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When the colon drops into a space it should not occupy.

Sigmoidocele

The sigmoid colon descends into the rectovaginal space (the pouch of Douglas). It is a posterior-compartment prolapse that ordinary speculum exams and static ultrasounds often miss. Grade 1 means “mild” on a ruler. It does not mean mild in a body.

What it is

  • Sigmoidocele is grouped with enterocele and peritoneocele: peritoneal-lined herniations into the rectovaginal septum. An enterocele carries small bowel; a sigmoidocele carries sigmoid colon.
  • On defecography, descent is measured against the pubococcygeal line (PCL). A common grading: grade I less than 2 cm below the PCL, grade II 2–4 cm, grade III more than 4 cm. Grade is anatomy, not a pain scale.
  • Grade 1 can still occupy the space the rectum needs to empty, and can transmit pressure onto the vaginal apex and cervix, especially when rectal intussusception is happening in the same compartment.
  • It is a disorder of support and of straining. Childbirth, chronic constipation, connective-tissue laxity, and years of “just push through it” all contribute. It is under-diagnosed because you have to look while the patient is defecating, not while she is lying still.

What it can feel like

  • Pelvic pressure that worsens as the day goes on, or with standing and lifting
  • Obstructed defecation: you go, but it does not feel finished
  • A bulge or heaviness toward the vagina or rectum
  • The need to splint or reposition to empty
  • A sense that something is pushing on the uterus or cervix from behind

What you were probably told

  • “Grade 1 is nothing. We don’t treat grade 1.”
  • “Your exam looks fine. Try more fiber.”
  • “That’s just constipation. Everyone strains a bit.”
  • “If you can’t see it at rest, it is not a prolapse.”

How it actually gets named

  • Symptoms of obstructed defecation plus a pelvic exam that may show posterior or apical descent — or may look unimpressive at rest.
  • Defecating proctogram (fluoroscopic) or MR defecography: the studies that actually catch sigmoidocele, enterocele, intussusception, and perineal descent.
  • Static MRI, colonoscopy, and a well-woman exam are not substitutes. A “normal colonoscopy” says nothing about support.
  • POP-Q exam for the vaginal compartments; colorectal exam for the rectal wall. You want both.

What tends to help

  • Stop straining as a lifestyle. Soft, bulky stool; feet on a stool; time and privacy; no “get it over with” pushing.
  • Pelvic floor PT focused on coordination and defecatory dynamics — not Kegels as a default.
  • Pessary in selected patients if the vaginal bulge or pressure is the leading symptom.
  • Surgery is for bothersome anatomy that failed conservative care: approaches may include ventral mesh rectopexy, sacrocolpopexy / sacrocolpoperineopexy, or combined urogynecologic–colorectal repair. Grade alone should not be the indication.
  • Treat the neighbors: intussusception, rectocele, cervical descent, and a hypertonic floor. Isolated “sigmoidocele surgery” in a crowded pelvis is how people get incomplete answers.

Take these into the room

  • Has anyone ordered a defecating proctogram or MR defecography, or are we guessing from a rest exam?
  • What grade is the sigmoidocele, and what else descended with it?
  • If this is “only grade 1,” how do we explain the emptying and the pressure on my cervix?
  • Do you work with a colorectal surgeon, or am I being sent between two waiting rooms?