Rectal Prolapse

What rectal prolapse is

The rectum is normally held in place in the pelvis by its attachments and supported by the pelvic floor muscles. When these supports weaken and the anal sphincter loosens, the rectum can telescope downward on itself and push out through the anus.

Types

• Full-thickness rectal prolapse (procidentia): the entire wall of the rectum protrudes. This is "true" rectal prolapse.
• Mucosal prolapse: only the inner lining slips out. Common in children and often confused with hemorrhoids.
• Internal prolapse (rectal intussusception): the rectum folds into itself but does not come out through the anus. It causes obstructed defecation and a feeling of incomplete emptying.

Symptoms

• A bulge or lump coming out of the anus, first only when straining, later on coughing, standing or walking, and eventually all the time
• A deep red, moist mass with concentric rings of folds
• Mucus discharge, which can stain underwear
• Rectal bleeding from the exposed lining
• Fecal incontinence in up to half to three-quarters of patients, as the sphincter is stretched
• Constipation, straining and a feeling of incomplete emptying
• Discomfort, aching or pressure in the rectum, and anal itching

Rectal prolapse vs hemorrhoids

Prolapsed hemorrhoids are much more common and are often mistaken for rectal prolapse, and vice versa.

A doctor can tell them apart by looking while you strain.

Causes and risk factors

• Female sex and age: about 80 to 90% of adult patients are women, most over 50
• Long-term straining: chronic constipation, or diarrhea
• Pelvic floor weakness: after childbirth, especially difficult vaginal deliveries; often associated with pelvic organ prolapse of the bladder or uterus
• Weak anal sphincter from aging, injury or nerve damage
• Previous pelvic or anal surgery
• Neurological conditions: spinal cord injury, multiple sclerosis, cauda equina damage
• Children: usually under 4, linked to constipation, diarrhea, malnutrition, intestinal parasites, and cystic fibrosis
• Psychiatric conditions and some medicines are associated in younger adult men

Diagnosis

1. History and examination: your doctor may ask you to sit on a toilet and strain to reproduce the prolapse, then examine the area and check sphincter tone.
2. Colonoscopy: to rule out a tumor or polyp acting as a lead point and to check the rest of the bowel.
3. Defecography: an X-ray or MRI that watches the rectum while you empty a contrast paste. It shows internal prolapse and associated pelvic floor problems.
4. Anorectal manometry and ultrasound: measure sphincter strength and look for damage.
5. Colonic transit studies if severe constipation is present.
6. Sweat test in children with prolapse, to check for cystic fibrosis.

Treatment

Non-surgical measures

• High-fiber diet, plenty of fluids and stool softeners to stop straining
• Not spending long periods on the toilet, and using a footstool to raise the knees
• Pelvic floor physical therapy and biofeedback, especially for incontinence or internal prolapse
• Gently pushing the prolapse back after bowel movements

These help symptoms and mild cases, but full-thickness prolapse in adults rarely resolves without surgery.

Surgery

Recovery after laparoscopic rectopexy usually takes 2 to 6 weeks. Recurrence occurs in a small proportion after abdominal repair and more often after perineal procedures. Bowel control often improves after repair, although constipation can persist and may need ongoing management.

Children

Most children's prolapse resolves by itself as the child grows and once constipation or diarrhea is treated. Surgery is rarely needed.

Complications

• Strangulation or ulceration of a prolapse that cannot be reduced
• Persistent incontinence
• Bleeding
• Recurrence after repair

Frequently asked questions

What does rectal prolapse look like?

It looks like a smooth, deep red or pink, moist, finger- or tube-shaped bulge coming from the anus, with circular folds around it. It may be small or several inches long. Hemorrhoids, by contrast, look like separate purple or red lumps with grooves running outward.

Can rectal prolapse heal on its own?

In young children, yes: most cases resolve once constipation or diarrhea is treated. In adults, a full-thickness rectal prolapse rarely improves without surgery and often slowly worsens. Avoiding straining and pelvic floor therapy can control symptoms in mild or internal prolapse.

Is rectal prolapse an emergency?

Usually not, if it goes back in. It becomes an emergency if the prolapse is stuck outside and turns dark red, purple or black, is very painful, or bleeds heavily, because the blood supply may be cut off. Seek emergency care in that situation.

How do you push a rectal prolapse back in?

Lie on your side or knees, put on a glove, apply lubricant or use a damp cloth, and press gently and steadily on the prolapse to ease it back inside. If it will not go back, seek care urgently.

What is the recovery time after rectal prolapse surgery?

After laparoscopic rectopexy, most people go home within a few days and return to light activities within 2 weeks and normal activities by about 6 weeks. Perineal operations involve a short hospital stay and similar recovery. Avoid heavy lifting and straining for several weeks.