A rectocele is a weakness in the wall between the rectum (the last part of your bowel) and the vagina. When you strain to open your bowels, the rectum bulges forward into the vagina instead of emptying downwards as it should. This often makes it feel like there is more stool left behind, even after you have gone.
Obstructed defaecation syndrome (ODS) is the broader name for difficulty emptying the bowel — and rectocele is just one of its causes. Another common cause is called pelvic floor dyssynergia (a long word for a simple idea — the muscles around the bottom squeeze when they should relax, blocking things up). Other patients have a small telescoping of the rectum into itself (called intussusception), or simply have weak, poorly coordinated pelvic floor muscles.
If any of this sounds like what you have been dealing with, please know it is very common — and very treatable. Many people put up with it for years because they are embarrassed to mention it. You do not have to.
Childbirth — particularly multiple vaginal deliveries — is by far the most common cause of rectocele. The tissues that support the wall between the rectum and vagina can weaken over time, allowing the rectum to bulge forward.
Chronic constipation, long-term straining, getting older, and previous pelvic surgery all add to the risk. Pelvic floor dyssynergia often starts after a painful experience around the back passage (such as an anal fissure) or simply from years of straining — the muscles learn an unhelpful pattern that becomes a habit.
The most common symptom is a feeling of incomplete emptying — you go to the toilet, pass some stool, but feel like there is more sitting there. Many women find they need to press on the vagina or the area between vagina and anus to help everything come out — this is called digital splinting and is a classic sign of rectocele.
You might also notice: straining, spending a long time on the toilet, a sense of a bulge in the vagina or pressure in the pelvis, constipation even when stools are soft, and sometimes accidental staining or leakage later in the day from stool that was left behind. None of these symptoms are anything to be ashamed of — they are common, they are well-understood, and they respond to treatment.
Diagnosis begins with a careful conversation about your symptoms and a gentle pelvic and rectal examination. A rectocele can often be felt directly during the examination.
To better understand what is happening, a special test called defaecating proctography may be arranged. This is an X-ray taken while you empty contrast (which acts like soft stool) on a special toilet — it shows exactly what your rectum is doing during evacuation, including the rectocele and anything else going on. Anorectal manometry — a thin pressure-sensing tube — measures how well your pelvic floor muscles work and coordinate. These tests are not painful, just a little undignified — and they give very useful information.
Treatment almost always starts with simple, non-surgical measures — and for most people, these alone are enough.
The most important first step is pelvic floor physiotherapy, which retrains the muscles to coordinate properly. This is delivered by physiotherapists with specialist training and is very effective, especially for dyssynergia. Other helpful measures include eating plenty of fibre, drinking enough water, using a stool softener if needed, bowel retraining (going at the same time each day, using a footstool to raise your knees), and not delaying when you feel the urge.
If symptoms remain significant after a proper trial of these measures, surgical options can be considered. The mainstay is laparoscopic or robotic ventral mesh rectopexy, which lifts the rectum back into place from above and addresses any associated internal prolapse. A posterior repair (to fix the rectocele directly from below) is also an option in selected cases. The right operation depends on what the proctography shows and what is bothering you most. Surgery is never the first step — it is for the patients who have done everything else and still struggle.
Mr Nguyen's approach is to work out exactly what is going on for you, and to try gentler options thoroughly before considering surgery. Most of his patients improve substantially with pelvic floor physiotherapy and some practical changes — for some, that is all that is needed.
Where surgery is the right answer, it is chosen carefully based on the proctography findings, your specific anatomy, and what matters most to you. You will always understand the rationale for what is being recommended.
If you have been struggling with bowel emptying for more than a few months — particularly if you need to splint, or you feel like things are never quite finished — please speak to your GP about a referral. Many women wait years before mentioning these symptoms because they feel embarrassed. There is nothing to be embarrassed about, and earlier assessment usually means simpler, faster improvement.
Your GP will arrange a referral, and a careful history will be taken, you will be examined, and the right investigations are arranged. For almost everyone, the first step after that is referral to a pelvic floor physiotherapist — see the Pelvic Floor Physiotherapy article for what that involves. Surgery is only discussed once conservative treatment has been properly tried.
No, not quite. Constipation usually means infrequent or hard bowel motions. Obstructed defaecation is different — you have the urge, your stool is normal, but you cannot empty properly. The two often coexist, but the treatments are slightly different. Pelvic floor physiotherapy is much more important for ODS than for ordinary constipation.
Most patients do not. Pelvic floor physiotherapy and simple lifestyle changes get the majority of patients to a much better place. Surgery is only considered if those measures have not been enough and there is a clear anatomical problem on imaging that surgery can fix.
For most women, yes. Vaginal childbirth — especially multiple deliveries or a particularly difficult delivery — is the most common cause. The tissues weaken at the time and can give way more obviously later in life. It is not your fault, and it is not unusual.
Splinting is a clue, not a verdict. It is a sign that something is making it harder for the rectum to empty downwards as it should — most often a rectocele. It is not dangerous to do, but it is worth getting assessed so you do not have to rely on it forever.
Have questions about rectocele & obstructed defaecation?
Mr Nguyen sees patients at his consulting rooms in Heidelberg and operates at Warringal Private and Epworth Eastern. A GP or specialist referral is required.