If you need to press on the back wall of the vagina or the perineum to finish a bowel movement, a rectocele is a common reason. A rectocele is a bulge of the rectum into the vagina caused by weakened support between them. Stool collects in the pouch instead of passing out, and pressing pushes it back into line. Treatment ranges from bowel habit changes to surgical repair.
What a rectocele is
The rectum lies directly behind the back (posterior) wall of the vagina. Between them sits a layer of connective tissue, the rectovaginal septum, which is attached below to the perineal body, the firm area of muscle and tissue between the vagina and anus. When this layer stretches, thins or separates from the perineal body, the front wall of the rectum can balloon forward into the vagina when you strain. The medical term "posterior vaginal wall prolapse" describes what is seen on examination.
Childbirth is the most common cause, particularly deliveries with tears, forceps or a long second stage. Chronic constipation, repeated straining, menopause, heavy lifting and previous pelvic surgery also contribute.
Why you have to press to empty your bowel
During a normal bowel movement, abdominal pressure and rectal contraction push stool backward and down toward the anus. With a rectocele, part of that force is directed forward into the weak spot instead. Stool is pushed into the pouch, where it can become trapped. The result is a sense that the bowel is not empty even after a long effort.
Pressing with fingers on the back wall of the vagina, on the perineum or beside the anus, a technique doctors call splinting or digitation, flattens the pouch and redirects stool toward the anus. Many women discover this trick on their own and feel embarrassed to mention it, but it is a well-recognized clinical sign and an important clue for diagnosis.
Other symptoms of rectocele
Symptoms vary with size, and small rectoceles are often symptom-free. Common complaints include:
- A feeling of incomplete emptying or needing several trips to the toilet
- Straining for long periods or feeling blocked
- A soft bulge at the vaginal opening, especially when straining
- Pressure or heaviness in the vagina or rectum
- Soiling or difficulty wiping clean after a bowel movement
- Discomfort or looseness during sex
- Low back discomfort that eases when lying down
Not every difficult bowel movement is a rectocele
Obstructed defecation has several possible causes, and a rectocele may be present without being the main problem. Other conditions that can produce similar symptoms include:
- Pelvic floor dyssynergia, in which the muscles tighten instead of relaxing during defecation
- Slow-transit constipation, where stool moves slowly through the colon
- Internal rectal prolapse or intussusception
- An enterocele, where small bowel descends between the vagina and rectum
- Hemorrhoids, fissures or, rarely, a tumor
Because surgery for a rectocele will not fix these other problems, careful assessment matters before any operation. New bowel symptoms, rectal bleeding, weight loss or a change in bowel habit should always be investigated.
How a rectocele is diagnosed
Assessment usually includes:
- A detailed bowel history, including stool consistency, straining time and whether you use splinting.
- A vaginal and rectal examination at rest and while bearing down.
- POP-Q measurement to document posterior wall descent and check the other compartments.
- Assessment of anal sphincter and pelvic floor muscle function.
- In selected cases, defecography using X-ray or MRI to show how the rectum empties.
- Anorectal manometry or colonoscopy when another cause is suspected.
Treatment without surgery
Improving stool consistency and toilet habits
Many women improve significantly with simple measures. Soft, formed stools are much easier to pass through a weakened area. Helpful steps include adequate fluids, a fiber-rich diet or fiber supplement, and stool softeners when needed. Using a footstool to raise the knees above the hips straightens the anorectal angle and reduces the need to strain. Responding promptly to the urge to go and avoiding long straining sessions also help.
Pelvic floor physiotherapy and biofeedback
A pelvic health physiotherapist can teach coordinated relaxation of the pelvic floor during defecation and strengthen the muscles at other times. Biofeedback is particularly useful if dyssynergia is present.
Pessaries and splinting
Some pessaries support the posterior wall, although they tend to work better for front wall and uterine prolapse. Continuing to splint is a reasonable long-term strategy for women who prefer to avoid surgery.
Surgical repair of rectocele
Surgery is considered when symptoms are bothersome and conservative care has not helped. The most common gynecologic approach is posterior colporrhaphy, performed through the vagina: the surgeon opens the back wall, brings the supporting tissue together in the midline or repairs specific defects, and often rebuilds the perineal body. Colorectal surgeons sometimes repair rectoceles through the anus or the abdomen, especially when internal rectal prolapse is also present.
A Cochrane review of posterior compartment surgery concluded that the vaginal approach generally gives better anatomical outcomes than the transanal approach, and that adding synthetic or biological grafts does not clearly improve results. Possible risks include bleeding, infection, pain with sex, especially if the vagina is over-narrowed, and recurrence. Bowel symptoms improve for many, but not all, women, which is why realistic expectations are important.
Recovery usually takes about six weeks. During this time it is especially important to keep stools soft, avoid straining and heavy lifting, and wait for the surgeon's approval before resuming intercourse. Continuing good bowel habits for life is the best way to protect the repair, because ongoing straining is one of the main reasons a rectocele returns.
Frequently asked questions
Is splinting harmful?
No. Pressing on the vagina or perineum to help empty the bowel is not dangerous and is a recognized management strategy. Use clean hands, or a finger covered with toilet paper or a glove, and avoid excessive force.
Can a rectocele get worse over time?
It can, especially with ongoing straining, heavy lifting, weight gain or aging. Many rectoceles remain stable when constipation is controlled. Improving bowel habits is the single most useful step to slow progression.
Will rectocele surgery cure my constipation?
Surgery may improve emptying if the rectocele is the main cause, but it does not treat slow bowel transit or pelvic floor dyssynergia. Some women still need bowel management after repair. A careful assessment before surgery helps predict benefit.
Can I have a rectocele without a bulge?
Yes. A rectocele may cause bowel emptying problems without a visible bulge at the vaginal opening. It is often detected only when the doctor examines you while you strain.
Does rectocele repair affect sex?
Many women report improved comfort and confidence after repair. However, over-tightening or scarring can cause pain with intercourse in some cases. Discuss how the surgeon will avoid narrowing the vagina.
References
- American College of Obstetricians and Gynecologists and American Urogynecologic Society. Practice Bulletin No. 214: Pelvic Organ Prolapse. Obstet Gynecol. 2019.
- Mowat A, Maher D, Baessler K, Christmann-Schmid C, Haya N, Maher C. Surgery for women with posterior compartment prolapse. Cochrane Database Syst Rev. 2018.
- Haylen BT, Maher CF, Barber MD, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic organ prolapse (POP). Int Urogynecol J. 2016.
- DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992.
This article is for general education and does not replace an examination by a qualified gynecologist. Individual results vary, and every procedure carries risks.
