Rectal Prolapse
Summary
Rectal Prolapse is the protrusion of all or part of the rectal wall through the anus. It exists on a spectrum from Mucosal Prolapse (Only the rectal mucosa prolapses – Often associated with haemorrhoids) to Full-Thickness Rectal Prolapse (Procidentia) – where the entire rectal wall, including the muscular layers, protrudes. Full-thickness prolapse is most common in elderly women (Peak incidence 70s) accounting for ~80-90% of cases in adults. Risk factors include chronic constipation, straining, multiparity, and pelvic floor weakness. Patients present with a mass protruding from the anus (Initially on defecation, later spontaneously), faecal incontinence (~50-75%), mucus discharge, and bleeding. Management is surgical for full-thickness prolapse, with two main approaches: Perineal procedures (Delorme, Altemeier – Preferred for elderly/Frail) and Abdominal procedures (Rectopexy – Laparoscopic/Open – Better recurrence rates but more invasive). [1,2,3]
Clinical Pearls
"Concentric Rings = Full-Thickness": On examination, Full-thickness rectal prolapse has concentric mucosal folds (Like tree rings). Mucosal prolapse has radial folds (Like spokes).
"Prolapse + Incontinence = Common": Up to 75% of patients with full-thickness prolapse have faecal incontinence (Due to stretch of anal sphincter).
"Elderly Women": The typical patient is an elderly female with chronic constipation and pelvic floor weakness.
"Perineal for Frail, Abdominal for Fit": Perineal procedures (Delorme, Altemeier) = Less invasive, Higher recurrence. Abdominal rectopexy = More invasive, Lower recurrence.
Demographics
| Factor | Notes |
|---|---|
| Age | Peak: 70s. Rare in children (Different pathophysiology). |
| Sex | Female > Male (6:1). Pelvic floor laxity from childbirth contributes. |
| Prevalence | ~2.5 per 100,000 population. |
Risk Factors
| Risk Factor | Notes |
|---|---|
| Chronic Constipation | Straining increases intra-abdominal pressure. |
| Multiparity | Pelvic floor weakness. |
| Advanced Age | Muscle weakness, Connective tissue laxity. |
| Previous Pelvic Surgery | Hysterectomy. |
| Neurological Conditions | Dementia, MS, Spinal cord injury. |
| Psychiatric Illness | Increased straining, Poor bowel habits. |
| Cystic Fibrosis (Children) | Rectal prolapse can be presenting feature. |
Types of Rectal Prolapse
| Type | Description | Features |
|---|---|---|
| Full-Thickness (External) Prolapse | Entire rectal wall (Mucosa + Muscular layers) protrudes through anus. | Concentric mucosal folds. Most common. Requires surgery. |
| Mucosal Prolapse | Only the mucosa protrudes. | Radial folds. Often associated with haemorrhoids. Treated conservatively or with banding/Haemorrhoidectomy. |
| Internal Prolapse (Intussusception) | Rectum intussuscepts into itself but does NOT protrude through anus. | Detected on defecating proctogram. May cause obstructed defecation. |
Distinguishing Features
| Feature | Mucosal Prolapse | Full-Thickness Prolapse |
|---|---|---|
| Mucosal Folds | Radial (Like spokes) | Concentric (Like tree rings) |
| Thickness | Thin | Thick (Full wall) |
| Sulcus Between Anus and Mass | No sulcus | Sulcus present (Gap between anal verge and rectum) |
| Palpation | Soft | Feels like two layers (Doubled wall) |
Anatomy
- Rectum: Last ~12-15cm of large bowel. Continuous with sigmoid colon proximally, Anal canal distally.
- Pelvic Floor (Levator Ani): Supports rectum.
- Anal Sphincters: Internal (Involuntary, Smooth muscle) and External (Voluntary, Skeletal muscle).
- Ligaments: Lateral ligaments, Sacral attachments normally fix rectum in place.
Pathophysiology
- Pelvic Floor Weakness: Lax levator ani and pelvic floor muscles.
- Loss of Rectal Attachments: Weakened ligaments.
- Deep Pouch of Douglas: Allows peritoneum and small bowel to push rectum downwards.
- Intussusception: Rectum begins to fold into itself (Internal prolapse).
- Progression: Internal prolapse → External prolapse through anus.
- Sphincter Stretch: Repeated prolapse stretches anal sphincter → Faecal incontinence.
Symptoms
| Symptom | Notes |
|---|---|
| Palpable Mass | "Something coming out of my back passage." Initially on straining/Defecation. Later, spontaneously or on standing. |
| Faecal Incontinence | ~50-75%. Due to sphincter stretch. May have mucus soiling. |
| Mucus Discharge | From exposed rectal mucosa. |
| Bleeding | From mucosal trauma. Usually minor. |
| Constipation / Obstructed Defecation | Especially with internal prolapse. Difficulty evacuating. |
| Tenesmus | Feeling of incomplete evacuation. |
Examination Findings
| Finding | Notes |
|---|---|
| Inspection at Rest | May be normal. Excessive perineal descent. |
| Inspection on Straining | Ask patient to strain (Valsalva). Full-thickness prolapse becomes visible. |
| Prolapse Characteristics | Concentric folds = Full-thickness. Sulcus between anus and prolapse. |
| Digital Rectal Exam | Assess sphincter tone (Often reduced). Rule out mass. |
| Perineal Descent | May be excessive on straining. |
Diagnosis
| Investigation | Notes |
|---|---|
| Clinical Examination | Usually sufficient. Ask patient to strain in left lateral or sitting on toilet. |
| Photographs | Patient may bring photos if prolapse is intermittent. |
| Defecating Proctogram / MR Defecography | Useful for internal prolapse (Intussusception). Assesses rectocele, Enterocele. |
| Colonoscopy / Flexible Sigmoidoscopy | Rule out colonic pathology (Especially if bleeding). Age-appropriate screening. |
| Anorectal Physiology (Manometry) | Assess sphincter function pre-operatively. Predicts postoperative continence. |
Management Algorithm
RECTAL PROLAPSE DIAGNOSED
(Mass protruding from anus, Concentric folds)
↓
CONFIRM TYPE
- Full-Thickness vs Mucosal
- Internal (Proctogram) vs External
↓
MUCOSAL PROLAPSE?
┌────────────────┴────────────────┐
YES NO (Full-Thickness)
↓ ↓
Conservative / Banding / SURGERY INDICATED
Haemorrhoidectomy ↓
↓
ASSESS FITNESS
┌────────────────┴────────────────┐
FRAIL / HIGH-RISK FIT / LOW-RISK
↓ ↓
PERINEAL PROCEDURE ABDOMINAL PROCEDURE
(Delorme, Altemeier) (Laparoscopic Rectopexy)
- Less invasive - Lower recurrence
- LA/Sedation possible - May improve continence
- Higher recurrence - More invasive
Conservative Management
| Indication | Notes |
|---|---|
| Mucosal Prolapse | Treat underlying cause (Haemorrhoids, Constipation). |
| Patient Not Fit for Any Surgery | Supportive care. Manual reduction. Prolapse support. |
| Lifestyle | High-fibre diet, Avoid straining, Stool softeners. |
Surgical Management
| Approach | Procedure | Notes |
|---|---|---|
| PERINEAL | ||
| Delorme Procedure | Mucosectomy + Plication of muscle. Good for short prolapses. Lower recurrence than Thiersch. | |
| Altemeier Procedure (Perineal Rectosigmoidectomy) | Full-thickness excision of prolapsed bowel + Anastomosis. Higher recurrence than abdominal. Suitable for frail patients. | |
| Thiersch Procedure | Encircling suture/Band around anus. Rarely done now. High recurrence. | |
| ABDOMINAL | ||
| Laparoscopic Ventral Mesh Rectopexy (LVMR) | Mesh placed anteriorly to rectum, Fixed to sacral promontory. Becoming gold standard. Low recurrence. May improve continence. | |
| Suture Rectopexy | Rectum fixed to sacrum with sutures (No mesh). Lower recurrence than perineal. Avoids mesh complications. | |
| Resection Rectopexy | Rectopexy + Sigmoid resection. For those with significant constipation. Risk of anastomotic leak. |
Choice of Procedure
| Factor | Perineal | Abdominal |
|---|---|---|
| Patient Fitness | Frail, Multiple comorbidities | Fit, Low-risk |
| Anaesthesia | LA/Spinal | General |
| Recurrence Rate | Higher (~10-30%) | Lower (~5-10%) |
| Postoperative Recovery | Faster | Longer |
| Effect on Continence | Variable | May improve (Especially LVMR) |
Prolapse Complications
| Complication | Notes |
|---|---|
| Incarceration | Prolapse cannot be reduced. Oedematous. |
| Strangulation | Blood supply compromised. Ischaemic bowel. Emergency. |
| Ulceration / Bleeding | From mucosal trauma. |
| Faecal Incontinence | Progressive. From sphincter stretch. |
Surgical Complications
| Complication | Notes |
|---|---|
| Recurrence | Higher with perineal procedures. |
| Constipation | Can worsen after rectopexy (Especially posterior mesh). |
| Mesh Complications (LVMR) | Erosion, Infection. Rare. |
| Anastomotic Leak | With Altemeier/Resection rectopexy. |
| Pelvic Sepsis | Rare. Serious. |
| Factor | Notes |
|---|---|
| Recurrence | Perineal: 10-30%. Abdominal: 5-10%. |
| Continence | May improve after surgery (Especially LVMR). Some have persisting incontinence. |
| Quality of Life | Significantly improved after successful surgery. |
| Untreated | Progressive. Worsening prolapse and incontinence. |
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Rectal Prolapse | ACPGBI | Abdominal rectopexy for fit patients. Perineal for frail. |
| Pelvic Floor Disorders | NICE | MDT approach. Consider associated pathology (Cystocele, Uterine prolapse). |
Evidence Points
- LVMR (Laparoscopic Ventral Mesh Rectopexy): Low recurrence. Improved functional outcomes. Now widely preferred abdominal procedure.
- Mesh Concerns: Ventral mesh (Anterior to rectum) has lower erosion risk than posterior mesh.
What is Rectal Prolapse?
Rectal prolapse means that part or all of the wall of your rectum (The last part of your bowel) slides out through your back passage (Anus). It can look like a large lump coming out, especially when you strain.
What causes it?
It is caused by weakness of the muscles and ligaments that normally hold your rectum in place. Risk factors include:
- Chronic constipation and straining.
- Having had children (Weakens pelvic floor).
- Getting older.
What are the symptoms?
- A lump or mass coming out of your back passage (Especially when opening bowels).
- Leakage of mucus or stool (Faecal incontinence).
- Bleeding.
- Difficulty emptying your bowels.
What is the treatment?
Surgery is the main treatment for full-thickness prolapse. Options include:
- Perineal surgery: Done through the bottom. Less invasive. Suitable for frail patients.
- Keyhole abdominal surgery: The rectum is stitched or secured in place with mesh. Lower chance of it coming back.
Your surgeon will discuss which is best for you based on your overall health.
Can it come back?
Yes, There is a chance of recurrence (5-30% depending on the operation). Keeping your bowels regular and avoiding straining helps.
Primary Sources
- Titokowicz A, et al. Rectal prolapse: diagnosis and clinical management. Colorectal Dis. 2017;19(6):515-522. PMID: 28346789.
- D'Hoore A, et al. Laparoscopic ventral mesh rectopexy for rectal prolapse and obstructed defaecation. Colorectal Dis. 2006;8(8):654-660. PMID: 16970576.
- Bordeianou L, et al. Rectal prolapse: an overview of clinical features, diagnosis, and patient-specific management strategies. J Gastrointest Surg. 2014;18(6):1059-1069. PMID: 24668398.
Common Exam Questions
- Mucosal Folds: "How do you distinguish Full-Thickness Prolapse from Mucosal Prolapse?"
- Answer: Full-thickness = Concentric folds (Tree rings). Mucosal = Radial folds (Spokes).
- Typical Patient: "Describe the typical patient with full-thickness rectal prolapse."
- Answer: Elderly female with history of chronic constipation and pelvic floor weakness.
- Perineal Procedures: "Name two perineal procedures for rectal prolapse."
- Answer: Delorme Procedure (Mucosectomy + Plication), Altemeier Procedure (Perineal rectosigmoidectomy).
- Procedure for Fit Patient: "What is the preferred procedure for a fit patient?"
- Answer: Laparoscopic Ventral Mesh Rectopexy (LVMR).
Viva Points
- Sulcus Sign: Palpable sulcus between the anal verge and the prolapse = Full-thickness.
- Faecal Incontinence: Common (50-75%) due to chronic sphincter stretch.
- MR Defecography: For internal prolapse (Intussusception) and associated pathology.
- LVMR: Low recurrence, Improved continence, Preferred abdominal procedure.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.