Rectal Prolapse

Rectal prolapse is more common in the pediatric population than in adults. It may occur when anorectal and other pelvic muscles are not fully developed.

It can also occur when a child has frequent bowel movements which can happen due to diarrheal infections or inflammatory bowel disease such as ulcerative colitis. Conservative management is usually quite effective with up to 90% of the pediatric population avoiding surgery.

Rectal prolapse and hemorrhoids can both be uncomfortable and painful conditions. Rectal prolapse may initially feel like a bad case of hemorrhoids, and sometimes hemorrhoids on your anus may look like your rectum is emerging.

• Rectal prolapse. In rectal prolapse, the rectum has moved. Rectal prolapse can cause bleeding sometimes.
• Hemorrhoids. Hemorrhoids are actually swollen blood vessels in the walls of your rectum or anus. Hemorrhoids are quite common in their smaller, milder form. They can become painful and itchy and can leave red blood on the tissue when you wipe.

Read more: Why is there blood when you wipe?

If you suspect you have hemorrhoids or rectal prolapse, see a doctor. They can diagnose your condition and start the appropriate treatment.

There are three types of rectal prolapse. The type is identified by the movement of the rectum:

• Internal prolapse. The rectum starts to drop but has not yet pushed through the anus.
• Partial prolapse. Only part of the rectum has moved through the anus.
• Complete prolapse. The entire rectum extends out through the anus.

The symptoms of rectal prolapse tend to come on slowly. The first symptom you’ll notice is the feeling that there is a bulge at your anus. It may seem as though you are sitting on a ball.

With a mirror, you may be able to see a reddish-colored bulge peeking through or actually extending out of your anus.

Additional symptoms include:

• Part of the rectum may protrude during bowel movements but may be easily pushed back in place
• Physical activity, such as walking, sitting, and exercising, may also cause part of the rectum to push through your anus.
• There may be bleeding from the inner lining of the rectum.
• Eventually, you may have trouble controlling liquid or solid bowel movements and gas from your rectum.
• Chronic constipation occurs in 30 to 67 percent of people with rectal prolapse, and about 15 percent experience diarrhea.

Rectal prolapse can be caused by several medical conditions, including:

Nerve damage

If nerves that control the rectal and anal muscles are damaged, rectal prolapse can develop. These nerves can sometimes be damaged from:

• pregnancy or a difficult vaginal birth
• a spinal injury
• surgery in the pelvic area

Weakened anal sphincter

This is the muscle that prevents stool from involuntarily passing from your rectum. Common reasons this muscle may weaken are:

• pregnancy
• childbirth
• increased age

Chronic constipation

The strain of chronic bowel movement problems can make your rectum more likely to move down from its location. Straining while having bowel movements, if done often over a period of years, can also cause rectal prolapse.

While not directly linked to rectal prolapse, some conditions may increase the risk of it, including:

• chronic constipation
• chronic diarrhea
• cystic fibrosis
• dementia
• spinal cord problems
• stroke
• hysterectomy

Women over age 50 are also at an increased risk of rectal prolapse.

If you’ve been diagnosed with rectal prolapse, you may choose to delay treatment if your symptoms are mild enough and your quality of life is not significantly affected.

If the prolapse is mild, softening the stool can help you strain less during bowel movements so you may recover without surgery before it gets worse.

However, surgery is the only way to definitively treat rectal prolapse and relieve symptoms. The surgeon can do the surgery through the abdomen or through the area around the anus.

There are two main approaches to repairing rectal prolapse: abdominal and rectal.

Abdominal repair approaches

Some types of surgery involve making an incision in the abdominal wall and pulling the rectum back into place. This surgery, also known as abdominal rectopexy, can also be performed laparoscopically, using smaller incisions with a special camera and tools.

Rectal (perineal) repair approaches

There are two different types of perineal rectosigmoidectomy, which are surgical procedures that repair the rectal prolapse through the perineum, or the area between the anus and genitals. These types are:

• Altemeier procedure. This type of surgery involves removing part of the rectum that is sticking out and reattaching the two ends back together.
• Delorme procedure. This procedure is ideal for those with shorter prolapses. It involves removing the outer lining of the rectum and then folding and stitching the layer of muscle.

These surgeries are often recommended for people who have severe constipation and are not considered candidates for a laparoscopic procedure through the stomach.

After rectal prolapse surgery, you may need to stay in the hospital to recover and regain bowel function. The amount of time you spend in the hospital can vary depending on the specific type of surgery you had.

Generally, most people are able to fully recover and return to their normal daily activities within 6 weeks of surgery.

During your hospital stay, you will slowly transition from drinking clear liquids back to eating solid foods. Your doctor may also advise you on strategies to avoid a recurrence or a return of rectal prolapse. These strategies may involve:

• staying hydrated
• eating enough fiber
• using a stool softener to prevent constipation

Surgery through the abdomen is performed to pull the rectum back up and into its proper position. It can be done with a large incision and open surgery, or it can be done laparoscopically, using a few incisions and specially designed smaller surgical tools.

Surgery from the region around the anus involves pulling part of the rectum out and surgically removing it. The rectum is then placed back inside and attached to the large intestine. This approach is usually performed in people who are not suitable candidates for surgery through their abdomen.

Discuss your treatment options with your doctor. If they recommend one type of surgery, you should feel comfortable asking why it’s recommended.

Your doctor will ask about your medical history and have you describe your symptoms.

They will also do a complete physical examination. Your doctor will observe your rectum and may place a gloved finger in your anus to check the health or strength of the anal sphincter and the rectum itself. During your exam, your doctor may ask you to squat and strain as though you were having a bowel movement.

Other tests may be performed to help diagnose rectal prolapse. Prior to these tests you may be asked to fast and/or clean your colon with enemas. These other tests include:

• Anal electromyography (EMG). This test measure how effective the muscles and nerves in your rectum are. Electrodes are placed a few inches into your rectum. Then the test is performed and only takes a few minutes.
• Anorectal manometry. A flexible, thermometer-sized tube that has a small, deflated balloon attached to the end is inserted into the rectum. While connected to a machine, the tube is placed in several areas of your rectum, and the response to pressure is measured.
• Barium enema. During this test, a chalky liquid containing barium is placed in your rectum. Barium shows up on X-rays producing images of the area.
• Colonoscopy. During a colonoscopy, a thin, flexible tube with a small camera at the end is inserted into the rectum so the healthcare professional can do a visual exam.
• Defecography. This test can use X-rays and/or MRI to monitor your colon as you have a bowel movement.
• Lower GI series. During this test, a chalky liquid containing barium is placed in your large intestine so that the area is visible on X-ray and images may be taken.
• Transit study. In this study, you swallow one or more capsules that contain markers that can be seen on X-rays. After you swallow the capsule, you go in for X-rays each of the next 5 days so the doctor can see exactly how the markers pass through your intestines.
• Other exams. Your doctor may want to perform urological or gynecological exams to see if there are any weak areas in your pelvic floor or if other organs, like the uterus, have prolapsed.

Preventing rectal prolapse is not always possible. You can reduce your risk if you maintain good intestinal health. To help avoid constipation:

• Make high fiber foods part of your regular diet, including:
  • fruits
  • vegetables
  • bran
  • beans
• Reduce the amount of processed food in your diet.
• Drink plenty of water and fluids every day.
• Exercise most, if not all, days of the week.
• Manage your stress with meditation or other relaxation techniques.

Rectal prolapse may be associated with several serious complications including:

• Ulcers. Ulcers in your rectum may cause bleeding and pain.
• Damage to the sphincter. Your sphincter is the ring-shaped muscle that opens and closes the anus, and if it is damaged the function may be affected.
• Bowel control issues. Rectal prolapse may lead to problems with bowel control, including fecal incontinence.
• Gangrene. If left untreated, rectal prolapse can cause strangulation of the rectum, cutting off the blood supply to the tissue, causing it to die, and leading to gangrene. This is a medical emergency requiring surgery.

The outlook is generally positive for someone undergoing rectal prolapse surgery. You’ll be on a diet of liquids and soft foods for a while, and you’ll need to take a stool softener at first. This is to prevent constipation or straining during a bowel movement.

The amount of time spent in the hospital after surgery depends on your health and the type of surgery you had. A full recovery can be expected in about 6 weeks.

Rectal prolapse is rare and can be uncomfortable and painful, but it’s treatable. The sooner you see a doctor about your symptoms, the easier the surgery and recovery will be.