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Vaginal Prolapse May Not Correlate With Radiographic Findings in Symptomatic ODS Patients

Key findings

  • This study compared women with obstructive defecation syndrome (ODS) and radiographic rectoceles who did or did not have posterior vaginal wall prolapse, characterizing relationships between anatomical abnormalities and radiologic findings
  • Women with posterior vaginal wall repair prolapse had larger rectoceles on defecography than women without
  • Women with posterior vaginal wall prolapse on examination were more likely to splint during defecation than women without clinical rectocele

In women with chronic constipation, vaginal prolapse may contribute to obstructive defecation syndrome (ODS). This incomplete rectal evacuation may result from insufficient rectal propulsive forces and/or increased resistance to evacuation. ODS can also be secondary to dyssynergic defecation or anatomic abnormalities such as rectoceles, enteroceles, and internal rectal intussusception.

Massachusetts General Hospital researchers found in a retrospective case–control study that women with ODS who have constipation, radiographic rectoceles, and vaginal prolapse differ in notable ways from those with no evidence of prolapse. Milena M. Weinstein, MD, co-director of the Center for Pelvic Floor Disorders in the Department of Obstetrics and Gynecology, Marcus V. Ortega, MD, gynecologist and female pelvic medicine & reconstructive surgeon in the Department, and colleagues report the details and clinical implications in Diseases of the Colon and Rectum.


The study population was 106 women who presented to the Mass General Center for Pelvic Floor Disorders between January 2010 and December 2017 with ODS-type constipation as defined by ROME III criteria for functional constipation.

The 48 case subjects (45%) had rectoceles ≥2 cm on defecography and at least stage II posterior vaginal wall prolapse (Pelvic Organ Prolapse Quantification classification) on clinical examination. The 58 control subjects had rectoceles ≥2 cm but no evidence of prolapse.

Besides those assessments, patients underwent anorectal manometry and electromyography and were thoroughly questioned about symptoms, including being asked, "How often do you put your fingers in your vagina or rectum to help you move your bowels?" (splinting/digitation).


The significant differences between cases and controls were that:

  • Cases were significantly more likely to report splinting/digitation during defecation (64% vs. 27%; P<0.01)
  • On defecography, the mean size of rectoceles was greater in cases than in controls (3.4 vs. 3.0 cm; P<0.01)

These paradoxical results suggest a disconnection between the anatomical and functional meaning of the radiologic rectocele.

Furthermore, neither the presence of prolapse nor larger rectoceles were associated with more severe constipation.

Interpreting the Findings

There are two main potential explanations for the findings:

  • Patients who have both clinical prolapse and radiographic rectoceles may have a different disease phenotype than those who have radiographic rectoceles alone
  • There may be a continuum of prolapse development, such that women with radiographic rectoceles but no clinical prolapse are in an early stage of that continuum

Further work is needed to clarify whether constipation causes progression along this continuum or whether progression of prolapse worsens defecatory dysfunction.

Patient Counseling

Physicians should have a frank discussion with patients about what's reasonable to expect from surgical treatment. Resolving vaginal prolapse by reestablishing normal anatomy may not necessarily improve defecatory symptoms.

Learn more about the Female Pelvic Medicine and Reproductive Medicine Program

Refer a patient to the Department of Obstetrics and Gynecology

Related topics


In the first randomized, controlled trial of its kind, Milena M. Weinstein, MD, of the Department of Obstetrics and Gynecology, and colleagues found that use of a motion-based digital device for pelvic floor muscle training (PFMT) provides benefits beyond those of unsupervised PFMT alone.


Marcus V. Ortega, MD, and Milena M. Weinstein, MD, of the Division of Female Pelvic Medicine and Reconstructive Surgery, and colleagues found a substantial overlap of fecal and urinary incontinence in women, and they suggest comprehensive screening for both conditions at the time of initial evaluation.