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What is a rectocele?

A rectocele is a bulge of the front (anterior) wall of the rectum into the back (posterior) wall of the vagina.

It occurs when the rectovaginal septum, the layer of supportive connective tissue that normally separates and supports the rectum and vagina becomes stretched, thinned or defective. This allows the rectal wall to move forwards, into the vagina, particularly during straining or increases in abdominal pressure.

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For this reason, a rectocele is often described clinically as a posterior vaginal wall prolapse, and it is usually staged using the POP-Q (Pelvic Organ Prolapse Quantification) system.

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The important point is that a rectocele is not simply a problem with the rectum, or simply a problem with the vagina. It reflects a change in the relationship between the rectum, the vagina, the pelvic floor muscles, and the connective tissue that supports them.

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A rectocele can be small or more pronounced, and it can occur with or without symptoms, in fact, most rectoceles are asymptomatic. Rectoceles are identified on imaging in a substantial proportion of women with no bowel symptoms at all, and studies using defecography have found small-to-moderate rectoceles even in healthy, young, nulliparous volunteers. This is worth knowing, because it means the presence of a rectocele on examination or imaging is not, by itself, a diagnosis of a problem, it has to be interpreted alongside your symptoms.

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What happens with a rectocele?

Normally, the rectum sits behind the vagina and is supported by the rectovaginal septum, the pelvic floor muscles (including levator ani and puborectalis) and the surrounding connective tissue.

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During a bowel movement, the pelvic floor and anal sphincter need to relax and coordinate while the rectum and abdominal muscles generate the pressure needed to move stool towards the anus.

With a rectocele, part of the front wall of the rectum can bulge forwards into the vagina during this process. In some women, stool can collect within this bulging pocket rather than moving directly towards the anal canal, contributing to a sensation of incomplete emptying or difficulty passing stool. However, not every rectocele traps stool, and not every woman with a rectocele develops bowel-emptying problems.

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Why does a rectocele develop?

There is no single cause of rectocele. It is best understood as a **multifactorial condition**, where several factors can influence the strength, flexibility and coordination of the tissues and muscles supporting the rectum and vagina.

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These may include:

• Weakness or defects in the rectovaginal septum

• Altered or reduced support from the pelvic floor muscles and surrounding structures

• Repeated increases in pressure within the abdomen and pelvis

• Chronic straining associated with difficult bowel movements

• Constipation or disordered bowel emptying

• Changes in connective-tissue strength and elasticity over time

• Previous pelvic or vaginal surgery

• Pelvic floor injury or trauma, including obstetric injury- Individual differences in connective-tissue strength and pelvic anatomy

• Conditions affecting pelvic floor muscle coordination or relaxation (for example, an overactive or non-relaxing pelvic floor)

• Prolonged or difficult pushing during childbirth

• Habitual gripping or bracing of the buttock and pelvic floor muscles, which some women use unconsciously and which may be linked to broader patterns of pelvic floor overactivity, this connection is based on clinical observation rather than strong trial evidence, so it's best explored individually with a pelvic health physiotherapist rather than assumed.

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Pregnancy and vaginal childbirth are associated with pelvic floor and connective-tissue changes and are among the most consistently reported risk factors for prolapse, but they are not the sole explanation, a rectocele can occur in women who have never been pregnant, and studies have found rectovaginal septal defects on imaging even in some young nulliparous women. For some women, there is no single identifiable event that caused the rectocele, and it can develop or become more noticeable gradually over time.

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Rectocele and constipation

The relationship between rectocele and constipation can work in both directions.

Difficulty emptying the bowel may lead to repeated straining, which places additional mechanical stress on the pelvic floor and rectovaginal septum over time. Conversely, a rectocele may contribute to obstructed defaecation if stool becomes retained within the bulge, or if the normal mechanics of evacuation are altered.

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This means that simply being told to "stop straining" is not always enough. If you are repeatedly straining because you cannot empty your bowel properly, the underlying reason for that difficulty should be assessed, including stool consistency, bowel habits, diet, medication, and pelvic floor muscle coordination, which may all need to be addressed alongside the rectocele itself.

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What symptoms can a rectocele cause?

A rectocele may cause no symptoms at all. When symptoms do occur, they are most commonly related to bowel emptying.

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You may experience:

•  A feeling that your bowel has not completely emptied

• Difficulty getting stool out

• Needing to strain to pass stool

• Needing to return to the toilet shortly afterwards

• A sensation that stool is "stuck"

• A feeling of pressure or fullness in the vagina

• A vaginal bulge, or a sensation of something coming down

• Needing to change position to help empty your bowel

• Needing to press on the posterior vaginal wall or perineum to help stool pass

• Needing to use a finger to help empty the rectum

• Discomfort or pressure during bowel movements

• Difficulty controlling wind or stool, in some women

• Pain during intercourse

• Difficulty inserting a tampon, menstrual cup or pessary

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Pressing on the vaginal wall or perineum, or using a finger, to assist bowel emptying is sometimes called splinting or digital assistance. This symptom is clinically significant: research comparing women with and without examination-confirmed posterior vaginal wall prolapse found splinting was substantially more common in women with prolapse present, making it a useful marker of a functionally significant rectocele rather than an incidental finding.

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Does the size of a rectocele matter?

Not necessarily on its own.

A rectocele seen on examination or imaging does not automatically mean it is responsible for your symptoms. Some women have a relatively noticeable rectocele but little or no difficulty with bowel emptying; others have significant symptoms despite a less obvious anatomical bulge. Some studies do show that larger rectoceles are, on average, more strongly associated with posterior compartment prolapse and with symptoms such as splinting, but the correlation between size and symptom burden is inconsistent enough that anatomy and function must always be assessed together, not substituted for one another.

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Rectocele and obstructed bowel emptying

A rectocele may be associated with a condition known as obstructed defaecation syndrome (ODS) difficulty evacuating stool despite having the urge to open the bowels.

This difficulty often involves several factors rather than the rectocele alone. The pelvic floor muscles may not relax appropriately during attempted emptying (sometimes called dyssynergic defaecation or anismus), and rectal sensation, stool consistency, and the behaviour of other pelvic structures (such as rectal intussusception or an enterocele) can all influence how effectively the bowel empties. This is why treatment should not focus only on the visible bulge, a proper assessment considers the whole bowel-emptying mechanism.

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How is a rectocele diagnosed?

A rectocele is usually assessed through a detailed history and pelvic examination.

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Your healthcare professional may ask about:

• How often you open your bowels, and stool consistency

• Constipation, straining, and incomplete emptying

• Whether you need to return to the toilet repeatedly

• Whether you use vaginal, perineal or digital pressure to help evacuate

• Vaginal pressure or bulging

• Bowel or bladder leakage

• Previous pelvic surgery or pelvic floor problems

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During examination, you may be asked to bear down or strain so the movement of the posterior vaginal wall can be assessed and staged using the POP-Q system. Your pelvic floor muscles will usually also be assessed, including your ability to contract and, importantly, to relax them as difficulty relaxing the pelvic floor is a common and often under-recognised contributor to symptoms.

The POP-Q stage should not be interpreted in isolation from your symptoms.

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Do I need a scan?

Not everyone with a rectocele needs imaging, clinical assessment is usually the starting point. Further investigation may be appropriate where symptoms are significant, complex, persistent, or don't match examination findings, or where specialist assessment of the defaecation mechanism itself is needed.

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Depending on the circumstances, this may include:

• Defecography (X-ray imaging during bowel emptying)

• MR defecography (MRI assessment of pelvic structures during attempted evacuation)

• Anorectal physiology testing

• Other investigations where another bowel condition needs to be excluded

 

These are used selectively, not routinely, when the additional information is likely to change diagnosis or management.

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What can help a rectocele?

Treatment should be based on your symptoms, examination findings and personal goals. If a rectocele is present but not causing problems, treatment may not be necessary.

 

Bowel management

Keeping stools comfortably soft and avoiding unnecessary straining is an important part of managing symptoms. Depending on your bowel pattern, this may involve addressing constipation, stool consistency, fluid and dietary factors, bowel habits, or medications affecting bowel function. Bowel advice should be individualised, simply increasing fibre is not appropriate for everyone with difficult evacuation, and can worsen symptoms in some people with evacuation disorders.

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Pelvic floor rehabilitation

Pelvic floor muscle training can help appropriately selected women with symptomatic pelvic organ prolapse. NICE guideline NG123 recommends considering a supervised programme of pelvic floor muscle training for at least 16 weeks as a first option for women with symptomatic POP-Q stage 1 or stage 2 prolapse, with continued training afterwards if it proves beneficial.

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Pelvic floor rehabilitation is not simply about making the muscles stronger. Assessment should consider whether you can:

• Contract the pelvic floor effectively

• Relax the pelvic floor fully

• Coordinate relaxation with bowel emptying

• Manage changes in abdominal pressure

• Use the pelvic floor appropriately during everyday activity

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NICE recommends that supervised training be tailored to the individual's ability to contract and relax, and to her symptoms and goals. For women whose main problem is difficulty relaxing or coordinating the pelvic floor during defaecation, treatment often needs to focus on coordination and relaxation rather than strengthening alone.

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Vaginal pessary support

A vaginal pessary may be considered for women with symptomatic pelvic organ prolapse. NICE NG123 recommends considering a pessary, either alone or alongside supervised pelvic floor muscle training. A pessary can support the vaginal walls and reduce prolapse symptoms for some women, but it does not repair the rectovaginal septum or restore the supporting tissues, and it will not necessarily correct an underlying bowel-emptying disorder.

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Whether a pessary helps depends on your anatomy, the type and extent of prolapse, your symptoms and personal circumstances. Some women find a ring pessary makes bowel emptying more difficult, and may be better supported by a shaped pessary such as a dish, Gellhorn, Marland or Hodge, however, the evidence for matching specific pessary shapes to rectocele symptoms is largely based on clinical experience and observational reports rather than randomised trials, so fitting should be individualised with a clinician experienced in pessary care, and reviewed regularly.

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Specialist bowel or pelvic floor assessment

If bowel emptying remains difficult despite appropriate conservative management, referral to a specialist pelvic floor, colorectal or urogynaecology service may be appropriate, particularly if you are regularly needing to use your fingers or apply pressure to empty your bowel, or if symptoms are significantly affecting your quality of life.

 

Surgery

Surgery may be considered when symptoms are significant, non-surgical treatment hasn't provided sufficient relief, or individual assessment indicates it's appropriate. Surgery is not recommended simply because a rectocele is visible on examination.

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There is more than one surgical approach, and the right one depends on your anatomy, symptoms and which specialist you see:

 

Transvaginal repair (posterior colporrhaphy) performed by gynaecologists, this repairs and reinforces the rectovaginal septum through the vagina. NICE NG123 recommends offering posterior vaginal repair without mesh to women with posterior vaginal wall prolapse; mesh use in this compartment is now restricted to the circumstances set out in NICE's separate interventional procedures guidance (IPG599), reflecting ongoing safety concerns about mesh.

Transanal or stapled repair (for example STARR stapled trans-anal rectal resection) performed by colorectal surgeons, typically where obstructed defaecation symptoms dominate. Evidence comparing STARR with posterior colporrhaphy is mixed: some studies suggest STARR is more effective at relieving obstructed defaecation symptoms, but it has also been associated with specific risks (including urgency, incontinence and, rarely, more serious complications), and it is not considered a gold-standard approach by all specialists.

Transperineal repair sometimes preferred where there is a co-existing sphincter defect or faecal incontinence, typically performed by colorectal surgeons.

Abdominal or laparoscopic approaches (such as rectopexy or sacrocolpopexy), occasionally used, particularly where a rectocele coexists with apical or multi-compartment prolapse, or with rectal intussusception.

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Because gynaecological and colorectal approaches target the problem slightly differently, vaginal anatomy versus rectal/evacuation function, the choice of procedure, and which specialist leads it, should be guided by which symptoms are most troublesome, not simply by the presence of a bulge. A specialist should explain the available options, the evidence for each, and the potential benefits and risks, to support an informed decision.

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Can a rectocele occur with other problems?

Yes. Although a rectocele specifically involves the posterior vaginal wall and rectum, it commonly coexists with other pelvic floor conditions, studies suggest rectoceles coexist with anterior or apical (mid-compartment) prolapse in up to half of affected women. Related or coexisting conditions include:

•  Anterior vaginal wall prolapse (cystocele)

•  Uterine prolapse

•  Vaginal vault prolapse following hysterectomy

•  Enterocele

•  Sigmoidocele

•  Rectal intussusception

•  Pelvic floor muscle dysfunction

•  Urinary incontinence

•  Faecal or flatal incontinence

• -Other bowel-emptying disorders

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These should be assessed separately rather than assuming every pelvic symptom is caused by the rectocele.

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When should I seek professional advice?

Speak to your GP, a pelvic health physiotherapist, gynaecologist, urogynaecologist or colorectal specialist if you have:

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• Persistent difficulty emptying your bowel

• Frequent or severe straining

• A vaginal bulge or pressure

• A feeling that stool is becoming trapped

• A need to press on the vagina or perineum, or use your fingers, to empty your bowel

• New bowel or bladder symptoms

• Symptoms affecting your daily life or quality of life

 

You should also seek prompt medical assessment for any new, persistent or unexplained change in bowel habit, rectal bleeding, unexplained weight loss, or significant abdominal or rectal pain, these can indicate a bowel condition unrelated to prolapse and should never be assumed to be "just the rectocele."

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Your symptoms are valid

Difficulty emptying your bowel can be frustrating, embarrassing and hard to talk about.

If you've been told you have a rectocele, it's reasonable to ask not only "how big is my prolapse?" but also:

• "Is my rectocele actually affecting how my bowel empties?"

• "Are my pelvic floor muscles relaxing and coordinating properly when I open my bowels?"

• "Could there be another reason for my symptoms?"

• "What non-surgical options are appropriate for me?"

 

A rectocele does not automatically mean you need surgery, and finding a rectocele does not necessarily mean it's the cause of every bowel or pelvic symptom you have. Good pelvic healthcare means understanding the anatomy, the function, and the woman experiencing it, then choosing treatment based on all three.

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Pelvic Organ Prolapse & Bowel Symptom Diary

If you're experiencing symptoms that could be related to a rectocele, keeping a symptom diary can help identify patterns. Download the Pelvic Angel diary from the free members area.

• You may wish to record:

• Bowel movements and stool consistency (see the Bristol Stool Chart)

• Straining and incomplete emptying

• Repeated trips to the toilet

• Vaginal pressure or bulging

• Whether you need to change position, press on the vagina or perineum, or use your fingers to assist evacuation

• Bowel or bladder leakage

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You can take your diary to your GP, pelvic health physiotherapist, gynaecologist, colorectal specialist or other appropriate healthcare professional.

Understanding a rectocele is about more than identifying a bulge. It's about understanding how the rectum, vagina, pelvic floor muscles and supporting tissues work together, and what happens when that system isn't working efficiently.

The right assessment can help you understand what's happening and identify the most appropriate options for you.

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Join our Rectocele and Bloating Exclusive Membership. Inside the portal you'll find clinical papers, symptom diaries, a 5-day rectocele training programme with movements to strengthen and relax the core, specific abdominal massage for rectocele and bloating, pessary advice, nutrition guidance, and ongoing support with free hop-on Zoom classes.

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References

National Institute for Health and Care Excellence. Urinary incontinence and pelvic organ prolapse in women: management. NICE guideline NG123. Published 2 April 2019; last updated 24 June 2019 (surveillance review confirmed currency, July 2026). 

National Institute for Health and Care Excellence. Transvaginal mesh repair of anterior or posterior vaginal wall prolapse. Interventional procedures guidance IPG599. www.nice.org.uk/guidance/ipg599
Grimes CL, et al. Rectoceles: Is There a Correlation Between Presence of Vaginal Prolapse and Radiographic Findings in Symptomatic Women? *Female Pelvic Med Reconstr Surg.* PubMed: 35272309
Panel LA, et al. The prevalence of abnormal posterior compartment anatomy and its association with obstructed defecation symptoms in urogynecological patients. PubMed: 26670577
GLOWM. The Pathophysiology, Diagnosis, and Management of Rectoceles. www.glowm.com
Grimes WR, Bhatt A. Management of Rectocele with and without Obstructed Defecation. *Clinics in Colon and Rectal Surgery.* ScienceDirect.
StatPearls (NCBI Bookshelf). Rectocele. NBK546689.
Medscape/eMedicine. Rectocele: Practice Essentials, Epidemiology.
Various authors. Comparative studies of posterior colporrhaphy vs. STARR and transperineal rectocele repair (PMC9866699; PubMed 24342163; PubMed 24881474).

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This page is provided for general information and does not replace individual clinical assessment. Always seek advice from a qualified healthcare professional about your own symptoms and circumstances.

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Page reviewed and updated August 2026