Rectocele and enterocele are forms of prolapse in the back compartment of the vagina (posterior wall prolapse). In a rectocele, the supporting layer between the rectum and the vagina weakens and the rectum pushes the back wall of the vagina inward. In an enterocele, part of the small bowel drops toward the upper back part of the vagina. Prolapse in the back compartment can occur together with anterior or uterine prolapse. These conditions should not be confused with rectal prolapse, in which the bowel comes out through the anus.
Causes
The main cause is pregnancy and vaginal birth; tears or an episiotomy during birth can weaken the support of the perineum, the area between the vagina and the anus. Long-term constipation and straining, excess weight, a persistent cough, frequent heavy lifting, menopause and aging also contribute to posterior wall prolapse.
Symptoms
Mild posterior wall prolapse often causes no complaints. When there are symptoms, they may include:
- A feeling of fullness or pressure, or a bulge that can be felt in the vagina
- Difficulty passing stool and a feeling that the bowel has not emptied completely
- Needing to press on the back wall of the vagina with a finger to pass stool
- Discomfort during intercourse
- Difficulty inserting tampons or vaginal applicators
Difficulty passing stool is not always caused by prolapse. Constipation and functional problems such as the pelvic floor muscles failing to relax during a bowel movement can cause similar complaints.
Assessment
Bowel habits, straining, current medicines and complaints related to urinary and sexual function are asked about. The examination is carried out vaginally and rectally; the support of the back wall and of the top of the vagina is assessed while straining. If prolapse is found on examination, imaging is usually not needed. If difficulty passing stool cannot be explained by the examination findings, tests that measure anal and rectal function or imaging taken during a bowel movement (defecography) may be requested; where needed, an assessment by colorectal surgery is arranged.
Non-surgical options
- Improving bowel habits: preventing constipation and straining with a high-fiber diet, enough fluids and, if needed, stool softeners can ease the complaints. Long-term straining can make prolapse worse.
- Pelvic floor muscle exercises (Kegel exercises): for mild to moderate prolapse that causes symptoms, a program supervised by a specialist and continued for at least 16 weeks is considered as a first option. If the pelvic floor muscles are found not to relax during a bowel movement, biofeedback therapy, which teaches correct use of these muscles, is recommended as first-line treatment.
- Pessary: it can be used alone or together with exercises for prolapse that causes symptoms. Its use is described on the Uterine Prolapse page.
- Vaginal estrogen: it may be recommended if there is vaginal dryness and thinning related to menopause.
Surgical treatment
Posterior repair (posterior colporrhaphy) is discussed for people whose complaints have not improved with non-surgical treatment or who do not want it. Through an incision in the back wall of the vagina, the weakened supporting layer between the rectum and the vagina is repaired with dissolving stitches. If needed, the perineal tissue between the vagina and the anus is also repaired (perineorrhaphy) to strengthen the support of the back wall. NICE, the body that issues national clinical guidance in England, recommends that posterior repair be carried out with the person’s own tissue, without synthetic mesh, and that transvaginal mesh for posterior wall prolapse be used only in the context of research. Regulations on this subject are described on the Cystocele (Bladder Prolapse) page.
For an enterocele, the repair may be planned together with an operation that supports the top of the vagina, depending on the location of the prolapse. Sacrocolpopexy, performed through the abdomen with mesh, is one of the methods used for vaginal vault prolapse and enterocele. If a rectocele repair is being considered because of difficulty passing stool, addressing functional causes such as constipation and failure of the pelvic floor muscles to relax is recommended before surgery. Posterior repair can be performed in the same operation as an anterior repair, surgery for incontinence or a vaginal hysterectomy.
Procedures for a feeling of vaginal laxity are covered on the Vaginal Tightening (Vaginoplasty) page, and procedures for scar tissue in the perineal area after childbirth are covered on the Episiotomy Scar Repair page.
After surgery
After the operation, there may be a urinary catheter and a vaginal pack for a short time. As the stitches dissolve, there may be discharge for a few weeks; foul-smelling discharge should be assessed. Constipation is common after surgery; a high-fiber diet, enough fluids and, if needed, stool softeners are recommended. During recovery, heavy lifting, straining and strenuous exercise are avoided. When intercourse can be resumed is decided at the follow-up examination.
Possible risks
Bleeding, infection, urinary tract infection, blood clots and problems related to anesthesia may occur. Injury to the rectum during the operation is a very uncommon complication. Some women develop pain during intercourse. Difficulty passing stool and a feeling that the bowel has not emptied completely do not always improve after surgery. The prolapse may come back over time or develop in another part of the vagina.