Chapter 17 — Retroverted Uterus and Its Relation to Obstructed Defecation
Chapter 16 described obstructed defecation syndrome, and its main causes. This chapter covers one specific cause in women, easily missed unless specifically examined for: a retroverted uterus. This cause is mechanical, not related to the rectum itself. It requires a combined surgical and gynaecological assessment, and a specific examination technique described in full below.
17.1 What Is a Retroverted Uterus
In most women, the uterus tilts forward, toward the bladder. This is called an anteverted uterus.
In some women, the uterus instead tilts backward, toward the rectum. This is called a retroverted uterus. It is a common anatomical variant. Most women with a retroverted uterus have no symptoms at all, from the uterus itself.
In a small number of women, however, a retroverted uterus presses directly against the rectum. This can cause a mechanical obstruction to defecation, separate from any of the causes described in Chapter 16.
17.2 Why It Causes Obstructed Defecation
The rectum lies just in front of the sacral hollow, at the back of the pelvis. Normally, nothing lies between the rectum and this hollow. There is space for the rectum to fill and empty freely.
In a retroverted uterus, the uterus tips backward into this same space. It comes to lie directly behind the rectum, pressing the rectum forward against the sacral hollow. Stool cannot pass easily through a rectum compressed in this way, even though the rectum, the anal canal, and the sphincters are all otherwise completely normal.
This is a purely mechanical problem. It is not a disease of the rectum. It will not be seen on colonoscopy. It will not be seen on proctoscopy. The rectum looks entirely normal from inside. This is precisely why the diagnosis is so often missed.
17.3 Presentation
Follow the history-taking method described in Chapter 2. The presentation closely resembles the obstructed defecation syndrome described in Chapter 16.
A sense of blockage or obstruction during defecation.
Straining, often prolonged and severe.
A feeling that something is physically in the way, rather than simply a sluggish bowel.
Normal, or near-normal, findings on any endoscopy already performed.
This last point is often the key clue. A patient who has already had a colonoscopy or a proctoscopy, with entirely normal findings, and who continues to have severe obstructive
symptoms, should raise suspicion of a retroverted uterus, in a woman of childbearing age or older.
Some patients will have already consulted several doctors, without a clear diagnosis. This is common with this condition, precisely because the cause lies outside the rectum, and is missed unless it is specifically looked for.
17.4 Examination — The Key Diagnostic Technique
Chapter 16 introduced the bimanual examination for suspected rectocele. This same technique is the key to diagnosing a retroverted uterus. It must, however, be performed with the patient actively straining, and ideally in the squatting position.
Place one finger in the rectum, and one finger in the vagina, together, at the same time.
Ask the patient to strain, as if attempting to defecate.
Feel for a firm mass pressing the rectum forward, from behind, against the examining rectal finger.
A retroverted uterus is felt as this firm mass. It is best felt during straining. A rectum that is compressed only when the patient strains, and free at rest, points strongly toward this diagnosis.
This examination cannot be rushed. The squatting position, with active straining, reproduces the exact mechanical situation that causes the patient's symptoms. An examination performed only with the patient lying flat and relaxed may miss the finding entirely.
17.5 Differential Diagnosis
Obstructed defecation syndrome — described in Chapter 16. A retroverted uterus is one specific cause within this broader group, not a separate condition.
Rectocele — described in Chapter 16. Both conditions can coexist in the same patient. The bimanual examination should specifically distinguish a bulge of the rectal wall itself, which is a rectocele, from a firm mass pressing from behind, which is a retroverted uterus.
Rectal intussusception — described in Chapter 15. This is a problem of the rectal wall itself, not an external mass.
Pelvic floor dyssynergia — described in Chapter 16. A muscle coordination problem, not a mechanical one.
17.6 Investigations
MRI defecography, described in Chapter 8 and Chapter 16, is particularly useful for this condition. It shows the rectum and the uterus together, during straining, and can directly demonstrate the uterus compressing the rectum.
A pelvic ultrasound confirms the retroverted position of the uterus, though it does not show the dynamic compression seen on defecography during straining.
A gynaecological opinion is valuable at this stage, both to confirm the finding, and to plan management jointly.
17.7 Principles of Management
Management proceeds in a deliberate, stepwise fashion, from the simplest measure to the most definitive.
Manual anteversion — the uterus is gently repositioned forward, into its normal anteverted position, by vaginal examination. This is the correct first step, and deserves a genuine, full trial. It is not merely a delaying measure before an inevitable operation. In some patients, it is fully and lastingly curative on its own.
Anteversion under general anaesthesia — if manual anteversion gives only brief relief, a repeat anteversion performed under general anaesthesia, with the uterus fixed in a more fully corrected position, is a reasonable next step.
Hysterectomy — reserved for a patient whose family is complete, and in whom the above conservative measures have failed to give lasting relief. This is a definitive, curative step in this situation, but it is not the first option, and should not be offered before conservative correction has been properly tried.
A woman who still wishes to have children needs a different discussion. Removal of the uterus is not appropriate. Fixation procedures that preserve the uterus should be discussed jointly with a gynaecologist.
17.8 Case Vignettes from Clinical Practice
The following two cases, from the author's own practice, illustrate the range of outcomes possible with this condition.
The first patient presented with severe, longstanding obstructed defecation. She had already undergone extensive endoscopic evaluation, with entirely normal findings, and had consulted several specialists without relief. Bimanual examination, with the patient straining in the squatting position, revealed a retroverted uterus pressing the rectum against the sacral hollow. Manual anteversion gave relief for only a few days, before her symptoms returned. A repeat anteversion, performed under general anaesthesia with the uterus fixed in a more fully corrected position, again gave only temporary relief. With her family already complete, hysterectomy was performed. Her obstructive symptoms resolved completely and permanently.
The second patient presented some years later, with the same underlying mechanism confirmed on the same bimanual examination. In her case, a single manual anteversion of the retroverted uterus was fully curative. She remained entirely well at follow-up, and did not return with this problem again.
Read together, these two cases show a genuine range of outcomes for the same mechanism. Conservative correction deserves a full and genuine trial in every patient. It is sometimes completely curative on its own. When it is not, escalation to a more definitive procedure should not be delayed once the diagnosis is clearly established.
17.9 Special Situations
Family not yet complete — hysterectomy is not appropriate. Manual anteversion, and if needed, a uterus-preserving fixation procedure, should be pursued instead, in consultation with a gynaecologist.
Coexisting rectocele — both conditions should be assessed and addressed together. Correcting the uterus alone will not relieve symptoms caused by a separate rectocele.
Diagnosis delayed by normal endoscopy — actively consider this diagnosis in any woman with obstructed defecation and an entirely normal colonoscopy or proctoscopy, rather than assuming the workup is complete.
17.10 Complications of Treatment
Manual anteversion carries very little risk, and is a safe first step in essentially every patient.
Anteversion under general anaesthesia carries the usual risks of a short general anaesthetic.
Hysterectomy carries the standard risks of major pelvic surgery, including bleeding, infection, and injury to adjacent structures. These risks should be discussed fully before proceeding, and weighed against the patient's reproductive plans.
17.11 Common Mistakes to Avoid
Relying on colonoscopy or proctoscopy alone, and concluding the workup is complete when these are normal.
Performing the bimanual examination with the patient relaxed and lying flat, rather than actively straining, and missing the finding as a result.
Proceeding to hysterectomy without first giving manual anteversion a genuine trial.
Offering hysterectomy to a woman whose family is not yet complete, without first exploring uterus-preserving options.
Treating this condition in isolation, without involving a gynaecologist in the assessment and management plan.
17.12 Recording and Follow-Up
Record the bimanual findings precisely. For example: "Retroverted uterus palpable on bimanual examination with straining, compressing rectum against sacral hollow. Endoscopy previously normal. Plan: trial of manual anteversion, gynaecology referral, review in 2 weeks." Arrange follow-up specifically to assess whether relief is lasting, since a brief initial response to manual anteversion does not by itself confirm a lasting cure.
17.13 Why This Chapter Matters
A retroverted uterus is a genuinely curable cause of obstructed defecation, but only if it is specifically looked for. A patient with normal endoscopy and severe symptoms deserves a bimanual examination performed with active straining, not a diagnosis of exclusion left
unexplained. The next chapter turns to another cause of difficult evacuation, arising from a different mechanism entirely: anal stenosis.