaginal opening). Not every rectocele causes problems. About 24% of women with large rectoceles in one study had no difficulty with bowel emptying at all, which is why surgery is reserved for women with bothersome symptoms rather than based on the size of the bulge alone.
Symptoms That Lead to Surgery
Many rectoceles are discovered incidentally during a pelvic exam and never need treatment. Surgery becomes an option when the prolapse causes daily problems: a persistent feeling of pelvic pressure, difficulty fully emptying the bowels, the need to press on the vaginal wall to complete a bowel movement (called splinting), or a sense that something is falling out of the vagina. Some women also experience discomfort during sex.
Correlation between the physical size of the prolapse and the severity of symptoms is surprisingly weak. A woman with a moderate bulge may have significant difficulty, while someone with a larger prolapse may feel fine. This makes the decision to operate a conversation between you and your surgeon based on how much the symptoms interfere with your life, not just what shows up on an exam.
What Happens During the Procedure
Posterior colporrhaphy is performed through the vagina, so there are no external incisions on the abdomen. The surgeon makes a vertical cut along the back wall of the vagina to expose the weakened connective tissue layer underneath. That layer is then folded together along the midline and reinforced with stitches, a technique called midline plication. This tightens the barrier between the vagina and rectum and pushes the bulging rectum back into its proper position. Finally, any excess vaginal skin is trimmed and the incision is closed with dissolvable stitches.
Most surgeons use simple interrupted sutures to reinforce the deep tissue layer, though some prefer a horizontal mattress technique for added strength. For closing the surface layer, a continuous locking suture is the second most popular choice after interrupted stitches. The procedure is typically done under general or regional anesthesia.
Native Tissue Repair vs. Mesh
The standard approach uses your own tissue for the repair, and this is what most surgeons recommend for posterior wall prolapse. Mesh, while sometimes used for anterior (front) wall repairs, has a much more limited role in posterior repairs. Only about 11% of surgeons in one survey reported using mesh for the back wall.
A large Cochrane review comparing permanent transvaginal mesh to native tissue repair across all prolapse types found a mixed picture. Mesh did reduce prolapse recurrence on physical exam and slightly lowered the chance of needing repeat prolapse surgery. But women who received mesh were more likely to need additional surgery overall when complications like mesh exposure and new-onset stress urinary incontinence were factored in. The risk of bladder injury was nearly four times higher with mesh. Based on this profile, the review concluded that transvaginal mesh has limited usefulness in primary surgery and recommended it be used only under strict oversight. For posterior colporrhaphy specifically, adding a biologic graft (a dissolvable tissue reinforcement, different from permanent mesh) showed no clear advantage. Objective failure rates were 37% with the graft and 42% without, a difference that was not statistically meaningful.
Success Rates and Possible Complications
Posterior colporrhaphy corrects the visible vaginal bulge in about 76% of women. In longer-term follow-up averaging around six years, 85% of women said they would recommend the procedure and 84% reported symptomatic improvement. About 15% eventually needed a reoperation.
The surgery reliably fixes the anatomical defect, but its effect on bowel and sexual function is less predictable. In one study tracking outcomes, prolapse-related symptoms dropped significantly after surgery (from 64% to 31%). However, some functional problems actually increased afterward. Constipation rose from 22% to 33%, difficulty fully emptying the bowels went from 27% to 38%, and sexual dysfunction increased from 18% to 27%. One in three women needed to splint (press on the vaginal wall or perineum) to have bowel movements after surgery. Fecal incontinence and incontinence of gas were reported by 11% and 19% of women, respectively. Women who had undergone multiple posterior repairs were at higher risk for stool incontinence.
These numbers don’t mean the surgery makes most women worse overall. The majority reported feeling better after the procedure. But they highlight that fixing the structural problem doesn’t always fix the functional symptoms, and in some cases can create new ones. This is why surgeons emphasize thorough discussion of bowel habits before deciding on surgery.
Preparing for Surgery
Preoperative instructions vary by surgeon. Some prescribe a bowel preparation the day before: a clear-liquid diet, two saline enemas in the late afternoon and evening, and nothing to eat or drink after midnight. Others simply ask you to eat normally and fast from midnight onward. Studies have compared these two approaches, and the evidence doesn’t strongly favor one over the other, so your surgeon’s preference will guide what you’re asked to do.
You’ll likely be told to stop certain medications that increase bleeding risk in the days before surgery. If you take blood thinners or anti-inflammatory drugs, bring this up early in your preoperative appointments.
Recovery and Activity Restrictions
Most women go home the same day or the day after surgery. The initial recovery period involves soreness, swelling, and some vaginal discharge or light bleeding, which gradually improves over the first two weeks.
Lifting restrictions are nearly universal. About 60% of gynecologic surgeons recommend keeping weight limits in place for at least six weeks. The most common limit is 10 pounds, roughly the weight of a gallon of milk. Stair climbing, driving, and sexual intercourse are also typically restricted during recovery, though the exact timelines vary. Some sources suggest a return to light daily activity within one to two weeks, while more strenuous activity and intercourse are usually cleared at the six-week mark.
Constipation is one of the biggest concerns during recovery because straining puts pressure on the repair. Stool softeners and a high-fiber diet are standard recommendations starting before surgery and continuing for several weeks afterward. Keeping bowel movements soft and easy to pass protects the surgical site while the tissue heals.