Rectal Prolapse

WHAT IS RECTAL PROLAPSE?

Rectal prolapse is a condition in which the rectum (the last part of the large intestine before it exits the anus) loses its normal attachments inside the body, allowing it to telescope out through the anus, thereby turning it “inside out.” While this may be uncomfortable, it rarely results in an emergent medical problem. However, it can be quite embarrassing and often has a significant negative impact on patients’ quality of life.
 
Overall, rectal prolapse affects relatively few people (about 0.5% of the general population). This condition affects mostly adults, and women 50 years and older are six times as likely as men to develop rectal prolapse. While few men develop prolapse, those who do are much younger, averaging 40 years of age or less. In younger patients, there is higher rate of defecation disorders, autism, developmental delay, and psychiatric problems requiring multiple medications. Definitive treatment of rectal prolapse requires surgery.

CAUSES

While several factors are thought to be linked to rectal prolapse, there is no clear cut “cause.” An estimated 30% to 67% of patients have chronic constipation (infrequent stools or severe straining) and an additional 15% have diarrhea. In the past, this condition was assumed to be linked to giving birth multiple times by vaginal delivery. However, as many as 35% of patients with rectal prolapse never gave birth and it can occur in men. There might be some genetic predisposition to this condition; in other words: some patients are more prone based on their genes to develop this condition while others don’t.

SYMPTOMS

A common question is whether hemorrhoids and rectal prolapse are the same. Bleeding and/or tissue that protrudes from the rectum are common symptoms of both, but there is a major difference. Rectal prolapse involves an entire segment of the bowel located higher up within the body. Hemorrhoids involve only the inner layer of the bowel near the anal opening.
 
Rectal prolapse tends to develop gradually. Initially, the prolapse can come out after a bowel movement (BM), then return to its normal position. As the problem worsens, the protrusion may need to be pushed back in. For some people, it might stay outside and cause a sensation of “sitting on a ball.”

 

A = Rectal Prolapse                      B = Hemorrhoids

About half of the patients with rectal prolapse may also have constipation. The prolapse itself can worsen constipation by blocking stool from passing easily. As the prolapse worsens, it may even contribute to fecal incontinence (not being able to fully control gas or bowel movements). It is not unusual for some patients to note bouts of both constipation and incontinence as well.
 
Over time, the lining of the protruding rectum may become thickened and inflamed, leading to seepage of fluid, mucus, and sometimes significant bleeding. The prolapsed tissue can become stuck or “incarcerated” outside of the anus. This can lead to a serious condition in which the circulation of blood to the rectum diminishes or even stops, requiring emergency surgery.

DIAGNOSIS

During the first visit, your colon and rectal surgeon will perform a thorough medical history and anorectal examination. The surgeon will likely ask about bowel habits, constipation, fecal incontinence, urinary symptoms or bulging sensations in the vagina or perineum.
 
The surgeon will examine the anorectal area. You may be asked to squeeze and relax the anal sphincter muscles while the doctor is palpating the anal canal. This helps the doctor get a sense of how well the anal sphincter is functioning. 
 
If the prolapse is not visible while you are on the examination table, you may be asked to sit on a toilet and strain as if you are having a bowel movement. It is important for the surgeon to see the prolapsed tissue in order to distinguish between prolapsed hemorrhoids versus rectal prolapse, since the treatment of these conditions is very different. Some patients bring in photos of the prolapsed rectum which they have taken at home, since it may be uncomfortable or not possible to show the surgeon the extent or severity of the prolapse in an office setting.
 
In some cases, a rectal prolapse may be "hidden" or internal, making diagnosis more difficult. Your doctor may request additional testing for diagnosis. These may include:

  • Defecography: This is a study in which the patient is given an enema to simulate having a bowel movement, and then pictures are taken using an X-ray or MRI machine. This shows the motion of the pelvic organs and muscles during a bowel movement. Defecography may also show other problems related to the pelvic floor. These should be addressed by a urogynecologist (a specialist of the urinary and reproductive organs) when planning the appropriate mode of treatment. Sometimes, fixing rectal prolapse can cause other pelvic floor problems to worsen if they are not simultaneously dealt with.
  • Anorectal Manometry: A small probe is inserted into the rectum to test and measure muscle functions and reflexes of the pelvis, rectum and anus used during bowel movements. 
  • Colonic transit study (“Sitzmark” test): Patients with rectal prolapse in the setting of lifelong constipation may be asked to undergo a transit study to evaluate their colon’s ability to evacuate stool. This involves swallowing a capsule containing multiple markers that can be seen on an abdominal x-ray. Several x-rays are then taken over a five-day period to see how the markers move through the small intestine and colon, referred to as “transit time.” Patients found to have unusually long transit times may benefit from having some or, less likely all, of their colon removed at the time of the repair of their rectal prolapse.
  • Colonoscopy: Colonoscopy is a procedure where a long, flexible, tubular instrument called a colonoscope is used to look at the entire inner lining of the colon (large intestine) and the rectum. This will often be necessary to rule out any associated polyps or cancer prior to treatment for rectal prolapse. 

 

TREATMENT

If left untreated, rectal prolapse does not turn into cancer. But, the amount of prolapsing tissue will likely increase over time. Although constipation and straining play a role in this condition, correcting this may not improve an existing rectal prolapse. The prolapse events may occur more easily, such as with standing rather than just after having a BM. The risk of permanent or worsening fecal incontinence increases with time as well, due to stretching of the anal sphincter muscle and risk of nerve damage. The length of time that these changes will occur is widely variable and differs from person to person.
 
There are several methods used to surgically repair rectal prolapse. Generally speaking, rectal prolapse can be repaired either through the abdomen, or from the bottom (by operating on the perineal side). Options include removing part of the rectum, or pulling the rectum back up and anchoring it. Sometimes mesh is used to reinforce the rectum.
 
The optimal treatment depends on the size of the prolapse and the patient’s overall health. An abdominal approach offers the best chance for a long-term successful repair of rectal prolapse, provided the patient is medically fit for surgery. Operations from the perineal side are often reserved for elderly or frail patients, or those with very severe medical conditions that limit options for anesthesia during surgery.


ABDOMINAL APPROACHES

ABDOMINAL RECTOPEXY WITH POSSIBLE BOWEL RESECTION:

For rectal prolapse repair through the abdomen, the surgeon might make an incision in the lower abdomen, or use minimally invasive techniques such as laparoscopy or robotic-assisted surgery. This entails placing a camera and surgical instruments through small incisions to perform the surgery, which is called a rectopexy.
 

VENTRAL-RECTOPEXY.png

The rectum is dissected free from the sides of the pelvis, pulled upwards, then secured to the sacrum (back wall of the pelvis). Depending on the surgeon’s preference, the rectum may be sutured directly to the sacrum with stitches or a prosthetic material (mesh) may be included. Regardless of the specific technique used, the intent is to hold the rectum in the appropriate position until the body heals and scar tissue forms, securing the rectum in place. Overall, the result of this approach is very good, with less than 10% of patients experiencing a return of the prolapse. For patients with a long history of constipation, the surgeon may recommend removal of a portion of the colon during this operation in order to improve their bowel function.
 
It is important to note that although the prolapse can be fixed, the function (incontinence or constipation) may not always improve. In a small number of cases, a potential complication of abdominal rectopexy is the development of new or worsened constipation. Following abdominal rectopexy, 15% of patients will develop constipation for the first time and at least half of those who were constipated prior to surgery are made worse. Fiber, fluids, and stool softeners may be needed to ease constipation following rectal prolapse repairs of any type. Occasionally, mild laxatives may be needed temporarily after surgery.  Sexual dysfunction may be reported in some patients following the extensive pelvic dissection involved in this surgery.

PERINEAL APPROACHES

The choice to undergo a perineal approach to repair of rectal prolapse depends upon a number of factors, but these patients tend to be older, with more serious medical problems, or are undergoing emergency surgery for incarcerated prolapse (where the rectum is “stuck” on the outside) with worsening damage to the rectum.
 
The most common perineal approach is the perineal rectosigmoidectomy or “Altemeier” procedure, named after the surgeon who popularized this operation. During surgery, the prolapsed rectum is pulled down and out of the body, then removed. The remaining colon is then sewn or stapled to the anus. This surgery can be performed without general anesthesia and it is associated with less post-operative pain and a shorter hospital stay. However, the risk of recurrence can be as high as up to 30%.
 
Complications include bleeding, infection, or leakage of stool through the reconnected area and into the pelvis. Some patients experience worsening fecal incontinence afterward, so some surgeons recommend tightening the pelvic floor muscles with sutures (levatoroplasty) at the time of this surgery.


ALT-PROCEDURE-8.pngALT-PROCEDURE-10.pngALT-PROCEDURE.png



ALT-PROCEDURE-7.png














ALT-PROCEDURE-11.pngALT-PROCEDURE-12.png






 









A less commonly performed perineal procedure is the mucosal sleeve resection (“Delorme” procedure). Rather than remove the prolapsing rectum, the inner lining of the rectum is stripped away and then the muscles of the rectum are folded and sewn onto themselves to reduce the prolapse. This particular procedure may be recommended in the setting of a small prolapse, or if the prolapse involves part, but not all, of the circumference of the rectum. Incontinence is improved in 40-50% of patients after this procedure. The recurrence rate is generally quoted as 10-15%, which is higher than the abdominal approaches.

Delorme-2.pngDelorme-3.pngDelorme-4.pngDelorme-5-7.png
























 

Complications specific to the Delorme procedure included bleeding, leakage of the sewn connection, and narrowing of the anal opening (stricture). Prolapse can return in up to 26% of patients, and is generally felt to be higher than with perineal rectosigmoidectomy.


PROGNOSIS

For a large majority of patients, surgery relieves or greatly improves symptoms. Prolapse or some other condition may have weakened the anal sphincter muscles. However, these muscles have the potential to regain strength after the prolapse has been corrected.
 
Factors that influence outcome after surgery include the condition of the anal sphincter muscles before surgery, whether the prolapse is internal (intussusception) or external, the length of time that the patient has experienced symptoms, and the overall health of the patient. It may take as long as one year to determine the impact of surgery on bowel function. Chronic constipation and straining after surgical correction should be avoided.

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board-certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

DISCLAIMER

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention and management of disorders and diseases of the colon, rectum and anus. These brochures are inclusive but not prescriptive. Their purpose is to provide information on diseases and processes, rather than dictate a specific form of treatment. They are intended for the use of all practitioners, health care workers and patients who desire information about the management of the conditions addressed. It should be recognized that these brochures should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtain the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.

ASCRS committee members review and update information for accuracy.  We believe content is medically accurate at the time it was produced.

CITATIONS

Gurland B, Zutshi M. Chapter 60, “Rectal Prolapse”. Chapter in Steele SR, Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow CB, Eds. The ASCRS Textbook of Colon and Rectal Surgery, 3rd edition. Springer, New York, NY; 2016.
 
Bordeianou L, Paquette I, Johnson E, et al. Clinical Practice Guidelines for the Treatment of Rectal Prolapse. Dis Colon Rectum 2017;60(11):1121-1131
 
ASCRS textbook chapter on rectal prolapse 

 



Filter by Language:

Colorectal Cancer Risk Colorectal cancer—cancer of the colon and rectum—is the second leading cancer killer in the United States affecting both men and women.  Your risk increases as you age.  Some people are at even higher risk depending on their personal or family history....
Following treatment for either colon or rectal cancer, ongoing follow-up to detect recurrent disease is considered an important part of patient care for colorectal cancer. Colorectal cancer follow-up refers to a systematic approach to monitoring patients for new or recurr...
  Enhanced recovery after surgery, known as ERAS is a multimodal approach to surgical care that has been shown to improve recovery after surgery, especially in patients undergoing colorectal surgical bowel resections. Patients typically experience less pain, faster reco...
Irritable bowel syndrome (IBS) is a common disorder affecting over 15 percent of the population. The following information has been prepared to help patients and their families understand IBS, including the symptoms, causes, evaluation, and treatment options. IBS is one ...
OVERVIEW There are a variety of diseases and conditions of the colon and rectum for which surgery is recommended.  In addition to the decision to undergo surgery, patients are often faced with a choice of traditional or minimally invasive surgical techniques.  In order t...
Obstructed Defecation Syndrome (ODS)
WHAT IS HPV? HPV stands for human papillomavirus. HPV is a collection of 150 related viruses that can cause a variety of different problems of the genital and anal skin. It is the most common sexually transmitted infection (STI) and can cause genital and anal warts, a pr...
A rectocele is a bulging of the front wall of the rectum into the back wall of the vagina. The rectum is the bottom section of your colon (large intestine). This is a very common problem that often does not produce symptoms. Other pelvic organs can bulge into the vagina, incl...
WHAT ARE ANAL WARTS? Anal warts (also called "condyloma acuminata") are a condition that affects the area around and inside the anus. They may also affect the skin of the genital area. They first appear as tiny spots or growths, perhaps as small as the head of a pin, and may...
WHAT IS A RECTOCELE? A rectocele is a herniation (bulge) of the front wall of the rectum into the back wall of the vagina. The tissue between the rectum and the vagina is known as the rectovaginal septum and this structure can become thin and weak over time, resulting in a r...
Laparoscopic or “minimally invasive” surgery is a specialized technique for performing surgery. In the past, this technique was commonly used for gynecologic surgery and for gall bladder surgery. Over the last 10 years the use of this technique has expanded into intestinal s...
  Pelvic floor dysfunction is a group of disorders that change the way people have bowel movements and sometimes cause pelvic pain. These disorders can be embarrassing to discuss, may be hard to diagnosis and often have a negative effect on quality of life. Symptoms vary...
Pelvic floor dysfunction includes a group of disorders causing abnormalities of bowel storage and bowel emptying, as well as pelvic pain.   This information is intended to help patients gain a better understanding of the disorders making up pelvic floor dysfunction, as we...
Pruritis ani is a common medical problem affecting both men and women. This information was composed to help patients understand pruritis ani, its symptoms, evaluation, and treatment options.  This information may also be helpful to individuals or caregivers of patients w...
  OVERVIEW Anal cancer is an abnormal growth of cells in or around the anus or anal canal which is the short passage through which bowel movements pass. The most common type of cancer found in this location is believed to be related to a type of viral infection known as...
Anal warts (condyloma acuminata) are caused by the human papilloma virus (HPV), the most common sexually transmitted disease (STD). The warts affect the area around and inside the anus, but may also develop on the skin of the genital area. They first appear as tiny spots ...
WHY IS IT SO IMPORTANT? Colorectal cancer — cancer of the colon and rectum — is the second leading cause of cancer-related deaths in the United States. It surpasses both breast cancer and prostate cancer in mortality when both men and women are combined. The general populati...
WHY SHOULD THERE BE A POSTOPERATIVE FOLLOW-UP PROGRAM? Surgery is a highly effective treatment for colorectal cancer. But even when all visible cancer has been removed, it is possible that small clusters of cancer cells may be present in other areas of the body. These ca...
There are many myths surrounding colon cancer, and the following information helps to set the record straight. If you are concerned about colon cancer, or if you have a strong family history of colorectal cancer, you should ask your doctor if you need to see a colorectal ...
Colorectal Cancer Awareness Month March is Colorectal Cancer Awareness Month, and it is a great time to learn more about colorectal cancer. Here are some of the most frequently asked questions, and please ask your healthcare provider if you have additional questions.  What ...
WHAT IS CONSTIPATION Constipation is a common complaint and usually simple to prevent and easy to treat when it occurs. In some cases, constipation may reflect a more serious problem that will require the help of your medical provider to suggest tests, medical interventi...
Diverticular disease is the general name for a common condition that involves small bulges or sacs called diverticula that form from the wall of the large intestine (colon). Although these sacs can form  throughout the colon, they are most commonly found in the sigmoid c...
WHAT IS FECAL INCONTINENCE? Fecal incontinence (also called anal or bowel incontinence) is the impaired ability to control the passage of gas or stool. This is a common problem, but often not discussed due to embarrassment. Failure to seek treatment can result in social ...
THE ROLE OF GENETICS Genes are inherited from each parent. They determine various physical features and may predispose people to certain diseases. All cancers, but especially colon and rectal cancers, commonly referred to as colorectal cancer (CRC), have hereditary facto...
  Constipation is a very common complaint affecting upwards of 15% of all Americans.  Fortunately, constipation is usually is easy to avoid and easy to treat when it occurs. Occasionally, symptoms of constipation may be a sign of a more serious problem requiring medical ...
OVERVIEW Colorectal cancer is a common malignancy for both men and women.  Screening for colorectal cancer is the process of identifying apparently healthy people who may be at increased risk of developing this disease. This information was prepared to help patients unde...
WHAT IS THE RISK OF COLORECTAL CANCER? Colorectal cancer is the third most common non-skin cancer, affecting men and women of all ethnic groups. Over 140,000 people will be diagnosed with colorectal cancer each year and more than 50,000 will die; the lifetime risk is 1 i...
Get regular colorectal cancer screenings beginning at age 45.* If you have a personal or family history of colorectal cancer or colorectal polyps, or a personal history of another cancer or inflammatory bowel disease, talk to your doctor about earlier screening. Eat plen...
Screening tests for colorectal cancer can save 30,000 lives each year. These tests not only detect colorectal cancer early, but can prevent colorectal cancer. In one test, non-cancerous polyps are removed before they become cancer. When you turn 45* years of age you should ha...
WHAT IS THE COLON? The colon is also known as the large bowel or large intestine. It is an organ that is part of the digestive system (also called the digestive tract) in the human body. The digestive system is the group of organs that allow us to eat and to use the food we ...
WHAT IS ULCERATIVE COLITIS? Ulcerative colitis (UC) is an inflammatory disease affecting the large bowel (colon and rectum). In UC, the inflammation is confined to the internal lining of the intestinal wall (mucosa). Medical management is typically the first option for t...
OVERVIEW The purpose of this education piece is to provide information on the background, causes, and treatments of diverticular disease and its complications. This information is  intended for a general audience. Diverticular disease most commonly affects adults and may...
OVERVIEW The purpose of this patient education piece is to provide providers, patients and their families with information on the background, causes, and treatments of fecal incontinence.   WHAT IS FECAL INCONTINENCE? Fecal incontinence is the impaired ability to contr...
THE ROLE OF GENETICS Genes are made up of DNA. They are the basic units inside a cell by which we inherit traits from our ancestors and pass down traits to our children. Our genetic information, found in our DNA, determines much about us: for example, our eye and hair co...
OVERVIEW An ostomy is a surgically created opening between an internal organ and the body surface. Ostomies are often created as a part of intestinal surgery when there must be a new way for intestinal waste to leave the body.  This information was prepared to help patie...
Colorectal cancer — cancer of the colon and rectum — is the second leading cancer killer in the United States and all women and men aged 45 and older are at increased risk. The good news is that colorectal cancer is preventable and, if detected early, curable.    Dependin...
Pilonidal disease is a chronic skin infection in the crease of the buttocks near the coccyx (tailbone). It affects about 70,000 people in the US annually and is more common in men than women. Most often it occurs between puberty and age 40. People who are overweight and w...
OVERVIEW Crohn's disease is a chronic inflammatory disease of unknown origin potentially affecting all parts of the gastrointestinal tract. While medical management of the disease is often the first choice, surgery may be indicated for specific reasons. Crohn's disease m...
Colon cancer is a common malignancy in the United States. The treatment of patients with colon cancer can be complicated and may require a team of surgical and medical specialists. This review provides general information for patients and their families, covering colon ca...
WHAT IS RECTAL CANCER? The rectum is the last six inches of the large intestine which is composed of the colon and rectum. Colon and rectal cancers both arise from the inner lining. Despite the similarities, colon and rectal cancers are treated differently due to differenc...
  WHAT IS COLONOSCOPY? Colonoscopy is an effective procedure to diagnose abnormalities of the large intestine and to screen for colorectal cancer and colorectal polyps. A colonoscope is a long, thin flexible instrument that provides magnified views of the colon and rectum...
Anal pain can occur before, during, or after a bowel movement. It can range from a mild ache that can get worse over time to pain that is bad enough to restrict daily activities. Anal pain has many causes, most of which are common and treatable. However, if anal pain does not...
Colorectal polyps are commonly found during standard screening exams of the colon (large intestine) and rectum (the bottom section of your colon). They affect about 20% to 30% of American adults. Polyps are abnormal growths that start in the inner lining of the colon or rec...
Pruritis ani means “itchy anus” in Latin. This condition causes irritation of the skin near the anus, resulting in a strong urge to scratch the area. In many cases, no specific problem is found to explain the itching. These cases are called “idiopathic” (from unknown caus...
WHAT IS RECTAL PROLAPSE? Rectal prolapse is a condition in which the rectum (the last part of the large intestine before it exits the anus) loses its normal attachments inside the body, allowing it to telescope out through the anus, thereby turning it “inside out.” While thi...
Irritable bowel syndrome (IBS) is a common disorder, affecting an estimated 15% of the population. It is one of the several conditions known as functional gastrointestinal disorders. This means the bowel may function abnormally, but tests are normal and there are no detec...
  MINIMALLY INVASIVE SURGERY Many diseases and conditions of the colon and rectum are treated surgically. A surgeon may use traditional (open) or minimally invasive techniques depending on the individual case. Minimally invasive colon and rectal surgery is a continually...
The anal canal is a short tube surrounded by muscle at the end of your rectum. The rectum is the bottom section of your colon (large intestine). When you have a bowel movement, stool leaves your body from the rectum through the anal canal. Cancer begins when some of the b...
Often described as "varicose veins of the anus and rectum,” hemorrhoids are enlarged, bulging blood vessels in and around the anus and lower rectum. The rectum is the bottom section of your colon (large intestine). The tissues supporting the vessels stretch. As a result, ...
WHAT ARE HEMORRHOIDS? It is important to note that all people have hemorrhoidal tissue as part of their normal anatomy. Only in a minority of people do hemorrhoids become enlarged or otherwise symptomatic. Hemorrhoidal tissue lies within the anal canal and perianal area ...
The anal canal is a short tube surrounded by muscle at the end of your rectum. The rectum is the bottom section of your colon (large intestine). An anal fissure is a small rip or tear in the lining of the anal canal. Fissures are common, but are often confused with other ...
  WHAT IS AN ANAL FISSURE? An anal fissure is a small tear in skin that lines the opening of the anus. Fissures typically cause severe pain and bleeding with bowel movements.  Fissures are quite common in the general population, but are often confused with other causes ...
ANAL ABSCESS AND FISTULA An anal abscess is an infected cavity filled with pus near the anus or rectum.  An anal fistula (also called fistula-in-ano) is a small tunnel that tracks from an opening inside the anal canal to an outside opening in the skin near the anus. ...
WHAT IS AN ANAL ABSCESS OR FISTULA? An anal abscess is an infected cavity filled with pus found near the anus or rectum.  Ninety percent of abscesses are the result of an acute infection in the internal glands of the anus. Occasionally, bacteria, fecal material or foreig...