Rectocele: Symptoms, Types, Causes and Treatment

Rectocele is a common but often misunderstood condition that affects the pelvic floor. Characterized by a bulge of the rectum into the vagina, rectocele can have a significant impact on a person's quality of life. Understanding its symptoms, types, underlying causes, and available treatments is essential for anyone seeking answers about pelvic floor health. This comprehensive guide synthesizes the latest evidence and clinical experience to provide a clear and engaging overview of rectocele.

Symptoms of Rectocele

Rectocele often goes unnoticed until symptoms become bothersome. This section introduces the spectrum of symptoms, ranging from mild discomfort to significant interference with daily life. Recognizing these signs is the first step toward effective management.

Symptom	Description	Frequency/Severity	Source(s)
Vaginal bulge	Sensation or visible protrusion in vagina	Common, especially severe	10 15 16
Obstructed defecation	Difficulty passing stool, straining	Frequent in symptomatic	1 4 5 10 14
Incomplete emptying	Feeling of not fully evacuating bowels	Common in rectocele	1 2 4 14
Vaginal splinting	Need to press vagina to aid bowel movement	Distinctive symptom	1 5 10 14
Constipation	Chronic or recurrent	Often present	1 5 10 15
Urinary incontinence	Involuntary urine leakage	Sometimes associated	1 4
Pelvic/vaginal pressure	Heaviness or fullness in pelvis	Common	10 15 16
Pain	Pelvic or rectal discomfort	Less common	4 10
Sexual dysfunction	Pain or discomfort during intercourse	May occur	16 17

Table 1: Key Symptoms of Rectocele

The Spectrum of Symptoms

Rectocele symptoms can range from subtle to severe and may fluctuate over time. The most recognizable sign is a bulge or protrusion in the vaginal wall, which may be felt or seen, especially during straining or bowel movements. Many women describe a sensation of heaviness, fullness, or pressure in the pelvis, often worsening as the day progresses or with prolonged standing 10 15.

Bowel and Defecation Issues

A hallmark of rectocele is obstructed defecation. Patients frequently report:

• Straining during bowel movements
• A sensation of incomplete emptying
• The need to use their fingers to press against the posterior vaginal wall (vaginal splinting) to help empty stool 1 5 10 14

Notably, while constipation is common, research indicates that stool quality (e.g., hardness, dryness) can play a greater role in defecation symptoms than rectocele size itself 5.

Urinary and Sexual Symptoms

Urinary incontinence may co-occur, particularly in those with other pelvic floor disorders 1 4. Some women experience sexual dysfunction, including dyspareunia (pain with intercourse), especially if the rectocele is large or surgical repair leads to vaginal narrowing or scarring 16 17.

Impact on Daily Life

Symptoms can impede daily activities, social participation, and overall well-being. Many women adapt by altering toileting habits or avoiding certain physical activities, which can have emotional and psychological effects.

Types of Rectocele

Not all rectoceles are created equal. Understanding the different types helps tailor diagnosis and treatment, as each may have distinct anatomical and physiological features.

Type	Characteristics	Associated Factors	Source(s)
Type I	High resting anal pressure, localized defect	No prolapse, constipation	7 8 9
Type II	Associated with pelvic organ prolapse, low pressure	Genital prolapse, tissue laxity	7 9
Posterior	Bulge toward the back (rectum)	More common in males	3 7
Anterior	Bulge toward the front (vagina)	Classic in women	3 7 10
Complex/Mixed	With intussusception or multi-compartment prolapse	Multiple pelvic floor defects	4 7

Table 2: Types of Rectocele

Anatomical Classification

Rectoceles are primarily classified by their location and association with other pelvic floor conditions.

• Anterior rectocele: The most common type in women, where the rectum bulges into the posterior vaginal wall 10.
• Posterior rectocele: Less common, sometimes observed in men, usually involving a bulge toward the back 3.

Clinical and Functional Types

Videodefaecography and clinical evaluation have led to further subclassification:

• Type I (Digitiform): Localized defect with high resting anal pressure; often presents with constipation without significant prolapse 7 8 9.
• Type II: Accompanied by pelvic organ prolapse (e.g., uterine or vaginal vault prolapse), and typically features lower anal resting pressures 7 9.
• Complex or Mixed Types: May be associated with intussusception (telescoping of the rectum) or prolapse involving multiple pelvic compartments 4 7.

Male Rectocele

Though rare, rectocele can occur in men, usually posteriorly, and is often linked with significant pelvic floor dysfunction or a history of prostate surgery 3.

Importance of Differentiation

Distinguishing between types is crucial for selecting the most effective treatment. For example, surgical approaches may differ depending on whether the rectocele is isolated or associated with other pelvic floor disorders 7 8 17.

Causes of Rectocele

Understanding what leads to rectocele development can help with prevention and guide therapy. The causes are multifactorial, involving both anatomical and functional elements.

Cause	How It Contributes	Notable Risk Factors	Source(s)
Childbirth	Tears/stretching of rectovaginal septum	Vaginal delivery, high BW	12 13 15
Aging	Tissue weakening, decreased estrogen	Postmenopausal women	10 15
Chronic constipation	Straining increases pelvic floor pressure	Low fiber diet, hard stool	1 5 15
Pelvic surgery	Alters support structures	Hysterectomy, prostatectomy	1 3 15
Obesity	Increased intra-abdominal pressure	High BMI	4 13 15
Connective tissue disorders	Weakens pelvic support	Ehlers-Danlos, etc.	15
Other pelvic organ prolapse	Overloads rectovaginal septum	Multi-compartment issues	4 9 14

Table 3: Main Causes of Rectocele

The Role of Childbirth

Childbirth is the single most significant risk factor for rectocele, particularly vaginal delivery. During labor, the rectovaginal septum—the tissue separating the rectum from the vagina—can be stretched or torn, especially with large babies, prolonged second stage of labor, or assisted delivery 12 13 15. Studies show the prevalence of "true rectocele" increases substantially after childbirth, with both maternal and fetal factors contributing 13.

Aging and Hormonal Changes

With age, the pelvic tissues naturally lose strength and elasticity, partly due to decreased estrogen. This makes postmenopausal women more susceptible to rectocele, even if they have not had children 10 15.

Chronic Constipation and Straining

Repeated straining during bowel movements raises pressure on the pelvic floor and can gradually weaken the rectovaginal septum, especially in those with hard or infrequent stools 1 5 15. Interestingly, research suggests that improving stool quality can significantly alleviate symptoms, sometimes more so than addressing the rectocele itself 5.

Surgical and Medical Factors

Certain pelvic surgeries—such as hysterectomy in women or prostatectomy in men—can disrupt the support structures of the pelvic floor, increasing rectocele risk 1 3 15. Obesity and connective tissue disorders also predispose individuals by raising intra-abdominal pressure or compromising tissue integrity 4 13 15.

Associated Pelvic Floor Disorders

Rectoceles often coexist with other forms of pelvic organ prolapse (e.g., cystocele, enterocele), especially in cases of generalized connective tissue weakness or extensive childbirth-related injury 4 9 14. The presence of other disorders can influence both the presentation and management approach.

Treatment of Rectocele

Treatment for rectocele is highly individualized, ranging from conservative management to surgical repair. The main goal is to relieve symptoms and improve quality of life, not just correct anatomical changes.

Treatment	Approach/Technique	Outcomes/Considerations	Source(s)
Conservative	Fiber, stool softeners, biofeedback	First line, high success	19 20 5 15
Pelvic floor therapy	Biofeedback, physiotherapy	Effective for many	19 20 1
Pessary	Vaginal device to support wall	Useful in some women	15
Surgical repair	Posterior colporrhaphy, site-specific, grafts	For refractory/severe cases	2 6 7 8 11 16 17 18
Sphincterotomy	With repair in type I cases	May improve constipation	8
Minimally invasive	Laparoscopic or transanal approaches	Selected cases	20

Table 4: Treatment Options for Rectocele

Conservative Management

The majority of rectoceles—particularly mild or stage I cases—do not require surgery. Treatment often begins with:

• Increasing dietary fiber and water intake
• Using stool softeners or bulking agents
• Pelvic floor physiotherapy and biofeedback to retrain defecation habits 19 20 5

These measures resolve symptoms in the majority of patients, with studies showing over 70% respond to conservative therapy 19. Patients with coexisting intussusception may also respond well to biofeedback 19.

Pelvic Floor Therapy

Biofeedback and pelvic floor muscle training help address dysfunctional defecation and can be especially beneficial when rectocele coexists with functional disorders such as anismus (failure of pelvic muscles to relax during defecation) 1 20.

Pessary Use

Vaginal pessaries can provide internal support and symptom relief, but are generally reserved for women who are not surgical candidates or desire to delay surgery 15.

Surgical Options

Surgery is considered when symptoms are severe, persistent, and impact quality of life, or when conservative measures fail. Techniques include:

• Posterior colporrhaphy: Reinforcement of the vaginal wall 2 6 16
• Site-specific repair: Repairing discrete fascial defects, sometimes with graft augmentation (e.g., dermal or porcine grafts) 6 18
• Perineal levatorplasty: Tightening the perineal body, sometimes combined with other procedures 17
• Limited internal sphincterotomy: May be added to address high resting anal pressure in type I rectocele 8

Outcomes are generally favorable, with most women experiencing significant symptom relief and improved quality of life 2 6 16. However, recurrence and complications like dyspareunia or wound healing issues can occur depending on the technique used 6 16 17.

Individualizing Surgical Approach

The best surgical technique remains debated. Clinical and radiological evaluation helps tailor the approach:

• Simple, isolated rectoceles may be managed with endorectal or vaginal repair
• Complex cases with multi-compartment prolapse may require combined or abdominal procedures 7 11 17 20

Multidisciplinary and Long-term Care

Given the frequent coexistence of other pelvic floor disorders, a multidisciplinary approach involving gynecologists, colorectal surgeons, and physiotherapists provides the best outcomes 4 20.

Conclusion

Rectocele is a prevalent pelvic floor disorder with variable symptoms and outcomes. Understanding its complexity empowers patients and clinicians to make informed decisions about care.

Main Points:

• Rectocele symptoms range from vaginal bulge and pelvic pressure to obstructed defecation and sexual dysfunction, with severity varying widely 1 5 10 14 16.
• Types of rectocele differ anatomically and functionally; distinguishing them is key for treatment planning 7 8 9.
• Causes are multifactorial, with childbirth, aging, chronic straining, and pelvic surgery being major contributors 12 13 15.
• Most patients respond to conservative management; surgery is reserved for severe or refractory cases, and the optimal technique should be individualized 19 20 2 6 16 17.

The journey from symptoms to treatment is highly personal. With the right information and multidisciplinary care, most people with rectocele can achieve meaningful improvement and restored quality of life.