Posterior Compartment Prolapse
Posterior compartment pelvic organ prolapse is descent of the posterior vaginal wall — usually from rectovaginal support failure — allowing the rectum, peritoneal cul-de-sac, small bowel, or a deficient perineal body to protrude toward the vaginal lumen.[1][2] The most common posterior defect is a rectocele; enterocele and perineal deficiency commonly coexist and are easy to miss when the exam focuses only on the visible posterior bulge.
Posterior prolapse is rarely a pure mechanical problem. Symptoms sit at the intersection of vaginal support, stool consistency, pelvic-floor coordination, rectal emptying, anal sphincter function, and apical support. The practical question is always: is the patient bothered by a vaginal bulge, by obstructed defecation, by sexual dysfunction, or by a mixed functional-anatomic disorder that needs bowel management, pelvic-floor therapy, and selective surgery rather than a posterior colporrhaphy?
See also: POP Overview for the DeLancey framework, POP-Q, pessary management, and shared surgical principles. This page covers what is distinctive about the posterior compartment. The functional overlap is in Defecatory Disorders.
Definition and Terminology
| Term | Meaning | Operative relevance |
|---|---|---|
| Posterior compartment prolapse | Descent of the posterior vaginal wall | POP-Q point Bp captures the leading posterior wall point |
| Rectocele | Anterior rectal-wall bulging into the posterior vagina | Most common posterior defect; may cause bulge, splinting, stool trapping, obstructed defecation |
| Enterocele | Peritoneal sac (often containing small bowel) descending between rectum and vagina | Apex-related; may mimic or coexist with rectocele |
| Perineal deficiency | Weakness / shortening / disruption of the perineal body | Widened genital hiatus, gaping introitus, distal rectocele, stool trapping |
| Obstructed defecation syndrome (ODS) | Difficulty evacuating despite urge and effort | May be structural, functional, or both — rectocele repair helps selected patients only |
POP-Q uses point Bp for the most distal point of the posterior vaginal wall. Point Ap is the fixed posterior point 3 cm proximal to the hymen; GH and PB measurements are essential because a widened genital hiatus or deficient perineal body changes repair planning.[3]
Compartment-Specific Pathophysiology
Posterior support comes from the posterior vaginal fibromuscular layer / rectovaginal septum, lateral attachments to the pelvic sidewall and levator ani, the perineal body, and Level I apical support.[1][4] The generic DeLancey framework lives in the parent. Whether a discrete histologic "rectovaginal fascia" exists as a separate layer is debated; operatively, the useful concept is plication or reattachment of the posterior fibromuscular layer without levator over-tightening or rectal injury.
Defect patterns — posterior-specific
| Defect | Pattern | Clues |
|---|---|---|
| Midline rectocele | Central attenuation of posterior support | Smooth posterior bulge; stool trapping; treated with midline plication |
| Transverse / apical posterior defect | Separation near the vaginal apex or cul-de-sac | Enterocele, high posterior wall descent, apical descent on POP-Q |
| Distal perineal defect | Perineal body deficiency | Short PB, widened GH, gaping introitus, distal stool trapping |
| Enterocele / sigmoidocele | Peritoneal sac descent between rectum and vagina | Often occult; rectovaginal exam, defecography, or MRI helpful |
| Functional outlet disorder | Dyssynergic contraction or nonrelaxing puborectalis | ODS out of proportion to anatomy; abnormal balloon expulsion / manometry |
Posterior-specific causality problem
A rectocele does not prove causality for symptoms. Rectoceles exist in nulliparous and asymptomatic women, while many patients with ODS have pelvic-floor dyssynergia, constipation, rectal intussusception, or other anorectal disorders that will not improve with vaginal-wall repair alone.[5][6] This is the dominant posterior-compartment counseling point:
- A rectocele on exam is necessary but not sufficient reason to operate.
- The operation treats the vaginal wall. Whether it helps the bowel depends on which mechanism is driving the symptoms.
Clinical Presentation
Defecatory symptoms — the posterior-specific dimension
| Symptom | Association with posterior prolapse |
|---|---|
| Splinting / digitation | Strongest practical clue for a symptomatic rectocele — vaginal, perineal, or rectal pressure to evacuate |
| Stool trapping | Rectocele that fills but fails to empty on defecography |
| Incomplete evacuation | May reflect stool trapping or functional outlet obstruction |
| Straining | Common but nonspecific — also reflects constipation and dyssynergia |
| Pain with defecation | Fissure, pelvic-floor spasm, levator pain, difficult evacuation |
| Fecal urgency / liquid FI | Can coexist; evaluate stool form and sphincter function |
| Constipation | Reported in 30–70% of rectocele patients but not proof the rectocele is causal |
Defecatory symptoms most linked to posterior-wall anatomy — particularly splinting, straining, and incomplete evacuation — are the ones most likely to improve after posterior repair.[7][8] Posterior prolapse does not necessarily cause new defecatory symptoms in asymptomatic women, but it may increase persistence or progression of existing symptoms.[8]
Sexual function — posterior-specific concerns
Symptomatic prolapse is associated with worse sexual function than asymptomatic anatomic prolapse.[9][10] Posterior-specific drivers of dyspareunia or avoidance: posterior bulge protrusion, body-image concern, fear of soiling. Posterior repair has a recognized risk of de novo dyspareunia, particularly with levatorplasty, aggressive introital narrowing, untreated GSM, or pelvic-floor hypertonicity.
Compartment-Specific Evaluation
Generic exam framework is in the parent. The posterior-specific maneuvers and investigations that matter:
- Split speculum isolation — retract the anterior wall to isolate posterior descent.
- Rectovaginal exam — distinguish rectocele, enterocele, perineocele, and stool trapping; assess rectovaginal septum integrity.
- Apex reduction — if posterior descent improves when the apex is reduced, the posterior defect is apex-driven.
- Perineal body / GH — record PB and GH; widening flags a perineal component requiring perineorrhaphy.
Adjunctive imaging and physiology — when to get it
| Test | Use |
|---|---|
| Defecography (fluoroscopic) | Complex ODS, suspected stool trapping, intussusception, enterocele, sigmoidocele, or recurrent posterior repair |
| MR defecography | Multicompartment pelvic-floor disorder, or distinguishing rectocele from cul-de-sac hernia (enterocele) |
| Translabial ultrasound | Dynamic rectocele depth, levator avulsion, hiatal area, enterocele |
| Anorectal physiology (ARM + BET) | ODS out of proportion to anatomy, suspected dyssynergia, fecal incontinence, or colorectal co-management |
Clinically meaningful rectocele features on imaging: preferential filling during defecation, failure to empty / contrast trapping, and larger size. A threshold of >2 cm is often used for definition; >5 cm + trapping + bothersome symptoms is more persuasive when considering surgery for ODS.[5][6][11]
See Defecatory Dysfunction for anorectal-physiology framing.
Surgical Management
Generic pessary management and non-surgical options are in the parent. What follows is posterior-specific.
Indication — who benefits from surgery
Surgery is for bothersome posterior vaginal bulge, pressure, sexual dysfunction, or defecatory dysfunction that persists despite appropriate conservative treatment.[1][6][11] Stronger selection features for rectocele repair in ODS:
- Bothersome vaginal bulge or protrusion
- Need for vaginal or perineal splinting
- Large rectocele, especially >5 cm
- Trapping / non-emptying on defecography
- Failure of bowel optimization and pelvic-floor biofeedback
- Dyssynergia, intussusception, and severe sphincter dysfunction addressed (or excluded) first
Posterior colporrhaphy and perineorrhaphy
Posterior colporrhaphy is the standard transvaginal native-tissue repair for symptomatic rectocele — midline plication of the posterior vaginal fibromuscular tissue after separating vaginal epithelium from rectum. Perineorrhaphy reconstructs the perineal body when distal support is deficient.[2][12]
| Step | Principle |
|---|---|
| Posterior midline vaginal incision | From distal posterior wall toward the apex as needed |
| Rectovaginal dissection | Develop the safe plane; avoid rectal entry |
| Fibromuscular plication | Midline delayed-absorbable plication; avoid excessive narrowing |
| Enterocele repair if present | Reduce sac, restore apical / cul-de-sac support |
| Perineorrhaphy if needed | Reapproximate perineal muscles; normalize GH/PB, do not over-tighten |
| Rectal exam at closure | Confirm no rectal suture or injury |
Midline fascial plication is preferred over levatorplasty. Levatorplasty narrows the introitus but carries higher dyspareunia risk and is not routine for posterior-compartment prolapse.[2][12]
Transvaginal rectocele repair improves vaginal bulge in most selected patients and improves ODS symptoms in a majority, but recurrence increases with follow-up length.[12][13]
Approach comparison
| Approach | Role | Tradeoffs |
|---|---|---|
| Transvaginal native tissue | Standard for symptomatic posterior vaginal wall prolapse | Best anatomic posterior data; dyspareunia risk if over-tightened |
| Transanal | Selected colorectal use when rectal mucosal pathology dominates | Inferior anatomic posterior-wall outcomes; rectal morbidity; less ODS improvement |
| Transperineal | Distal rectocele / perineal body deficiency; limited data | Useful for perineal reconstruction; less standardized evidence |
| Ventral mesh rectopexy | Rectal intussusception, rectal prolapse, complex ODS with colorectal indication | Abdominal mesh; colorectal collaboration; longer op time |
Transvaginal > transanal for posterior vaginal wall prolapse in Cochrane and FIGO data.[2][12][14] STARR (stapled transanal rectal resection) is not recommended for routine rectocele repair because of complication rates and better alternatives.[6]
Mesh and biologic grafts — the posterior-specific stance
Synthetic mesh and biologic grafts do not improve routine posterior vaginal wall repair outcomes enough to justify use and may increase complications.[1][14] ACOG recommends against routine mesh or graft placement through posterior vaginal wall incisions for primary posterior wall prolapse repair. This is separate from abdominal mesh procedures for selected indications (ventral mesh rectopexy, sacrocolpopexy) where risk–benefit counseling differs.
Ventral mesh rectopexy — when to collaborate with colorectal
Laparoscopic ventral mesh rectopexy suspends the anterior rectal wall to the sacral promontory; primarily a colorectal operation for rectal prolapse or internal intussusception with ODS. In selected anterior rectocele cohorts it may outperform posterior colporrhaphy on defecographic correction and improvements in constipation, sexual symptoms, and QoL — at the cost of longer op time and mesh-specific risk.[15] Not the default for a vaginal rectocele. Best considered when rectal prolapse, intussusception, enterocele, or complex posterior pelvic-floor disease is driving symptoms.
Sexual Function Outcomes — Posterior-Specific Counseling
Posterior prolapse surgery often improves sexual function when the preoperative driver is bulge, avoidance, stool trapping, or body-image concerns.[9][10] De novo dyspareunia risk is real, especially with levatorplasty or aggressive narrowing. Counseling must cover:
- Baseline dyspareunia and pelvic-floor tenderness
- Desire for future penetrative vaginal intercourse
- Planned degree of perineorrhaphy / introital narrowing
- GSM treatment when indicated (see parent — hypoestrogenic tissue)
- Expectation that bowel and sexual symptoms may not track with anatomic success
Long-Term Outcomes and Recurrence
Endpoint matters. Bulge, splinting, constipation, dyspareunia, anatomic success, and reoperation are not interchangeable.
| Outcome | Pattern |
|---|---|
| Bulge | Usually improves substantially after posterior colporrhaphy in selected patients |
| Splinting / stool trapping | Most likely to improve when rectocele is large and traps stool |
| Global constipation | Less predictable; depends on stool form, transit, and dyssynergia |
| Dyspareunia | May improve if prolapse-related; may worsen if repair is over-tightened |
| Recurrence | Increases with longer follow-up and uncorrected apical / hiatal support failure |
Defecatory symptoms most strongly associated with degree of posterior-wall descent tend to improve most after surgery.[7] Symptoms can progressively deteriorate over time, so long-term bowel management matters even after a technically successful repair.[13]
Key Recommendations
- Treat only symptomatic posterior prolapse. Incidental rectocele on exam or imaging does not mandate repair.
- Use POP-Q Ap, Bp, GH, PB, C/D, and a rectovaginal exam to define anatomy.
- Look for apical prolapse and enterocele before calling a defect "isolated rectocele."
- Treat constipation, stool form, and pelvic-floor dyssynergia before surgery for ODS-predominant symptoms.
- Favor transvaginal native-tissue posterior colporrhaphy for symptomatic posterior vaginal wall prolapse.
- Add perineorrhaphy when the perineal body is deficient or the genital hiatus is widened.
- Avoid routine levatorplasty — dyspareunia risk.
- Do not routinely place synthetic mesh or biologic grafts through posterior vaginal wall incisions.
- Collaborate with colorectal surgery for rectal prolapse, intussusception, complex ODS, fecal incontinence, or failed posterior repairs.
See Also
- POP Overview
- Anterior Compartment Prolapse
- Apical Prolapse
- Female Pelvic Examination
- Chronic Constipation
- Defecatory Dysfunction
- Fecal Incontinence
- Posterior Colporrhaphy
- Perineorrhaphy
- Vaginal McCall's Culdoplasty
- Prolapse Repair
References
1. "Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214." Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519
2. Mowat A, Maher D, Baessler K, et al. "Surgery for Women With Posterior Compartment Prolapse." Cochrane Database Syst Rev. 2018;3(3):CD012975. doi:10.1002/14651858.CD012975
3. Bump RC, Mattiasson A, Bo K, et al. "The Standardization of Terminology of Female Pelvic Organ Prolapse and Pelvic Floor Dysfunction." Am J Obstet Gynecol. 1996;175(1):10-17. PMID:8694033
4. Bordeianou LG, Carmichael JC, Paquette IM, et al. "Consensus Statement of Definitions for Anorectal Physiology Testing and Pelvic Floor Terminology (Revised)." Dis Colon Rectum. 2018;61(4):421-427. doi:10.1097/DCR.0000000000001070
5. van Gruting IM, Stankiewicz A, Thakar R, et al. "Imaging Modalities for the Detection of Posterior Pelvic Floor Disorders in Women With Obstructed Defaecation Syndrome." Cochrane Database Syst Rev. 2021;9(9):CD011482. doi:10.1002/14651858.CD011482.pub2
6. Alavi K, Thorsen AJ, Fang SH, et al. "The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Evaluation and Management of Chronic Constipation." Dis Colon Rectum. 2024;67(10):1244-1257. doi:10.1097/DCR.0000000000003430
7. Karjalainen PK, Mattsson NK, Nieminen K, Tolppanen AM, Jalkanen JT. "The Relationship of Defecation Symptoms and Posterior Vaginal Wall Prolapse in Women Undergoing Pelvic Organ Prolapse Surgery." Am J Obstet Gynecol. 2019;221(5):480.e1-480.e10. doi:10.1016/j.ajog.2019.05.027
8. Handa VL, Munoz A, Blomquist JL. "Temporal Relationship Between Posterior Vaginal Prolapse and Defecatory Symptoms." Am J Obstet Gynecol. 2017;216(4):390.e1-390.e6. doi:10.1016/j.ajog.2016.10.021
9. Fatton B, de Tayrac R, Letouzey V, Huberlant S. "Pelvic Organ Prolapse and Sexual Function." Nat Rev Urol. 2020;17(7):373-390. doi:10.1038/s41585-020-0334-8
10. Handa VL, Cundiff G, Chang HH, Helzlsouer KJ. "Female Sexual Function and Pelvic Floor Disorders." Obstet Gynecol. 2008;111(5):1045-1052. doi:10.1097/AOG.0b013e31816bbe85
11. Wald A, Bharucha AE, Limketkai B, et al. "ACG Clinical Guidelines: Management of Benign Anorectal Disorders." Am J Gastroenterol. 2021;116(10):1987-2008. doi:10.14309/ajg.0000000000001507
12. Karram M, Maher C. "Surgery for Posterior Vaginal Wall Prolapse." Int Urogynecol J. 2013;24(11):1835-1841. doi:10.1007/s00192-013-2174-z
13. Ferrari L, Cuinas K, Hainsworth A, et al. "Transvaginal Rectocoele Repair for the Surgical Treatment of a Symptomatic Rectocoele When Conservative Measures Fail: A 12 Year Experience of 215 Patients." Neurogastroenterol Motil. 2022;34(11):e14343. doi:10.1111/nmo.14343
14. Doumouchtsis SK, Raheem AA, Milhem Haddad J, et al. "An Update of a Former FIGO Working Group Report on Management of Posterior Compartment Prolapse." Int J Gynaecol Obstet. 2020;148(2):135-144. doi:10.1002/ijgo.13006
15. Abdelnaby M, Fathy M, Abdallah E, et al. "Laparoscopic Ventral Mesh Rectopexy Versus Transvaginal Posterior Colporrhaphy in Management of Anterior Rectocele." J Gastrointest Surg. 2021;25(8):2035-2046. doi:10.1007/s11605-020-04823-z