What is Rectal Prolapse: Causes, Symptoms, Treatment, Surgery, Prognosis, Diagnosis

Rectal prolapse is a condition in which the rectum or the lower portion of the large intestine, protrudes out through the last part of the large intestine or the anus. Prolapse is dragging or slipping down of a part from its original position. In rectal prolapse, the rectum begins to slip down from its position, through the anus. Rectal prolapse is usually seen in elderly people and in those who have experienced long term constipation and straining.

Rectal prolapse is also common in those having weakness of the pelvic floor muscles. While rectal prolapse can occur in younger people too, older adults are also commonly seen having rectal prolapse. Also, women are more likely to experience rectal prolapse than others.

In rectal prolapse, the walls of the rectum or the mucosa, protrudes out through the anus. Depending on the degree of protrusion, rectal prolapse is classified into further types of rectal prolapse. These include:

• Partial Rectal Prolapse – In this type of rectal prolapse, only a portion of the rectum or the lining of the rectal mucosa slips down and is pushed out through the anus. It is also known as mucosal prolapse. This may usually occur when a person strains while passing motions and this type of rectal prolapse can be commonly thought to be hemorrhoids. Partial prolapse may be seen more in younger children.
• Complete Rectal Prolapse – In this type of rectal prolapse, the entire rectal wall protrudes through the anus and is also known as full thickness rectal prolapse.
• Internal Rectal Prolapse – This type of rectal prolapse occurs when a part of the large intestine or the rectal mucosa gets folded over the next part, but the folded part or the prolapsed section does not come out through the anus. This is also called internal intussusception. This condition of rectal prolapse is commonly seen in children.

Rectal prolapse is commonly noted in elderly women, post-menopausal women and those with a history of pelvic floor weakness, constipation or straining to pass motions. Rectal prolapse is influenced by an increase in the intra-abdominal pressure, which is seen in conditions like pregnancy, benign enlargement of prostate, chronic cough, cystic fibrosis or pulmonary disorders with persistent sever coughing.

The commonest risk factors seen associated with rectal prolapse include chronic constipation, unsatisfactory passing of stools, straining and constipation alternated with diarrhea. Pelvic floor weakness contributing to rectal prolapse may be found in women who have had multiple deliveries but rectal prolapse has also been noted in young women who have never delivered a baby. People who have undergone previous surgeries, who have experienced neurological disorders, trauma to the spine or lower back, spinal or lumbar disc problems and tumors of the spine can also be at an increased risk of rectal prolapse.

Younger children may also sometimes experience rectal prolapse, but it may resolve by itself without any intervention. Rectal prolapse seen in children may be sometimes associated with disorders of the bowel or colon, rectal polyps, congenital megacolon, Hirschsprung’s disease or conditions of chronic cough.

While rectal prolapse often presents itself gradually, the main symptom shown is the protrusion of mass through the anus. Initially the mass may protrude or appear in the anus only on straining or when passing motions and will mostly resolve after passing motions or on standing. Gradually, in rectal prolapse, the mass may protrude on any straining, coughing or sneezing; on performing activities that increase the intra-abdominal pressure.

Eventually in rectal prolapse, the rectal mass may come out of the anus even when standing, walking or when performing routine daily activities. This condition may progress, when rectal prolapse begins to affect the daily life of a person. When this condition of rectal prolapse continues, it may cause more difficulty and the protruding mass may have to be replaced manually.

These symptoms of protrusion of rectal mass in rectal prolapse vary from person to person. In most cases, people experience as if some mass was falling out when the mass protrudes or as if they are sitting on a ball until the protruded mass in rectal prolapse is pushed back.

In addition to the mass protrusion, rectal prolapse also presents with several other symptoms like:

• Symptoms of pain in rectum and anus with bowel movements and when passing motions is commonly seen in rectal prolapse. Pain and discomfort may also be felt deep inside the lower abdomen.
• Constipation is an associated factor in most of the cases of rectal prolapse. Constipation causes straining and increases the chances of rectal prolapse.
• In rectal prolapse, discharges mixed with mucus or blood may be passed with stools.
• Rectal prolapse may sometimes also present with inability to control bowel movements or passing of stools; it is called fecal incontinence, where stools are passed voluntarily without being controlled. Rectal prolapse often presents with leakage of stools, mucus or blood from the anus.

Greater degrees of rectal prolapse may present with lack of urge to pass stools and a constant feeling of heaviness in the rectum. Rectal prolapse with internal prolapse or internal intussusception may show symptoms of difficulty in bowel movements. This often leads to a sensation of incomplete bowel movements and unsatisfactory bowel clearance. Symptoms may sometimes also include a burning, itchy sensation at the anus with increased irritation in the area accompanied with bleeding.

Sometimes, the rectal mucosa, which is prolapsed in rectal prolapse can become thick and get ulcerated. This can produce severe pain and bleeding through the rectum and on rare occasions, the rectal prolapse can get stuck up outside the anus, which may require immediate medical attention.

Complaints associated with rectal prolapse may mimic other medical ailments as well, hence understanding the condition is essential. Diagnosis of rectal prolapse can be made by taking a personal history, noting history of previous ailments, past surgeries or hospitalization. Clinical examination of the local area or rectal examination is important and it helps to reveal signs related to rectal prolapse. The physician may notice a loose mass of tissue sticking out of the rectum, which may be suggestive of rectal prolapse.

Contraction of anal sphincter is also studied. Advanced tests may be done to note the protrusion of the rectal mass in rectal prolapse. Enema may be given to aid the observation and confirm the diagnosis of rectal prolapse.

Tests for rectal examination may be performed to detect abnormalities in the large intestine, rectum or anus and its correlation to possible rectal prolapse. These tests may include:

Proctography, in which scans of the rectum and anus can be obtained during a bowel movement. Ultrasound of the anal region may be done to view the muscles that control the bowel movement.

Some tests help to rule out conditions like ulcers, tumors or other problems blocking the intestinal passage leading to rectal prolapse. These tests include

• Sigmoidoscopy – In this test, a sigmoidoscope is used to view the lower part of the large intestine, which helps to observe growths, sore areas or any abnormalities causing rectal prolapse. It is also used as a screening test for colon or colorectal cancer and can help to detect tumors or cancers in the area and help with early treatment.
• Colonoscopy – In this test, a long instrument, called colonoscope is used to view the entire colon for any abnormalities related to complaints of the colon or the rectum. Bleeding through rectum, conditions causing rectal prolapse or other possible conditions may be ruled out using this test.
• Barium Enema – In this test, barium contrast material is put into the anus, through enema and is filled in the colon. X-rays are then taken, in which the intestinal area becomes visible due to the barium contrast. Abnormalities in the colon are noted and possible causes or findings related tor rectal prolapse are detected. This test helps to identify causes of rectal bleeding, inflammatory bowel disorders, diverticulosis and other problems of the colon.

Other tests may be ordered, if found appropriate to find out causes and conditions leading to rectal prolapse or to rule out other ailments. These tests may be able to detect abnormalities with the muscles, nerves or damage to any soft tissue causing rectal prolapse. They may also help to find any specific abnormalities in the colon including gastrointestinal and colon disorders, polyps, tumors or cancers.

Treatment for rectal prolapse depends on the condition, cause of rectal prolapse and the age of the person.

The common causes or conditions leading to rectal prolapse may be treated with medications. Constipation is treated with laxatives and similar medicines. Medicines that aid in better digestion may be given for some. Treating constipation and avoiding straining when passing stools is important to manage rectal prolapse. Manual correction of rectal prolapse may be tried by the physician and if necessary, may be repeated as appropriate. Soft support may be advised after manual correction of rectal prolapse.

Putting the prolapse rectal mass into original position, must be done with physician’s advice.

A diet that includes roughage, fresh fruits and vegetables, salads, multigrain, etc. may be advised to reduce constipation and make bowel movements more regular and smooth.

Drinking enough water and fluids also helps and is commonly advised.

Regular exercise and physical activity is also often recommended to regularize bowel movements and also aids in digestion. Therapeutic exercises may be prescribed to strengthen the abdominal muscles and structures of the pelvic floor. This is particularly needed in people who have undergone previous surgeries or deliveries leading to rectal prolapse. Kegel exercises are a great way to strengthen the muscles in the pelvic region; these are best performed with expert’s guidance.

Those who have milder degrees of rectal prolapse, these management tips generally help. For those with severe degrees of rectal prolapse, complete rectal prolapse or partial prolapse that does not respond to medical treatment and diet, may have to be considered for surgical treatment of rectal prolapse.

In children with rectal prolapse, recommendations of diet, exercise and lifestyle management for rectal prolapse and constipation are important. For children who have constipation, it is important to relieve constipation to improve rectal prolapse and also educate them on passing stools more regularly and normally without straining. Following a healthy balanced diet, staying well hydrated and exercising regularly can help children with rectal prolapse.

In children, rectal prolapse may resolve without treatment in most cases; however some children may require advanced treatment, depending on the severity of the condition. This may include injecting certain medicines that help to keep the rectal mucosa in place. In case this treatment does not help, surgical correction may have to be considered in very few children.

Surgery for rectal prolapse may depend on the severity of the condition, age and the success of the previous treatment given. Surgery for rectal prolapse may be performed as an abdominal surgery or a perineal surgery, depending on the condition. Possible options of surgical approaches include:

• Abdominal Rectopexy With Possible Bowel Resection to Treat Rectal Prolapse – This surgery for rectal prolapse is performed through the abdomen, and the rectum is pulled up in an appropriate manner. This procedure can manage the prolapse however, the problems with functioning like constipation or incontinence may not improve.
• Minimally Invasive Rectopexy With Possible Bowel Resection – This surgery for rectal prolapse uses minimally invasive techniques like robotic or laparoscopic surgery. The surgical options for rectal prolapse treatment are preferred as they cause less pain and reduce hospital stay. These options may be considered as appropriate.
• Perineal Rectosigmoidectomy – It is done through the anus and not through the abdomen. This is the commonest perineal approach surgery for treatment of rectal prolapse and is also termed as Altemeier procedure. This procedure too may have reduced hospital stay and less pain, also without abdominal incision.
• Mucosal Sleeve Resection (Delorme Procedure) – In this procedure of rectal prolapse treatment, only an inner lining of rectum is stripped and sewed in a particular manner to reduce rectal prolapse.

It is important to consider all options for treating rectal prolapse and discuss possible side effects of each procedure with the treating physician. The most appropriate procedure may be decided depending on the condition and the severity.

Rectal prolapse can be cured once the cause is treated; surgical correction usually completely cures rectal prolapse. If rectal prolapse is left untreated, it may develop further complications like constipation, loss of bowel control. Also there are chances that the protruded rectal mass may remain prolapsed, can cause pain and can increase chances of bleeding and infection, if not treated in time. In children, rectal prolapse almost always gets cured after treating the cause.