Rectocele (bowel prolapse): symptoms, causes and treatment

The uterus, bladder and rectum are held in place inside the pelvis by ligaments and a sling of muscles known as the pelvic floor. When these supports are overstretched or weakened, an organ can bulge into the vagina. The RCOG explains that when the rectum bulges into the back wall of the vagina, this is a posterior vaginal wall prolapse, also called a rectocele. The small bowel can bulge there too, which is called an enterocele.

It is common to have more than one type of prolapse at once. A rectocele may sit alongside a bladder bulge at the front wall or a drop of the uterus. The NHS says the severity may be graded from 1 to 4, with 4 being the most severe, and the RCOG notes that stage 1 usually causes mild or no symptoms and rarely needs treatment.

Symptoms vary with the size of the bulge. The NHS lists a feeling of heaviness, discomfort or pressure in the lower tummy or vagina, feeling or seeing a lump in or coming out of the vagina, pain or numbness during sex, and problems with the bowel such as constipation. The RCOG adds that heaviness is often worse after standing for a long time and eases on lying down.

What distinguishes a rectocele from other prolapse types is the bowel pattern. The RCOG describes constipation or incomplete bowel emptying, and says some women need to press on the bulge with their fingers to help open their bowels. Bladder symptoms can also appear because prolapse often involves more than one wall.

• A dragging or heavy sensation in the vagina or back passage.

• A bulge you can feel or see at the vaginal opening.

• Difficulty emptying the bowel, or needing to support the vaginal wall to do so.

• Discomfort or a change in sensation during sex.

• Backache or pressure that builds up through the day.

You do not have to treat a prolapse that is not bothering you. The NHS says that if there are no symptoms, or the prolapse is not troublesome, medical treatment may not be needed. When symptoms are affecting daily life it lists hormone treatment, support pessaries, physiotherapy with pelvic floor muscle training, and surgery for severe cases.

The RCOG gives more detail. Pelvic floor training with a specialist women's health physiotherapist may last 3 to 6 months, and may not remove the prolapse but is likely to improve symptoms. After the menopause, vaginal oestrogen can ease discomfort. A pessary is a plastic or silicone device that supports the pelvic organs, and ring pessaries are used most often. The RCOG says pessaries should be changed or removed, cleaned and reinserted every 4 to 6 months, and may occasionally cause infection, discharge, bleeding or ulceration.

Bowel habits matter more with a rectocele than with most other forms of prolapse. The NHS advises eating more fibre, drinking plenty of water and gentle exercise such as walking to avoid constipation, keeping to a healthy weight, doing regular pelvic floor exercises, and avoiding activities that strain the pelvic floor such as heavy lifting, running and trampolining. It also advises stopping smoking, since this lowers the chance of a persistent cough.

The RCOG makes a similar list and adds managing a long-standing cough and avoiding constipation. It recommends continuing pelvic floor training even if surgery is being considered, to improve the chance of a good result.

Weakness of the pelvic floor is the common thread. The NHS lists pregnancy and childbirth, being overweight, long-term constipation and straining, persistent coughing and pelvic surgery such as a hysterectomy. It adds that prolapse becomes more common with age, particularly after the menopause, and that joint hypermobility syndrome, Marfan syndrome and Ehlers-Danlos syndromes can make it more likely.

The RCOG states that it is often a combination of factors, including a natural tendency to develop prolapse. For a rectocele in particular, years of straining against hard stool places repeated pressure on the same wall, which is why bowel care is part of treatment rather than an afterthought.

Diagnosis is by internal examination. The NHS says a GP will ask about symptoms and examine you, and you can ask for a chaperone or a female doctor. The RCOG explains that a speculum is used to see which organ is bulging, and that you may be examined lying on your side with knees drawn up or standing.

Further tests are usually directed at the bladder rather than the bowel. The RCOG says a urine test is offered to check for infection, and that bladder scans or urodynamics may be advised if there are urinary symptoms. If bowel emptying is the main problem, a specialist may arrange additional assessment of the back passage.

For a rectocele, repair is usually a pelvic floor repair, in which the walls of the vagina are repaired to support the pelvic organs. The RCOG says this is usually done through the vagina. Gloucestershire Hospitals NHS Foundation Trust states that pelvic floor repair is used for a prolapse of the front or back wall of the vagina.

The RCOG lists common risks as bleeding, infection, pain during intercourse and return of the prolapse. Sacrocolpopexy and the use of mesh are more relevant to vault prolapse than to rectocele alone. On mesh, the NHS says vaginal mesh surgery for prolapse is no longer done on the NHS unless there is no alternative. The RCOG advises avoiding heavy lifting and vaginal intercourse for 6 to 8 weeks after surgery, and notes that no operation can be guaranteed to cure prolapse permanently.

The RCOG says it is common to have more than one type of prolapse at the same time, so your examination will describe exactly which walls and organs are involved.

The NHS advises seeing a GP if you have a lump in or around the vagina or any other symptoms of pelvic organ prolapse. Prolapse is not an emergency, but a reasonable time to seek help is when it interferes with bowel emptying, sex, exercise or confidence.

Seek prompt advice if you have a pessary and develop unusual bleeding or discharge, or if you cannot pass urine. Private gynaecology and urogynaecology services exist alongside NHS referral, and the treatments are the same; the difference lies mainly in how quickly an appointment is available.