Rectal prolapse

What is rectal prolapse?

Rectal prolapse is a condition where the rectum loses its normal attachments inside the body and turns inside out through the anus. It affects mostly adults, and women over 50 are about six times as likely as men to develop it. It does not resolve on its own, and surgery is the definitive treatment.

The rectum is the final part of the large bowel. When the supporting muscles and ligaments weaken, it can telescope down. A complete prolapse shows as concentric folds of tissue, while a partial mucosal prolapse is more limited. The condition is often associated with long-term constipation and straining, and sometimes with leakage.

What causes rectal prolapse?

Rectal prolapse has no single cause. It is linked to a weak pelvic floor, long-term constipation and straining, and nerve injury from childbirth, and becomes more common with age. An estimated 30 to 67 percent of patients have chronic constipation, and prolapse also occurs in people who have never given birth.

• Weakened pelvic floor and supporting ligaments
• Long-term constipation and straining
• Childbirth and pelvic nerve injury
• Ageing
• Chronic cough or raised abdominal pressure

What are the symptoms?

Rectal prolapse first appears as a reddish lump that comes out of the anus after a bowel movement and returns by itself. Later it needs pushing back or stays out. Other symptoms are mucus, bleeding, a feeling of incomplete emptying, constipation and leakage of stool.

• A reddish lump protruding from the anus
• Mucus and bleeding
• A feeling of incomplete emptying
• Leakage of stool
• Constipation and straining

When should I see a colorectal surgeon?

Rectal prolapse needs assessment by a colorectal surgeon, since prolapse and piles are treated differently. See one for any lump that comes out of the anus. Seek urgent care if the tissue cannot be pushed back or turns painful or dark, or if there is heavy bleeding.

The warning signs below need prompt attention.

• Tissue that cannot be pushed back
• Painful or dark tissue
• Heavy bleeding
• Inability to pass stool or wind

How is it diagnosed?

Rectal prolapse is diagnosed by examination, sometimes while you strain on a toilet so the prolapse can be seen. Full-thickness prolapse shows concentric folds of tissue, while piles show radial folds. Colonoscopy rules out polyps or cancer, and tests of continence and pelvic floor function help plan the repair.

• Examination, sometimes while straining
• Assessment of bowel habits and continence
• Sigmoidoscopy or colonoscopy
• Tests of pelvic floor and nerve function
• Imaging in selected cases

How is rectal prolapse treated?

Surgery is the usual treatment for rectal prolapse, as it cannot be corrected without an operation. The abdominal approach, often by keyhole, fixes the rectum in place and offers the best chance of a lasting repair for people fit for surgery. The perineal approach through the anus suits older or frailer patients.

• Abdominal repair, often laparoscopic, to fix the rectum in place
• Perineal surgery through the back passage for those less fit
• Treatment of constipation to reduce straining
• Pelvic floor and continence care
• Combined management when prolapse and leakage occur together

What are the risks and complications?

The main risks of rectal prolapse surgery are the prolapse returning, which is higher after perineal repair, and new or worse constipation. Other risks are leakage, bleeding, infection and the usual risks of anaesthesia.

• Recurrence, higher with some perineal approaches
• Worsening or new constipation
• Leakage
• Bleeding and infection
• The usual risks of surgery and anaesthesia