What is a Rectocele?
A rectocele is a structural defect of the rectovaginal septum where the anterior rectal wall herniates through the posterior vaginal wall, creating a bulge that protrudes into the vaginal cavity. 1, 2
Anatomic Definition
A rectocele represents a herniation of the rectum with protrusion of the anterior rectal wall through the posterior wall of the vagina, occurring as a mechanical/positional problem rather than a mucosal abnormality. 3, 4
This condition is classified as a posterior compartment pelvic organ prolapse, distinct from other pelvic floor disorders like cystocele (anterior compartment) or enterocele/sigmoidocele (cul-de-sac hernias). 5, 3
The defect arises from either a tear or stretching of the rectovaginal fascia, which normally provides structural support between the rectum and vagina. 6
Pathophysiology and Risk Factors
Chronic straining and increased intra-abdominal pressure weaken pelvic floor support structures over time, with key risk factors including advanced age, menopause, vaginal multiparity, obesity, and repetitive straining behavior with defecatory disorders. 2
Direct or denervation injury to pelvic floor musculature increases stress on the fascia, particularly following operative vaginal birth, though the defect may not become apparent until many years later. 2, 7
The pathogenesis involves opening of the vulva secondary to damage of the pelvi-perineal musculature, similar to other forms of vaginal prolapse. 8
Clinical Presentation
The pathognomonic symptom is the need for manual pressure toward the vaginal wall (splinting) or digital disimpaction maneuvers to facilitate defecation. 3, 4
Patients commonly report obstructive defecation symptoms including dyschezia, constipation, perineal and vaginal pressure, and the sensation of a pelvic mass or bulge. 4, 6
Additional symptoms may include pelvic heaviness, anal incontinence, and dyspareunia, though the correlation between rectocele size and symptom severity is weak. 2, 4
Epidemiology
Rectoceles are extremely common, with an estimated prevalence of 30-50% of women over age 50. 4
Approximately one-third of patients with posterior vaginal wall bulging have rectoceles, though many are asymptomatic and clinically occult. 1, 3
Diagnostic Approach
Physical examination only detects 7% of rectoceles seen on imaging, meaning most rectoceles exist before they are discovered through clinical examination alone. 2
Fluoroscopic cystocolpoproctography (defecography) is the initial imaging test of choice, with a sensitivity of 94% for detecting rectoceles compared to physical examination. 1, 2, 3
MR defecography provides high soft-tissue contrast resolution for direct visualization of pelvic organs, pelvic floor muscles and fascia, and can differentiate rectocele from enterocele or sigmoidocele. 1, 5
Normal endoscopy is expected because rectoceles are structural defects of the rectovaginal septum, not mucosal abnormalities—endoscopy evaluates the mucosal surface but cannot assess dynamic function or structural support. 3
Important Clinical Pitfalls
Rectoceles may be isolated or associated with other pelvic floor disorders including cystocele, uterine prolapse, rectal intussusception, or enterocele, requiring comprehensive evaluation of all pelvic compartments. 1, 4
Functional relevance matters more than anatomic presence—many rectoceles are incidental findings without clinical significance, and treatment decisions should be based on symptom intensity and quality of life impact rather than imaging findings alone. 2
Imaging may detect clinically occult sigmoidoceles, enteroceles, and rectoanal intussusceptions that can be present in isolation or combination with rectoceles, altering clinical management in a significant percentage of patients. 1