Rectal Prolapse Overview

The term rectum refers tothe lowest 12-15 centimeters of the large intestine. The rectum is located just above the anal canal. Normally, the rectum is securely attached to the pelvis with the help ofligaments and muscles. This attachment firmly holds the rectum in place. Various factors, such as age, long-term constipation, and the stress of childbirth, may cause these ligaments and muscles to weaken, which means that the rectum's attachment to the body also weakens. This causes the rectum to prolapse, meaning it slips or falls out of place. Occasionally, large hemorrhoids (large, swollen veins inside the rectum) may predispose the rectum to prolapse.

Rectal prolapse issimilarto, but not the same as,rectocele,which is a common conditionin women. A rectocele is a prolapsed rectum that can result whenthe backside (or posterior) wall of the vagina prolapses.

In the early stages of rectal prolapse, the rectum becomes poorly attached but stays within the body most of the time. This stage of rectal prolapse is called mucosal prolapse, or partial prolapse, meaning that only the inner lining of the rectum (rectal mucosa) protrudes from the anus. This occurs when the connective tissues within the rectal mucosa loosen and stretch, allowing the tissue to protrude through the anus. When long-term hemorrhoidal disease is the cause, the condition usually does not progress to complete prolapse.Determining if the problem is hemorrhoids or rectal prolapse is important. Hemorrhoids occur commonly, but they rarely cause rectalprolapse.

As the rectum becomes more prolapsed, the ligaments and muscles may weaken to the point that a large portion of the rectum protrudes from the body through the anus. This stage is called complete prolapse, or full-thickness rectal prolapse, and is the most commonly recognized stage of the condition. Initially, the rectum may protrude and retract depending on the person's movements and activities. However, if the disease goes untreated, the rectum may protrude more frequently or even permanently.

Another condition commonly considered a form of prolapsed rectum is called internal intussusception. Its effects on the rectum are similar to those of mucosal prolapse or complete rectal prolapse; however, in internal intussusception, the rectum neither protrudes from the body nor enters the anal canal.

Rectal prolapse is an uncommon disease and primarily affects elderly people. The disease is rare among children. Affected children are usually younger than 3 years. Men develop rectal prolapse much less frequently than women do (80-90%). In the United States, 0.42% of the overall population have rectal prolapse. In people older than 65 years, the prevalence is 1%.

Rectal Prolapse Symptoms

  • The symptoms of a prolapsed rectum are similar to those of hemorrhoids; however, rectal prolapse originates higher in the body than hemorrhoids do. A person with a prolapsed rectum may feel tissue protruding from the anus and experience the following symptoms:

    • Pain during bowel movements

    • Mucus or blood discharge from the protruding tissue

    • Fecal incontinence (inability to control bowel movements)

    • Loss of urge to defecate (mostly with larger prolapses)

    • Awareness of something protruding upon wiping

  • Early in the development of a prolapsed rectum, the protrusion may occur during bowel movements and retract afterwards. The protrusion may become more frequent and appear when the person sneezes or coughs. Eventually, the protruding rectum may need to be manually replaced or may continually protrude.

  • People with internal intussusception, in which the rectum is displaced but does not protrude from the body, often experience difficulty with bowel movements and a sense of incomplete bowel movements.

 

Rectal Prolapse Causes

  • Rectal prolapse is caused by weakening of the ligaments and muscles that hold the rectum in place. In most people with a prolapsed rectum, the anal sphincter muscle is weak. The exact cause of this weakening is unknown; however, rectal prolapse is usually associated with the following conditions:


  • Long-term hemorrhoidal disease is frequently associated with mucosal prolapse thatdoes not progress to complete rectal prolapse.

 

When to Seek Medical Care

Almost all cases of rectal prolapse require medical care. Occasionally, successful treatment of the underlying cause of a prolapsed rectum resolves the problem. However, these scenarios usually involve infants or children. In most people, surgery is necessary to treat a prolapsed rectum.

 

Exams and Tests

To confirm the presence of a prolapsed rectum, the doctor may ask the person to sit on the toilet and strain. If the rectum does not protrude, the doctor may administer a phosphate enema to confirm the diagnosis. The main condition to distinguish rectal prolapse from is protruding or prolapsing hemorrhoids.

A defecogram (a test that evaluates bowel control) may help distinguish between a mucosal prolapse and a complete prolapse.

 

Rectal Prolapse Treatment

Many cases of rectal prolapse are caused by constipation or straining, but correcting these may not be enough to correct the prolapse. Most prolapsed rectums worsen without surgery.

 

Self-Care at Home

For infants and children, reducing the need to strain during bowel movements with stool softeners may correct a prolapsed rectum. Strapping the child's buttocks together between bowel movements may cause the rectum to heal on its own. A doctor should always be consulted before any attempt to treat this condition at home.

 

Medical Treatment

Medical treatment is normally used to ease the symptoms of a prolapsed rectum temporarily or to prepare the person for surgery. Bulking agents (such as bran or psyllium), stool softeners, and suppositories or enemas are used for these purposes.

 

Medications

Stool softeners, such as sodium docusate (Colace) or calcium docusate (Surfak), may be used to reduce pain and straining during bowel movements. Bulk agents, such as psyllium (Metamucil or Fiberall) or methylcellulose (Citrucel) may also be used.

 

Surgery

The goal of all of the surgical techniques involved in correcting a prolapsed rectum is to attach or secure the rectum to a backside (or posterior)part of the inner pelvis. Surgery is performed through either the abdomen or the perineum.

  • Surgery through the abdomen

    • Typically performed in younger or healthier people

    • Type of abdominal surgery usually determined by severity of associated constipation

    • Associated with higher morbidity rate than perineal approach but lower recurrence rate of prolapse

    • Performed under general anesthesia

    • Usually involves a hospital stay of 3-7 days

  • Perineal approach

    • Typically performed in elderly people or people in poor health

    • Approach for people who cannot tolerate general anesthesia

    • Associated with higherrecurrence rate than abdominal approach

    • Usually involves short hospital stay

For people too weak for surgery, a doctor can prevent a prolapse by inserting a wire or plastic loop to hold the sphincter closed.