Enterocele
What is an Enterocele?
An enterocele is a type of pelvic organ prolapse in which a loop of the small intestine, together with the surrounding peritoneal sac, descends into the upper or back part of the vagina.
The small intestine normally sits within the abdominal cavity and is supported by the surrounding connective tissues, ligaments and pelvic structures. When these supporting structures become stretched, weakened or displaced, the small bowel and the peritoneal sac around it can move downwards and create a bulge towards the vagina.
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An enterocele is sometimes described as a small-bowel prolapse or a hernia of the peritoneal sac.
An enterocele can occur on its own, but it can also occur alongside other forms of pelvic organ prolapse, including:
Cystocele – the bladder bulges into the front wall of the vagina
Rectocele – the rectum bulges into the back wall of the vagina
Uterine prolapse – the uterus descends towards or into the vagina
Vaginal vault prolapse – the top of the vagina descends, usually following a hysterectomy
It is quite possible to have more than one type of prolapse at the same time.
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Why does an enterocele happen?
There is usually not one single cause of an enterocele.
Pelvic organ prolapse is considered to be multifactorial. The support of the pelvic organs depends on a combination of muscles, connective tissues, ligaments, fascia and the bony pelvis. These structures can be affected by pregnancy and childbirth, ageing, previous pelvic surgery and repeated increases in abdominal pressure, among other factors.
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Factors that may contribute to pelvic organ prolapse include:
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Pregnancy and childbirth, particularly where there has been significant stretching or injury to the pelvic support structures
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Previous pelvic or vaginal surgery, including hysterectomy
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Increasing age and changes in connective tissue over time
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Menopause and changes in the vaginal and genitourinary tissues associated with reduced oestrogen
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Long-term constipation and repeated straining
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Chronic coughing or other conditions that repeatedly increase abdominal pressure
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Regular heavy lifting or activities involving repeated high abdominal pressure
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Individual differences in connective-tissue strength and pelvic anatomy
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Previous pelvic organ prolapse
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Having one or more of these factors does not mean that you will develop an enterocele, and an enterocele can occur without an obvious single cause.
It is also important to understand that an enterocele should not simply be described as a “weak pelvic floor.” The pelvic floor is part of a much larger support system, and prolapse can involve several different structures and compartments.
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What are the symptoms of an enterocele?
Some women with an enterocele have no symptoms at all and may only discover it during an examination or investigation.
When symptoms are present, they can vary considerably from woman to woman.
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Possible symptoms include:
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A feeling of heaviness, dragging or pressure in the pelvis
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A sensation that something is dropping or falling down
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A feeling of fullness or pressure in the vagina
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A soft or rounded bulge within or at the opening of the vagina
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Vaginal discomfort
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Lower abdominal or pelvic pressure
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Aching in the lower back or pelvis
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Discomfort during sexual intercourse
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A sensation that becomes worse after prolonged standing, walking or physical activity
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Bowel symptoms, particularly when an enterocele occurs alongside a rectocele or another posterior-compartment problem
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​Excessive bloating
Some women describe the sensation as:
“It feels as though something is pushing down from above.”
Symptoms can change throughout the day and may become more noticeable with standing, lifting, coughing, straining or other activities that increase abdominal pressure.
Importantly, the size or stage of a prolapse does not always correspond to how much it bothers a woman. A woman with a relatively small prolapse may experience significant symptoms, while another woman with a more advanced prolapse may have very few symptoms.
Your symptoms, your quality of life and what matters to you should all be part of the discussion about treatment.
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How is an enterocele diagnosed?
This is an important distinction.
A pelvic examination is an essential part of assessing pelvic organ prolapse. It allows a clinician to identify and document prolapse and assess the anterior, central and posterior vaginal compartments. Prolapse can be documented using the POP-Q (Pelvic Organ Prolapse Quantification) system.
However, a manual examination does not always tell us exactly what is contained within a vaginal bulge.
An enterocele can sometimes be difficult to distinguish clinically from a rectocele or another type of posterior or upper vaginal prolapse.
For this reason, if an enterocele is suspected but the diagnosis my be inconclusive, or if your symptoms are not explained by the examination, dynamic pelvic imaging may provide valuable additional information.
What imaging may be used?
Depending on your symptoms, the clinical question and what is available locally, investigations may include:
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Dynamic pelvic floor ultrasound
A transperineally or pelvic floor ultrasound can assess the pelvic structures dynamically while you strain or bear down. It can be useful in assessing several compartments of the pelvic floor and can help identify an enterocele in appropriate cases.
MRI of the pelvic floor / MR defecography
MRI can provide detailed images of the pelvic organs and surrounding tissues and can assess how the pelvic floor behaves during different manoeuvres.
MR defecography is particularly useful when there are complex or multi-compartment pelvic floor problems, and can help identify an enterocele and distinguish it from other conditions such as a rectocele or rectal intussusception.
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Fluoroscopic defecography
Also known as a defecating proctogram, this investigation uses X-ray imaging while you empty your bowel. It can provide important functional information and is particularly useful for identifying conditions such as an enterocele, rectocele or intussusception.
Current international guidance recognises the particular value of defecography when an enterocele is suspected.
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Does everyone with prolapse need a scan?
No!
Routine imaging is not recommended simply to document ordinary pelvic organ prolapse that has already been identified clinically. NICE recommends examination as the primary assessment, and its guideline committee specifically noted evidence that imaging does not add benefit when vaginal prolapse has already been adequately diagnosed by physical examination.
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Imaging is more likely to be useful when:
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An enterocele is specifically suspected
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The type or compartment of prolapse is uncertain
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Your symptoms aren't explained by the examination findings
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More than one compartment appears to be involved
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You have significant bowel or defecatory symptoms
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You have recurrent or complex prolapse
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Imaging findings would change how surgery is planned
One study looking specifically at posterior compartment prolapse found that adding a second imaging modality to clinical assessment changed the recommended treatment plan in around a quarter of cases, and that a related finding, peritoneocele (the peritoneal sac component of an enterocele), could only be reliably quantified on MRI defecography, not on conventional imaging or examination alone.
This is a useful illustration of why imaging is reserved for cases where the diagnosis genuinely affects the plan, rather than being routine.
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The 2025 International Urogynecological Consultation concluded that enteroceles can be better visualised with defecography or MRI than with physical examination alone, while also recognising that imaging should not replace a proper clinical assessment.
Lipetskaia L, et al. International Urogynecological Consultation Chapter 2.2: Imaging in the Diagnosis of Pelvic Organ Prolapse. Int Urogynecol J. 2025.
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If you have been told you have an enterocele
It is reasonable to ask:
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“How was the enterocele identified?”
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“Is this based on examination, imaging, or both?”
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“Do you know what is actually contained within the prolapse?”
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“Could dynamic pelvic imaging help clarify whether this is an enterocele, rectocele or another type of prolapse?”
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"Can I use a pessary"?
You do not need to be afraid of asking for a clearer explanation of your diagnosis.
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What can I do if I have an enterocele?
An enterocele does not automatically mean that you need surgery.
Management should be individualised according to your symptoms, the type and extent of prolapse, your overall health, your lifestyle and your personal preferences.
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Depending on your circumstances, management may include:
Pelvic floor rehabilitation
A properly assessed and individualised pelvic floor muscle programme may form part of conservative prolapse management.
Pelvic floor rehabilitation is about more than simply repeatedly squeezing the pelvic floor muscles.
A pelvic health professional can assess how your pelvic floor muscles function and how they coordinate with breathing, movement, abdominal pressure, posture and everyday activities.
NICE recommends considering a programme of supervised pelvic floor muscle training for at least 16 weeks as a first option for women with symptomatic stage 1 or stage 2 pelvic organ prolapse.
The right programme will depend on your individual assessment.
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Looking after bowel health
Constipation and repeated straining can increase pressure on the pelvic floor.
Managing constipation, allowing yourself enough time to empty your bowel and avoiding unnecessary straining are important parts of pelvic floor and prolapse care.
NICE recommends considering advice to prevent or treat constipation and to minimise heavy lifting in women with pelvic organ prolapse.
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Managing menopausal vaginal symptoms
Changes associated with menopause can affect vaginal and genitourinary tissues.
For women with pelvic organ prolapse who also have menopause-associated genitourinary symptoms, vaginal oestrogen may be considered where clinically appropriate.
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Vaginal oestrogen is not a treatment that puts an enterocele back into place. Its role is to treat associated genitourinary symptoms and changes in the vaginal tissues.
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NICE NG123 recommends considering vaginal oestrogen for prolapse-associated genitourinary symptoms, cross-referring to NICE's menopause guideline for women with a history of breast cancer.
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Pessary support
There is no pessary designed to directly support an enterocele or hold the small bowel in place.
An enterocele occurs higher within the pelvic support system, where the peritoneal sac containing small bowel can descend towards the upper part of the vagina. A vaginal pessary cannot be placed around or behind the small bowel to directly support the enterocele.
However, this does not mean that a pessary can never be useful for a woman who has an enterocele.
In some women, particularly where an enterocele occurs alongside another type of pelvic organ prolapse, a pessary may provide symptomatic relief, a feeling of support or greater pelvic comfort.
The benefit is individual.
A pessary may improve symptoms caused by another component of the prolapse while having little or no effect on symptoms specifically related to the enterocele.
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Whether a pessary is appropriate depends on:
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Your individual pelvic anatomy
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The type and location of your prolapse
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Your symptoms
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Vaginal tissue health
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Previous pelvic surgery
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Your lifestyle and activities
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Your personal preferences
A pessary should be selected and fitted by someone with appropriate training and experience in pessary management.
A pessary does not cure or reverse the underlying prolapse, and it should not be presented as a treatment that directly supports an enterocele.
NICE recommends considering pessaries for women with symptomatic pelvic organ prolapse and advises that women should be informed about possible complications, including discharge, bleeding, difficulty removing the pessary and expulsion.
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If a pessary causes pain, increasing pressure, bleeding, difficulty passing urine or stool, repeated expulsion or other troublesome symptoms, it should be reviewed by an appropriately trained clinician.
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If you have an enterocele and are considering a pessary
Ask:
“What symptoms do you expect the pessary to help with in my particular case?”
“Is the pessary being used to support another part of my prolapse rather than the enterocele itself?”
Understanding what the pessary is intended to do can help you make an informed decision about whether it is right for you.
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Surgery
Surgery may be considered when prolapse symptoms significantly affect your quality of life and non-surgical management has not provided enough improvement, or when you choose surgery after discussing your options with an appropriate specialist.
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The type of surgery depends on which structures are involved, your previous surgery, your symptoms, your health and your personal goals.
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If surgery is being considered, it is important to have a clear discussion about:
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What type of prolapse you have What the proposed operation is intended to correct
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Whether the enterocele is being specifically addressed
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The expected benefits
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Possible complications
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The effect on bladder, bowel and sexual function
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Recovery time
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The possibility of recurrent prolapse
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Alternative non-surgical options
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NICE recommends shared decision-making when surgery is being considered, including discussion of non-surgical management, benefits and risks, changes in urinary, bowel and sexual function, and the possibility of recurrent prolapse.
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When should I seek professional advice?
If you have noticed a new vaginal bulge, pelvic pressure, dragging, a feeling that something is dropping, bowel symptoms or discomfort that you think could be related to an enterocele, arrange an assessment.
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You can ask your GP, gynaecologist, urogynaecologist or appropriately trained pelvic health professional for an assessment.
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You may find it helpful to say:
“I am experiencing symptoms that make me concerned that I may have pelvic organ prolapse. I would like a pelvic floor and prolapse assessment.”
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If an enterocele is suspected, you can also ask:
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What type or types of prolapse do I have?
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Is an enterocele suspected, and how was this determined?
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Could this be a rectocele or another type of prolapse?
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Would dynamic pelvic imaging be appropriate in my situation?
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What symptoms are likely to be coming from the enterocele?
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Would pelvic floor rehabilitation be appropriate for me?
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Could a pessary help my symptoms, and what exactly would it be supporting?
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Do I need referral to a urogynaecology, colorectal or pelvic-floor specialist?
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What should I do if my symptoms change or become worse?
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Can you refer me to a nutritionist or dietician?
Most importantly...
An enterocele is not something you have caused by doing something wrong.
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Pelvic organ prolapse is complex, and there is no single explanation or treatment that is right for every woman.
Some women have an enterocele without significant symptoms and may not require active treatment. Others may benefit from pelvic floor rehabilitation, bowel management, pessary use for associated prolapse symptoms, or specialist surgical assessment.
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The important first step is to understand what type of prolapse you have, what is causing your symptoms, and what options are available to you.
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You deserve to have your symptoms listened to and your treatment explained clearly.
You do not have to simply put up with prolapse symptoms.
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This information is for education and does not replace an individual clinical assessment, diagnosis or treatment plan. If you have new, severe or unexplained pelvic, abdominal or bowel symptoms, seek appropriate medical assessment.
Page reviewed and updated August 2026
