Rectal Prolapse

Symptoms and signs of rectal prolapse include painful bowel movements, fecal incontinence, protruding tissue, and bloody discharge.

The rectum refers to the lowest 12-15 centimeters of the large intestine. The rectum is located just above the anal canal. Normally, the rectum is securely attached to the pelvis with the help of ligaments and muscles that hold it in place.

What Are the Causes and Risk Factors for Rectal Prolapse?

Causes of rectal prolapse include factors such as age of 40 years, long-term constipation, the stress of childbirth, or large hemorrhoids (large, swollen veins inside the rectum) that may cause these ligaments and muscles to weaken, causing the rectum to prolapse, meaning it slips or falls out of place. Other risk factors of include long-term diarrhea, long-term straining during defecation, previous surgery, cystic fibrosis, chronic obstructive pulmonary disease, whooping cough, multiple sclerosis, and paralysis.

What Are the Symptoms of Rectal Prolapse?

Signs and symptoms of include pain during bowel movements, mucus or blood discharge from the protruding tissue, fecal incontinence, a loss of urge to defecate, and awareness of something protruding upon wiping.

How Is Rectal Prolapse Treated?

Medical treatment helps ease the symptoms of a prolapsed rectum temporarily or to prepare the patient for surgery. Bulking agents, stool softeners, and suppositories or enemas are used as treatment to reduce pain and straining during bowel movements.

Surgery to repair of this condition usually is performed by a colorectal surgeon and involves attaching or securing the rectum to the back side (or posterior) part of the inner pelvis.

What Is the Prognosis for Rectal Prolapse?

The outlook for a patient with this health condition generally is good, and most people recover well after surgery.

What Can You Do to Prevent Rectal Prolapse?

Prevention of involves eating a high-fiber diet and drinking plenty of fluids to reduce constipation; avoid straining during bowel movements; treat any long-term diarrhea, constipation, or hemorrhoids.

What Is the Rectum?

The term rectum refers to the lowest 12-15 centimeters of the large intestine (colon). The rectum is located just above the anal canal (the junction is called the anorectal area). Normally, the rectum is securely attached to the pelvis with the help of ligaments and muscles that hold it in place. When these ligaments and muscles weaken, the rectum can slip or fall out of place, or prolapse (also called rectal procidentia).

How Does Rectal Prolapse Occur?

In the early stages of rectal prolapse, the rectum becomes poorly attached but stays within the body most of the time. This stage is called mucosal prolapse, or partial prolapse, meaning that only the inner lining of the rectum (rectal mucosa) protrudes from the anus. This occurs when the connective tissues within the rectal mucosa loosen and stretch, allowing the tissue to protrude through the anus. When chronic hemorrhoidal disease is the cause, the condition usually does not progress to complete prolapse. Determining if the problem is hemorrhoids or rectal prolapse is important. Hemorrhoids occur commonly, but they rarely cause the condition.

As the rectum becomes more prolapsed, the ligaments and muscles may weaken to the point that a large portion of the rectum protrudes from the body through the anus. This stage is called complete prolapse, or full-thickness rectal prolapse, and is the most commonly recognized stage of the condition. Initially, the rectum may protrude and retract depending on the person's movements and activities. However, if the disease goes untreated, the rectum may protrude more frequently or even permanently.

What Conditions Are Similar to Rectal Prolapse?

Rectal prolapse is similar to, but not the same as, a rectocele, a common condition in women, where the rectum falls forward into the backside (or posterior) wall of the vagina, causing a lump inside the vagina.

Another condition commonly considered a type of prolapsed rectum is called internal intussusception. Its effects on the rectum are similar to those of mucosal prolapse or complete rectal prolapse; however, in internal intussusception, the rectum neither protrudes from the body nor enters the anal canal.

How Common Is Rectal Prolapse?

• Rectal prolapse is an uncommon disease and primarily affects elderly people.
• The disease is rare among children. Affected children are usually younger than 3 years of age.
• Men develop the condition much less frequently than women do.
• It is extremely rare in the United States.

Rectal prolapse is caused by weakening of the ligaments and muscles that hold the rectum in place. In most people with a prolapsed rectum, the anal sphincter muscle is weak. The exact cause of this weakening is unknown; however, risk factors usually are associated with the following health conditions.

• Age over 40 years
• Long-term constipation
• Long-term diarrhea
• Long-term straining during defecation
• Pregnancy and the stresses of childbirth and vaginal delivery
• Being female
• Women who have had more than five pregnancies (multiparity)
• Previous surgery (particularly pelvic surgery)
• Cystic fibrosis
• Chronic obstructive pulmonary disease (COPD)
• Whooping cough
• Multiple sclerosis
• Dementia
• Stroke
• Pelvic floor dysfunction (such as paradoxical puborectalis contraction, nonrelaxing puborectalis muscle, abnormal perineal descent)
• Pelvic floor anatomic defects (such as rectocele, cystocele, enterocele, deep cul-de-sac)

Long-term hemorrhoidal disease is frequently associated with mucosal prolapse (partial prolapse) that does not progress to complete prolapse of the rectum.

The symptoms of a prolapsed rectum are similar to those of hemorrhoids; however, it originates higher in the body than hemorrhoids do. A patient with the condition may feel tissue protruding from the anus and experience the following symptoms:

• Pain during bowel movements
• Mucus or blood discharge from the protruding tissue
• Fecal incontinence (inability to control bowel movements)
• Loss of urge to defecate (mostly with larger prolapses)
• Awareness of something protruding upon wiping

Early in the development of this condition, the protrusion may occur during bowel movements and retract afterwards. The protrusion may become more frequent and appear when the patient sneezes or coughs. Eventually, the protruding rectum may need to be manually replaced or may continually protrude.

Patients with internal intussusception in which the rectum is displaced but does not protrude from the body, often experience difficulty with bowel movements and a sense of incomplete bowel movements.

To confirm the presence of a prolapsed rectum, the doctor may ask the person to sit on the toilet and strain. If the rectum does not protrude, the doctor may administer a phosphate enema to confirm the diagnosis. The main condition to distinguish prolapse of the rectum from is protruding or prolapsing hemorrhoids.

A defecogram (a test that evaluates bowel control) may help distinguish between a mucosal prolapse and a complete prolapse of the rectum in a patient.

• Stool softeners, such as sodium docusate (Colace) or calcium docusate (Surfak), may be used to reduce pain and straining during bowel movements.
• Bulk agents, such as psyllium (Metamucil or Fiberall) or methylcellulose (Citrucel) also may be used.

Almost all cases require medical care, and in most cases, surgery is required to treat and cure the problem. Most cases will worsen without surgery. Occasionally, successful treatment of an underlying cause of a prolapsed rectum may resolve the problem. However, these scenarios usually involve infants or children. The cause of this condition in many patients is constipation or straining while having a bowel movement.

The following tips may help ease bowel movements and ease symptoms.

• Try to avoid or reduce straining during a bowel movement. However, it may not be enough to correct the condition.
• Ease constipation and straining by eating plenty of fruits and vegetables and other fiber-filled foods, and drinking lots of water.
• Use stool softener if needed to help prevent straining during bowel movements.
• If a doctor has diagnosed you with the condition, and with his or her guidance you may be able to manually push the prolapse back into place. Check with your doctor about whether this is something you should do yourself, and how to do it effectively.
• For infants and children, reducing the need to strain during bowel movements with stool softeners may correct a prolapsed rectum.
• Women may find pelvic floor exercises (for example, Kegel exercises) can help improve symptoms.
• A doctor should always be consulted before any attempt to treat this condition at home.

The treatment standard to cure rectal prolapse is surgery. Medical treatment is normally used to ease the symptoms of a prolapsed rectum temporarily or to prepare the patient for surgery. Bulking agents (such as bran or psyllium), stool softeners, and suppositories or enemas are used for these purposes.

Surgery for Rectal Prolapse

Surgery through the abdomen typically performed in younger or healthier patients. The type of abdominal surgery usually determined by severity of associated constipation. Associated with higher morbidity rate than perineal approach but lower recurrence rate of prolapse performed under general anesthesia.

Perineal Approach

The perianal approach is typically performed in elderly people or people in poor health who cannot tolerate general anesthesia. The perianal approach is associated with higher recurrence rate than abdominal approach, and usually involves a shorter hospital stay.

If a patient is too weak for surgery, a doctor can prevent a prolapse by inserting a wire or plastic loop to hold the sphincter closed.

After surgery, a Foley catheter may be left in place for 1-2 days and the patient may need to follow a liquid diet until normal bowel functions return. A perineal surgery may require 1-3 days in the hospital, and abdominal surgery may require up to a week.

The recovery time following either type of surgery is several weeks and involves adding fiber to the diet and avoiding:

• Straining with bowel movements
• Sexual intercourse
• Sneezing
• Lifting
• Coughing
• Extended periods of standing

The patient will likely need one or two follow-up visits to their doctor within the first month after surgery to check that incisions are healing well and to make sure bowel movements are normal.

Rectal prolapse can be prevented with measures such as:

• High-fiber diet and daily intake of plenty of fluids
• Avoiding straining during bowel movements
• Seeking treatment for long-term diarrhea, constipation, or hemorrhoids

With timely and appropriate treatment, most people who undergo surgery experience few or no symptoms related to rectal prolapse after surgery. Several factors, including age, severity of the prolapse, type of surgical approach, and health of the patient, contribute to the quality and speed of a person's recovery.