Prolapse occurs when the rectum becomes unattached inside the body and comes out through the anus, effectively turning itself inside out.
Rectal prolapse is a relatively rare condition, with the American Society of Colon and Rectal Surgeons estimating that it affects less than 3 in every 100,000 people.
- A rectal prolapse tends to become noticeable gradually over time.
- Often it is associated with weak muscles in the pelvis.
- There can be complications if it is not treated promptly and properly.
- Treatment will depend on age, general health, and the cause of the prolapse.
There are three types of rectal prolapse:
- Full-thickness: The full thickness of the wall of the rectum sticks out through the anus. This is the most common type of rectal prolapse. There can be a partial or complete protrusion.
- Mucosal: Only the lining of the anus (known as the mucosa) sticks out through the anus.
- Internal: The rectum folds in on itself but does not stick out through the anus.
Causes, risk factors, and related conditions
Rectal prolapse may be internal or external.
There is a range of risk factors and causes associated with rectal prolapse, although doctors do not fully understand why some people get it.
It can be triggered by a variety of things including:
- constipation or chronic straining
- diarrhea — present in around 15 percent of people
- conditions that make a person cough a lot
There are also some neurological conditions that affect the nerves associated with rectal prolapse:
- multiple sclerosis
- lumbar disc disease
- spinal tumors
- injury to the lower back or pelvis
Rectal prolapse is more common in adults than children, and it is particularly prevalent in women aged 50 years or older, who are six times more likely to be affected than men.
Most women who have rectal prolapse are in their 60s, while most men are aged 40 or younger.
In the case of older women, rectal prolapse will often occur at the same time as a prolapsed uterus or bladder. This is because of general weakness in the pelvic floor muscles.
Symptoms and complications
A prolapsed rectum may cause a number of symptoms, inluding constipation and bleeding from the rectum.
At first, the person might only notice a lump or swelling coming out of their anus when they have a bowel movement.
Initially, the person may be able to push the rectal prolapse back in. Over time, however, the prolapse is likely to protrude permanently, and a person will be unable to push the prolapse back.
As time goes on, a rectal prolapse may happen when a person coughs, sneezes, or stands up. Some people with a rectal prolapse have described it as like "sitting on a ball."
Some people may experience an internal rectal prolapse, which is different in that the prolapse will not protrude. However, the person may feel as if they have not passed everything during a bowel movement.
Other symptoms of a rectal prolapse include:
- difficulty controlling bowel movements, which occurs in around 50 to 75 percent of cases
- bright red blood coming out of the rectum
- constipation, present in about 25 to 50 percent of people who have a rectal prolapse
- Strangulated prolapse: This occurs when part of rectum becomes trapped and cuts off the blood supply, causing tissue to die. This can develop gangrene, and the area will turn black and drop off. It is rare and requires surgery.
- Solitary rectal ulcer syndrome: Present in mucosal prolapse, ulcers can develop on the part of the rectum sticking out. This complication often requires surgery.
- Recurring prolapse: People who have surgery for rectal prolapse may have another prolapse at some point in the future.
When to see a doctor
Although a rectal prolapse is not often defined as an emergency medical problem, it can be uncomfortable, embarrassing, and have a significant adverse effect on the person's mental and physical life.
Therefore it is essential for anyone who has noticed any signs or symptoms of rectal prolapse to see a doctor as soon as possible.
In order to diagnose a rectal prolapse, the doctor will look at the person's medical history, ask them about their symptoms, and conduct a physical examination.
A physical examination will involve the doctor inserting a lubricated, gloved finger into the rectum. While this can be uncomfortable and possibly embarrassing, it should not be painful and is very important for an accurate diagnosis.
Further tests may be required to clarify the diagnosis or rule out other processes, which include:
- Proctography: A type of X-ray that shows the rectum and anal canal during a bowel movement.
- Colonoscopy: A long, flexible, tube-like camera called a colonoscope is inserted to take a closer look at the large intestine and rectum.
- Endoanal ultrasound: A thin ultrasound probe looks at the muscles used to control the bowels
Treatment and management options
If constipation cannot be treated, surgery may be recommended for treating the rectal prolapse.
In the first instance, it is important to treat constipation. This might be achieved by eating plenty of foods that are high in fiber, such as fruit, vegetables, and wholegrains.
Bulking laxatives, which help a person have a bowel movement without straining, may also be recommended, as well as drinking plenty of water.
If that does not work, then surgery may be advised. The type of surgery will depend on a number of factors:
- type of prolapse
- the person's age
- other medical problems
- whether the person is constipated or not
There are two general types of surgery for rectal prolapse:
- Abdominal: Entry through the belly through a cut or several cuts in the abdominal wall. Often used for full-thickness prolapse.
- Perineal: Involves cutting out the full thickness segment of the prolapsing rectum. Suitable for people who cannot have a general anesthetic.
Rectal prolapse or hemorrhoids?
While rectal prolapse affects the rectal wall, hemorrhoids affect the blood vessels in the anal canal. These two conditions require different treatment, so it is important to get the correct diagnosis.
There are some lifestyle changes people can make to try and avoid rectal prolapse, including:
- eating plenty of fiber
- drinking plenty of water
- exercising regularly
- avoiding excessive straining during a bowel movement
Most people make a full recovery after treatment for rectal prolapse and lead a normal life.
However, proper recovery is crucial and how long this will take will depend on the type of treatment.
Typically, people who have had surgery spend 3 to 5 days in the hospital after the operation, and most make a complete recovery within 3 months. After undergoing surgery for a rectal prolapse, people should avoid straining and heavy lifting for at least 6 months afterward.