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Health condition

Enterocele, the small-bowel prolapse - and how UK urogynaecology treats it today.

Bulge, dragging, splinting to open your bowels - all common, all treatable. A stepped plan through physio, pessary and, when needed, specialist surgery does most of the work.

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Why trust this guide

  • 01

    Editorial team

    Written by our editorial team from the UK sources listed on each page.

  • 02

    Sourced from guidance

    Checked against NICE NG123, BSUG, BSGE and peer-reviewed sources you can see at the end.

  • 03

    Current for 2026

    Reflects modern UK guidance including the MHRA vaginal-mesh pause and the Cumberlege Review recommendations.

Key facts

Enterocele at a glance.

The essentials, in plain English - what it is, the types, and how UK urogynaecology treats it today.

  • What it is

    A type of pelvic-organ prolapse where small bowel and peritoneum herniate through the pouch of Douglas into the posterior vaginal wall.

  • Types

    True, traction (secondary to other prolapse), pulsion (chronic straining) and iatrogenic (typically after hysterectomy).

  • Common company

    Often co-exists with cystocele, rectocele, uterine prolapse or vault prolapse - it is rarely alone.

  • Foundation therapy

    Lifestyle changes, specialist pelvic-floor physiotherapy and a well-fitted pessary carry most people a long way.

  • Surgery is specialist

    When surgery is needed it is done by a BSUG-registered urogynaecologist, often jointly with a colorectal surgeon.

  • Mesh is restricted

    Vaginal mesh remains paused in the UK; abdominal sacrocolpopexy mesh is available only through commissioned mesh centres with explicit consent.

Why this guide matters

A stepped plan, not a rushed decision.

Enterocele is common, treatable and - with the right ladder - usually well-controlled without heroic surgery. The three points below shape everything else on this page.

  • Conservative care does most of the work

    Lifestyle changes, specialist pelvic-floor physiotherapy and a well-fitted pessary carry most women a very long way.

  • Surgery is a specialist decision

    Repair belongs with a BSUG-registered urogynaecologist and, for apical or post-hysterectomy prolapse, a joint urogynaecology and colorectal MDT.

  • Mesh has changed in the UK

    Vaginal mesh remains paused; abdominal sacrocolpopexy is available only through commissioned mesh centres, with strict indications and explicit consent.

How the diagnosis is made

From first bulge to a clear plan.

The steps a UK GP and urogynaecologist will normally follow, in order - so you know what to expect and why.

  1. 01

    Assessing

    Symptom history and questionnaires

    A structured history of bulge, heaviness, splinting and dyspareunia, with PISQ and POP-SS to score impact.

  2. 02

    Assessing

    Pelvic examination and POP-Q

    Inspection, speculum and a Valsalva manoeuvre with formal POP-Q staging of every compartment.

  3. 03

    Assessing

    Bladder and bowel screen

    Urinalysis, post-void residual and a check for splinting or obstructed defecation - enteroceles often cross specialties.

  4. 04

    Confirming

    Dynamic pelvic MRI

    Defecography MRI is excellent for enterocele - it shows the small bowel descending through the pouch of Douglas in real time.

  5. 05

    Confirming

    Defecation proctography (selective)

    Used when obstructed defecation and splinting dominate the picture - often shared with colorectal.

  6. 06

    Planning

    Urodynamics (selective)

    Reserved for coexisting incontinence, voiding difficulty or before surgery when the picture is mixed.

  7. 07

    Planning

    Urogynaecology MDT

    Complex, recurrent or post-hysterectomy prolapse is reviewed in a specialist MDT with urogynaecology and colorectal input.

Typical timeline: a first visit to a settled plan in a few weeks, once imaging is done.

Symptoms

What an enterocele actually feels like.

The classic mix of bulge, heaviness, splinting and dyspareunia - and the features that mean it is time to escalate.

  • Vaginal bulge

    A sensation of something coming down - often more obvious by the end of the day or after standing.

  • Heaviness and dragging

    A low, dull pelvic ache that eases when lying down and worsens with lifting or long periods on your feet.

  • Pressure with straining

    The bulge becomes prominent with coughing, sneezing or bearing down - typical of a pulsion enterocele.

  • Splinting to open bowels

    Needing to press on the vaginal wall or perineum to pass stool - a strong clue to a posterior compartment problem.

  • Dyspareunia

    Discomfort with intercourse, from pressure or from the mechanical effect of the bulge itself.

  • Coexisting prolapse

    Cystocele, rectocele, uterine or vault prolapse very often travel with an enterocele.

  • Post-hysterectomy vault descent

    Around 5 to 30% of women develop vault prolapse and enterocele in the years after hysterectomy.

  • Red flag - obstruction or ulceration

    Severe pain, urinary retention, bleeding from an ulcerated bulge or sudden change deserves urgent review.

Treatment

How enterocele is treated in the UK.

Lifestyle and physiotherapy first, a pessary next - and specialist urogynaecology surgery when symptoms and anatomy demand it.

  • Lifestyle and load

    Weight loss where relevant, treating chronic cough or constipation, and avoiding heavy lifting - the foundations, whatever else you choose.

  • Pelvic-floor physiotherapy

    Specialist supervised pelvic-floor muscle training - first-line for mild to moderate prolapse and useful before and after any surgery.

  • Vaginal pessary

    Ring, Gellhorn, cube, shelf or donut - fitted in a urogynaecology clinic and reviewed regularly. A robust alternative to surgery.

  • Vaginal oestrogen

    Topical oestrogen for post-menopausal women - improves vaginal tissue quality and pessary tolerance as an adjunct.

  • Vaginal repair

    McCall culdoplasty, Moschcowitz, Halban and posterior colporrhaphy - native-tissue vaginal repairs done by a specialist urogynaecologist.

  • Sacrospinous fixation

    The Richter procedure - vaginal fixation of the apex to the sacrospinous ligament for apical enterocele and vault prolapse.

  • Laparoscopic sacrocolpopexy

    The gold-standard apical repair - abdominal mesh via keyhole or robotic surgery in a commissioned mesh centre with explicit consent.

  • Colpocleisis

    Obliterative surgery for frailer women who no longer wish to be sexually active - short, safe and highly effective.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP or urogynaecologist knows your history and examination and can tell you which parts of this apply to you. If in doubt, get seen.

  • NICE. Urinary incontinence and pelvic organ prolapse in women: management (NG123).

  • British Society of Urogynaecology (BSUG). Guidance on prolapse assessment and surgery.

  • British Society for Gynaecological Endoscopy (BSGE) and RCOG green-top guidance on prolapse.

  • MHRA and the Independent Medicines and Medical Devices Safety Review (Cumberlege). Vaginal mesh pause and recommendations.

Red flags

When enterocele needs urgent attention.

Most prolapse is managed in outpatients. These are the situations that are not - and where a specialist opinion is needed sooner rather than later.

  • Acute urinary retention

    Sudden inability to pass urine with a prominent bulge - go to the emergency department for catheterisation and urgent review.

  • Bowel obstruction features

    Severe pain with vomiting, distension and no flatus alongside a large enterocele - needs same-day assessment.

  • Ulcerated or bleeding prolapse

    A tender, ulcerated bulge that bleeds is uncommon but needs urgent urogynaecology review.

  • Post-hysterectomy vault prolapse

    New bulge or dragging after hysterectomy deserves early referral - this is a common site for enterocele.

  • Complications after mesh

    New pain, dyspareunia, discharge or bleeding after any mesh procedure should be reviewed in a specialist mesh centre.

  • Rapid worsening in pregnancy

    Sudden or severe prolapse in pregnancy - discuss urgently with your obstetric and urogynaecology team.

  • Neurological red flags

    Saddle anaesthesia, new leg weakness or bladder-and-bowel dysfunction together - rule out cauda equina in the emergency department.

  • Suspected malignancy

    Post-menopausal bleeding, unexplained weight loss or a hard fixed pelvic mass - fast-track gynae-oncology assessment.

  • Severe untreated constipation

    Chronic obstructed defecation feeds prolapse and complicates surgery - address it before considering repair.

Living with it

A treatable condition, with a clear ladder.

Four things that make the biggest difference day to day - protecting the pelvic floor, backing physiotherapy, using a pessary well, and choosing the right surgeon if surgery is needed.

A quiet reminder

Consistency beats intensity, every time.

Daily pelvic-floor work and steady bowel habits do more, over months, than any heroic week.

  1. 01 Load

    Protect the pelvic floor

    Treat constipation, manage chronic cough, drop excess weight where relevant and swap heavy lifting for smarter mechanics.

  2. 02 Training

    Give physiotherapy a real chance

    Supervised pelvic-floor muscle training over three to six months is genuine treatment - not a token gesture.

  3. 03 Pessary

    Pessaries are proper treatment

    A well-fitted pessary, reviewed on a schedule, keeps many women out of theatre for decades - and remains an option after surgery too.

  4. 04 Surgery

    Choose your surgeon carefully

    For repair, a BSUG-registered urogynaecologist - and, for apical or post-hysterectomy prolapse, a commissioned centre - is the standard to expect.

Frequently asked

Everything we get asked about enterocele.

Quick answers on pessaries, physiotherapy, mesh and surgery.

  • What is an enterocele?

    An enterocele is a type of pelvic-organ prolapse where the small bowel and its peritoneal covering herniate through the pouch of Douglas and push into the posterior vaginal wall. It sits in the posterior compartment alongside rectocele, and often coexists with cystocele in the anterior compartment or uterine and vault prolapse.

  • Do I definitely need surgery?

    No. Many enteroceles are managed very effectively without surgery - lifestyle changes, specialist pelvic-floor physiotherapy and a well-fitted pessary are genuine long-term treatments. Surgery is offered when symptoms are significant, conservative options have been tried, or the anatomy makes a pessary impractical.

  • Why is a pessary offered before surgery?

    NICE NG123 recommends a pessary as a first-line alternative to surgery for prolapse. It is safe, reversible, avoids anaesthetic and lets you judge how much of your symptoms are truly from the prolapse. It can be used for years or as a bridge to a planned repair.

  • Is vaginal mesh still used in the UK?

    No - vaginal mesh for prolapse has been paused since 2018 following the MHRA and Cumberlege Review. Abdominal mesh via sacrocolpopexy remains available, but only in commissioned mesh centres, with strict indications and detailed consent. Native-tissue repairs and colpocleisis are the more common routes today.

  • Why does prolapse often follow hysterectomy?

    Removing the uterus can leave the vaginal apex without its normal ligamentous support. Around 5 to 30% of women develop vault prolapse and enterocele in the years afterwards. Modern surgery increasingly includes apical support at the time of hysterectomy to reduce that risk.

  • What is splinting?

    Splinting is pressing on the vaginal wall, perineum or buttock to help pass stool. It is a strong clue to a posterior compartment problem such as an enterocele or rectocele and is worth mentioning explicitly - people often feel awkward describing it but clinicians expect the question.

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