Definition

Rectal prolapse occurs when the lower portion of the rectum turns itself inside out and comes out through the rectal opening. It occurs most often in elderly women, but it can occur at any age.  It occurs much more frequently in women than men.

Causes

Rectal prolapse is associated with chronic straining to pass stool. Attachments of the rectum to the pelvic bones progressively weaken; when these attachments are particularly weak, straining to pass stool causes the rectum to turn itself inside out. In many cases however, the cause is unknown.

Symptoms

The primary symptom is the feeling of tissue coming out of the rectum. Bleeding and mucus drainage frequently accompany rectal prolapse. When the problem first starts, the rectum may turn itself inside out but not come out the rectal opening. During this phase, a common symptom is the frequent urge to have a bowel movement when there is no need to pass stool. As the prolapse progresses, it occurs just with bowel movements or straining and returns into the rectum by itself. Later, the prolapse may occur with any activity and finally, just standing up may cause it. It may become necessary to push the tissue back into the rectum.

Constipation commonly occurs with rectal prolapse. The chronic straining associated with constipation may be cause of the prolapse, or it might be a result from the prolapse partially blocking the rectal opening. Continued straining or the prolapse itself may damage the sphincter muscle that controls the passage of stool. If this occurs, there may be an episode of fecal incontinence or accidental leakage of stool. It can be difficult at times to differentiate true incontinence from the mucus discharge of the prolapsed tissue.

Diagnosis

Your doctor can usually diagnose rectal prolapse by taking a careful history and performing a complete anorectal examination. To demonstrate the prolapse, the patient may be asked to strain as if having a bowel movement or to sit on the commode and strain prior to examination.

If the prolapse is internal or the diagnosis uncertain, a video defecogram (x-ray pictures taken while the patient is passing contrast instilled in the rectum) can help the doctor determine whether surgery would be helpful and what procedure would be best. Anorectal manometry, a test that measures whether or not the muscles around the rectum are functioning normally, may also be used.

Hemorrhoids may sometimes be confused with rectal prolapse. Hemorrhoids are a cluster of anal cushions (spongy tissue with a lot of blood vessels). A ring of hemorrhoids lies under the skin just outside the rectal opening. A second ring lies under the lining of the anal canal just inside the rectal opening. If an inside hemorrhoid enlarges, it may come out the rectal opening with a bowel movement or during exercise. However, only the lining and the blood vessels come out, unlike rectal prolapse where all layers of the rectal wall come out. An examination is necessary to determine the diagnosis.

Treatment

Rectal prolapse can be corrected. Treatment depends on the age and co-morbidities of the patient along the severity of the condition. In adults, a high-fiber diet to prevent constipation is recommended if the symptoms are mild. Surgical correction is usually required in adults if the prolapse does not resolve by itself, in which case the prolapse can be successfully repaired through either an abdominal or rectal procedure. Our surgeons have vast experience in both approaches to this condition. Your surgeon will explain the differences between the two types of operations and make a recommendation based on your particular medical condition. Rectal prolapse in children frequently corrects itself. The doctor will instruct parents how to reduce the prolapse when it occurs and how to prevent constipation in their child.

If incontinence accompanies the prolapse, the incontinence improves more than half the time after the prolapse is corrected. If continence does not improve, other treatments are available.

Visit the American Society of Colon & Rectal Surgeons website for more information