What is rectal prolapse?
Rectal prolapse occurs when the rectum (the last
section of the large intestine) falls from its normal position within the pelvic
area. (The word "prolapse" means a falling down or slipping of a body part from
its usual position.)
The term "rectal prolapse" can describe three types of prolapse:
- the entire rectum extends out of the anus
- only a portion of the rectal lining is pushed through the anus
- the rectum starts to drop down but does not extend out the anus
Rectal prolapse is common in older adults with a
long-term history of constipation or a weakness in the pelvic floor muscles. It
is more common in women than in men and even more common in women over the age
of 50 (postmenopausal women) but occurs in younger people too. Rectal prolapse
can also occur in infants – which could be a sign of cystic fibrosis – and in older children.
What are the symptoms of rectal prolapse?
The symptoms of rectal prolapse include the feeling of
a bulge or the appearance of reddish-colored mass that extends outside the anus.
At first, this can occur during or after bowel movements and is a temporary
condition. However, over time – due to an ordinary amount of standing and
walking – the end of the rectum may extend out of the anal canal and needs to be
pushed back up into the anus by hand.
Other symptoms of rectal prolapse include pain in the
anus and rectum and rectal bleeding from the inner lining of the rectum. These
are rarely life threatening symptoms. Fecal incontinence is another symptom.
Fecal incontinence refers to leakage of mucus, blood or stool from the anus.
This occurs as a result of the rectum stretching the anal muscle. Symptoms
change as the rectal prolapse itself progresses.
What causes rectal prolapse?
Rectal prolapse can occur as a result of many conditions, including:
- Chronic constipation or chronic diarrhea.
- Long-term history of straining during bowel movements.
- Older age. Muscles and ligaments in the rectum and anus naturally
weaken with age. Other nearby structures in the pelvis area also loosen with
age, which adds to the general weakness in that area of the body.
- Weakening of the anal sphincter. This is the specific muscle that
controls the release of stool from the rectum.
- Prior injury to the anal or pelvic areas.
- Damage to nerves. If the nerves that control the ability of the
rectum and anus muscles to contract are damaged, rectal prolapse can result.
Nerve damage can be caused by pregnancy, difficult vaginal childbirth, anal
sphincter paralysis, spinal injury, back injury/back surgery, and/or other
surgeries of the pelvic area.
- Other diseases, conditions, and infections. Rectal prolapse can be a
consequence of diabetes, cystic fibrosis, chronic obstructive pulmonary
disease, hysterectomy, and infections in the intestines caused by parasites
– such as pinworms and whipworms – and diseases resulting from poor
nutrition or from difficulty digesting foods.
Is rectal prolapse just another name for hemorrhoids?
No. Rectal prolapse results from a sagging of the last
portion of the large intestine. Hemorrhoids are swollen blood vessels that
develop in the anus and lower rectum. Hemorrhoids can produce anal itching and
pain, discomfort, and bright red blood on toilet tissue. Early rectal prolapse
can mimic internal hemorrhoids that have slipped out of the anus (ie,
prolapsed), making it difficult to tell these two conditions apart.
How is rectal prolapse diagnosed?
First, your doctor will take your medical history and
will perform a rectal exam. You may be asked to "strain" while sitting on a
commode to mimic an actual bowel movement. Being able to see the prolapse helps
your doctor confirm the diagnosis and plan treatment.
Other conditions are could be present along with
rectal prolapse such as urinary incontinence, bladder prolapse and
vaginal/uterine prolapse. Because of the variety of potential problems,
urologists, urogynecologists and other specialists are often team together to
share evaluations and make joint treatment decisions. In this way, surgeries to
repair any combination of these problems can be done at the same time.
There are several tests doctors can use to diagnose
rectal prolapse and other pelvic floor problems. Tests used to evaluate and make
treatment decisions include:
- Anal electromyography (EMG) – This test determines if nerve damage
is the reason why the anal sphincters are not working properly. It also
examines the coordination between the rectum and anal muscles.
- Anal manometry – This test studies the strength of the anal
sphincter muscles. A short, thin tube, inserted up into the anus and
rectum, is used to measure the sphincter tightness.
- Anal ultrasound – This test helps evaluate the shape and structure
of the anal sphincter muscles and surrounding tissue. In this test, a small
probe is inserted up into the anus and rectum to take images of the sphincters.
- Pudendal nerve terminal motor latency test – This test measures the
function of the pudendal nerves, which are involved in bowel control.
- Proctography (also called defecography) – This test is done in the
radiology department. In this test, an X-ray video is taken that shows how
well the rectum is functioning. The video shows how much stool the rectum
can hold, how well the rectum holds the stool, and how well the rectum releases the stool.
- Colonoscopy – This is an exam of the colon or large bowel. A
flexible tube with a camera is passed through the anus upwards to where the
large intestine joins the small intestine. This helps provide visual clues
as to the source of the problem.
- Proctosigmoidoscopy – This test allows the lining of the lower
portion of the colon to be viewed, looking for any abnormalities -- such as
inflammation, tumor, or scar tissue. To perform this test, a flexible tube
with a camera attached at the end is inserted into the rectum up to the sigmoid colon.
- Magnetic resonance imaging (MRI) – This test is done in the
radiology department. It is sometimes used to evaluate the pelvic organs.
How is rectal prolapse treated?
In some cases of very minor, early prolapse, treatment
can begin at home with the use of stool softeners and by pushing the fallen
tissue back up into the anus by hand. However, surgery is usually necessary to
repair the prolapse. There are several surgical approaches. The surgeon’s choice
depends on patient’s age, other existing health problems, the extent of the
prolapse, results of the exam and other tests, and the surgeon’s preference and
experience with certain techniques.
Abdominal and rectal (also called perineal) surgery are the two most common approaches to rectal prolapse repair.
Abdominal repair approaches
Abdominal procedure refers to making an incision in
the abdominal muscles to view and operate in the abdominal cavity. It is usually
performed under general anesthesia and is the approach most often used in
healthy adults. The two most common types of abdominal repair are rectopexy
(fixation [reattachment] of the rectum) and resection (removal of a segment of
intestine) followed by rectopexy. Resection is preferred for patients with
severe constipation. Rectopexy can also be performed laparoscopically through
small key-hole incisions or robotically.
Rectal (perineal) repair approaches
Rectal procedures are often used in older patients and
in patients with more medical problem. Spinal anesthesia or an epidural may be
used instead of general anesthesia in these patients. The two most common rectal
approaches are the Altemeier and Delorme procedures.
- Altemeier procedure. In this procedure -- also called a perineal
proctosigmoidectomy – the portion of the rectum extending out of the anus is
cut off (amputated) and the two ends are sewn back together. The remaining
structures that help support the rectum are stitched back together in an
attempt to provide better support.
- Delorme procedure. In this procedure, only the inner lining of the
fallen rectum is removed. The outer layer is then folded and stitched and
the cut edges of the inner lining are stitched together so that rectum is
now inside of the anal canal.
What are the risks/complications that may occur after surgery?
As with any surgery, anesthesia complications, bleeding, and infection are always risks.
Other risks and complications from surgeries to repair prolapse include:
- Lack of healing where the two ends of bowel reconnect. (This can happen
in a surgery in which a segment of the bowel is removed and the two ends of
the remaining bowel are reconnected.)
- Intraabdominal or rectal bleeding
- Urinary retention (inability to pass urine)
- Medical complications of surgery: heart attack, pneumonia, deep venous thrombosis (blood clots)
- Return of rectal prolapse
- Worsening or development fecal incontinence
- Worsening or development of constipation
After surgery, constipation and straining should be
avoided. Fiber, fluids, stool softeners, and mild laxatives can be used.
How successful is surgery?
Success can vary depending on the condition of
supporting tissues and the age and health of the patient. Abdominal procedures
are associated with a lower chance of the prolapse reoccurring compared with
perineal procedures. However, in most patients, surgery fixes the prolapse.
How long is recovery?
The average length of hospital stay is 3 to 5 days but
this varies depending on a patient’s other existing health conditions. Complete
recovery can usually be expected in 3 months; however, patients should avoid
straining and heavy lifting for at least 6 months. In fact, the best chance for
preventing prolapse from recurring is to make a lifetime effort to avoid
straining and any activities that increase abdominal pressure.
www.acg.gi.org. Accessed 12/10
American Society of Colon & Rectal Surgeons. Rectal Prolapse.
www.fascrs.org. Accessed 12/10
Mahmoud NN. Rectal Prolapse.
www.fascrs.org. Accessed 12/10
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 12/30/2010…#14615