Background <p>Anterior rectocele is one of the most common colorectal problems with symptoms of obstructed defecation or rectal emptying difficulties. The aim of this study is to compare the outcomes of laparoscopic ventral mesh rectopexy (LVMR) and transvaginal repair (TVR) for symptomatic anterior rectocele.</p> Methods <p>This is a prospective randomized controlled trial conducted with 40 women. Patients were randomized into two groups. LVMR was done in the first group, whereas the second group underwent TVR. Patient outcomes were compared regarding improvement in constipation using the Cleveland Clinic Constipation (CCC) score and sexual-related quality of life score using the short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) at 6- and 12-month follow-up.</p> Results <p>Forty females were enrolled in this trial. Each group comprised 20 patients. Preoperatively, the CCC score was 17 ± 2.8 in the LVMR group vs. 17.3 ± 2 in the TVR group (<i>P</i> = 0.278). A significant decrease in the constipation score was recorded in each group at 6 and 12&#xa0;months after surgery. Regarding sexual function, the mean PISQ-12 score at 6&#xa0;months was 32 ± 3.9 for LVMR vs. 35 ± 1.4 for TVR, <i>P</i> &lt; 0.001), while at 12&#xa0;months no difference was noted between the two groups. However, each group showed significant improvement in the PISQ-12 score at 6- and 12-month follow-up.</p> Conclusion <p>Comparable results were noted for LVMR and TVR in management of anterior rectocele. Obstructive defecation symptoms and sexual function showed significant improvement after 1 year of follow-up. Nevertheless, long-term follow-up is needed.</p> Clinical trial registration <p>The study was registered in the clinical trials registry with registration number NCT06633172.</p>