Enterocele
An enterocele is a bulge at the top of the vagina caused by a loop of small bowel pushing down into the space between the vagina and the rectum. That space is called the cul-de-sac. When the peritoneal sac and small intestine herniate into it, the upper vaginal wall descends and you feel a bulge or pressure.
Two related bulges get grouped with it: a sigmoidocele, where the sigmoid colon drops into the same space, and a peritoneocele, where the sac holds only fat or fluid and no bowel.
An enterocele is what’s known as an apical defect, a problem with support at the top of the vagina, and it usually travels with other kinds of prolapse rather than showing up alone.
When small bowel behind the vagina is normal
Not every loop of bowel in the cul-de-sac is a problem. A normal cul-de-sac extends 4 to 5 cm below the top of the vagina, and small bowel sitting there is a common finding in healthy women with no symptoms.
It becomes an enterocele that matters only when the tissue between the vagina and rectum separates, the bowel drops toward the pelvic floor, and it starts to press on neighboring organs.
That’s why I’m cautious about the labels on an imaging report. A cul-de-sac hernia can look dramatic on a scan and still cause nothing, and national reporting guidance now discourages calling one “high grade” or “stage 4” for exactly that reason. What matters is whether it’s bothering you, not the number on the scan.
Symptoms
The main symptom is a bulge or a feeling of pressure at the top of the vagina. Many women notice it more with standing, lifting, or straining, and less when lying down.
Because the bulge sits near the rectum, an enterocele can come with bowel symptoms: a sense of incomplete emptying, straining, or needing to press on or near the vagina to finish a bowel movement, which is called splinting. Splinting is the one bowel symptom that reliably tracks with posterior prolapse. The others correlate only weakly, and the size of a prolapse on exam doesn’t predict how much trouble it causes.
How I diagnose it
Most of the diagnosis happens in the office, with a history and a pelvic exam. On the exam I’m watching the upper vaginal wall descend and sorting out which compartments are involved, because an apparent rectocele or cystocele is often really a combination bulge with the vaginal vault coming down behind it. Missing that vault component is a common reason repairs fail.
Most women with a bulge and posterior wall prolapse don’t need imaging before surgery.
When I do order imaging, usually defecography, it’s to plan surgery rather than to make the diagnosis. Those studies measure the enterocele in centimeters below a fixed pelvic landmark (small under 3 cm, moderate 3 to 6 cm, large over 6 cm) and show whether a sigmoidocele, a rectocele, or rectal intussusception is also present.
Treatment options
Only a prolapse that actually bothers you needs treatment. Mild descent is common and, on its own, isn’t a reason to do anything. From there the choice is yours, and it comes down to how much the bulge affects your life and what you want out of treatment.
A pessary
A pessary is a support device that sits in the vagina and holds the bulge up. I offer it to everyone with symptomatic prolapse as a first option, and how severe the prolapse is doesn’t decide whether it will fit or work. Among women who keep using one, about 78% report their symptoms are much or very much better at a year. It’s also the option you can try and reverse.
We have pelvic floor physical therapists in the office, and therapy can ease the pressure and the bowel symptoms that come with a posterior bulge, though it doesn’t lift the anatomy back into place.
Surgery
Because an enterocele is an apical defect, repairing it means restoring support at the top of the vagina. That usually means suspending the vaginal apex, either with your own tissue or with mesh placed through the abdomen (a sacrocolpopexy). For women who don’t want future vaginal penetration, closing off the vaginal canal (colpocleisis) is sometimes an option.
The key at surgery is to fix every compartment that’s down at the same time. If an enterocele sits alongside vault prolapse, the vault gets suspended; if it sits alongside rectal intussusception, the plan may include a rectopexy. Repairing one bulge and leaving another is what drives repeat operations.
How I think about this
An enterocele rarely stands alone, so the most useful thing I do is map out every compartment before we commit to anything. A bulge that reads as dramatic on a scan may be causing you nothing, and a modest one may be the whole reason you’re uncomfortable. I treat symptoms and function, not pictures. Once we know what’s down and what’s bothering you, a pessary, physical therapy, surgery, or simply watching and waiting are all reasonable, and which one is right is your call.
References
- Sultan AH, Monga A, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction. International Urogynecology Journal. 2017. doi:10.1007/s00192-016-3140-3
- Paquette I, Rosman D, El Sayed R, et al. Consensus Definitions and Interpretation Templates for Fluoroscopic Imaging of Defecatory Pelvic Floor Disorders. Female Pelvic Medicine & Reconstructive Surgery. 2021. doi:10.1097/SPV.0000000000000956
- Ridgeway BM, Weinstein MM, Tunitsky-Bitton E. American Urogynecologic Society Best-Practice Statement on Evaluation of Obstructed Defecation. Female Pelvic Medicine & Reconstructive Surgery. 2018. doi:10.1097/SPV.0000000000000635
- Grimes CL, Lukacz ES. Posterior vaginal compartment prolapse and defecatory dysfunction: are they related? International Urogynecology Journal. 2012. doi:10.1007/s00192-011-1629-3
- Haylen BT, Vu D. Surgical anatomy of the vaginal vault. Neurourology and Urodynamics. 2022. doi:10.1002/nau.24963
- Hooper GL, Moynihan L, Leegant A, et al. Vaginal Pessary Use and Management for Pelvic Organ Prolapse. Urogynecology. 2023. doi:10.1097/SPV.0000000000001293
- Andy UU, Meyn L, Brown HW, et al. Outcomes at 12, 24, and 36 Months in Women Treated for Pelvic Organ Prolapse With Pessary or Surgery: Results From the Multicenter Pelvic Floor Disorders Registry. Urogynecology. 2025. doi:10.1097/SPV.0000000000001669
- Meriwether KV, Gold KP, de Tayrac R, et al. Joint Report on Terminology for Surgical Procedures to Treat Pelvic Organ Prolapse. Female Pelvic Medicine & Reconstructive Surgery. 2020. doi:10.1097/SPV.0000000000000846
- Ferrando CA, Bradley CS, Meyn LA, et al. Twelve Month Outcomes of Pelvic Organ Prolapse Surgery in Patients With Uterovaginal or Posthysterectomy Vaginal Prolapse Enrolled in the Multicenter Pelvic Floor Disorders Registry. Urogynecology. 2023. doi:10.1097/SPV.0000000000001410