The Bottom Line on Rectal Prolapse

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again, everyone, and welcome to another episode of Butts & Guts.

I'm your host, Scott Steele, president of the Main Campus and colorectal surgeon here at Cleveland Clinic in beautiful Cleveland, Ohio. And today I'm very pleased to welcome back Dr. Anna Spivak, a colorectal surgeon and the section chief of pelvic floor surgery here at the Cleveland Clinic. Anna, thanks for joining us on Butts & Guts.

Dr. Anna Spivak: Thank you very much for having me back.

Dr. Scott Steele: So we know that you've been on here before, but for those listeners who haven't heard you, why don't you go ahead and give us a little bit about your background, where are you from, where'd you train, and how did it come to the point that you're here at the Cleveland Clinic?

Dr. Anna Spivak: So I'm originally from Russia, St. Petersburg. I came to the United States as a kid, and I did all of my schooling here in the United States. I went to college in New York, to Yeshiva University, and then I went to medical school in Philadelphia, Philadelphia College of Osteopathic Medicine.

I trained in Philadelphia for residency and in Pittsburgh for colorectal surgery. And had my first job in Philadelphia and then got recruited to Cleveland and been there since, and love what I do. And I take care of the patients with diseases of pelvic floor.

Dr. Scott Steele: Fantastic. And we're glad to have you here. Whoever recruited you as a smart person. And so, today, we're going to talk a little bit about rectal prolapse. We kind of go into a little bit about causes, symptoms, current treatment options. And so to start, tell us a little bit what is rectal prolapse?

Dr. Anna Spivak: So there are different ways to describe it, and we will talk... get a little bit deeper into that today. But usually, when people think about rectal prolapse is something is coming out that shouldn't be coming out. So it's part of the rectum, it could be just a small amount or a lot of rectum. It can be just a few inches, few centimeters, a foot of rectum that's falling out of the anus. And it's certainly not normal.

It should not be happening. We will also talk a little bit about internal prolapse when things telescope on the inside. When the prolapse is external, it certainly warrants an evaluation by the colorectal surgeon. And if you notice this at home or somebody who's taken care of, you notices that there's something that needs to be evaluated.

Dr. Scott Steele: So what are the most common warning signs or symptoms, if you will, that someone might be having rectal prolapse?

Dr. Anna Spivak: I would say something that should not be there coming out of the rectum. And most of the time, people notice this when they're sitting on a toilet and having a bowel movement, and some amount of tissue is coming out. It could possibly be hemorrhoids, but rectal prolapse is a lot bigger.

It's usually more consistent sort of amount of tissue that's prolapsing. Sometimes patients, especially all the patients, note that this is coming out when they are doing any kind of activity, perhaps with walking.

Dr. Scott Steele: So Anna, you hinted at this a little bit earlier. Can you explain the difference between a partial, or sometimes called an internal prolapse, or a complete, or external rectal prolapse? And then if it's untreated on either case, can a partial rectal prolapse progress along to a complete rectal prolapse?

Dr. Anna Spivak: So I think it's important to note why rectal prolapse begins. And that's something that's certainly more common seen in women. And that is because of childbirth, and that is because of maybe injuries during childbirth, history of episiotomy, maybe pelvic trauma. And the biggest risk factor for developing this prolapse is constipation and straining. And we certainly see an increased number of patients with connective tissue disorder. So the complete prolapse is when entire sort of circumference on the rectum falls out, but it also could be just one layer or just one side, a small amount, but tissue is external.

So that would be, I would describe it as an external prolapse. Versus an internal prolapse is when the tissue starts to telescope. If you think of socks on your feet, they start to fall down. So kind of telescoping down into the anal canal or sometimes into the rectal out bulging into the vagina, which is called the rectocele. But this is something that is not coming quite external yet. It is still on the inside, but that can certainly be symptomatic and can also present difficulty with stooling, difficulty with evacuating bowel movements. We don't have great data to suggest that internal always becomes external, but we certainly see patients who present, maybe a few years ago, they came in, they had some straining, some constipation, they have an internal prolapse, and then it does become external. So it certainly happens, but I don't have a great percentage to say that every single time when there is an internal, it will become external. The biggest thing to differentiate, I think, is to the symptoms. How symptomatic are patients with internal prolapse, because that would guide us whether we need to start with conservative treatment versus go straight to surgery. External prolapse is always a surgical treatment. There's really nothing that can really be done to just have it go back and not come out again.

Dr. Scott Steele: And we're going to get into that a little bit later. So, when should someone see a doctor if they think they might have this condition?

Dr. Anna Spivak: As soon as you can get in to see someone, they should get evaluated by a colorectal surgeon, by a pelvic floor surgeon, and we will help you differentiate whether it's an external prolapse, internal prolapse, whether it's hemorrhoids, whether it's something else that maybe mimics prolapse.

So it's not an emergency. It's not somewhere where you need to be seen the same day. It's not dangerous to life, but it is something where if you notice that you have a prolapse, it certainly gets seen by a colorectal surgeon.

Dr. Scott Steele: So Anna, okay, walk me through. So now I think that I've had my rectum hanging out, I was able to successfully get it back in, and I'm now going to plan on going and seeing the doctor. How do doctors diagnose rectal prolapse, and what can they expect in terms of either tests or examinations when they come in to see you in your office?

Dr. Anna Spivak: So the first thing that I would do is I would speak to the patient and get symptoms, figure out when the prolapse coming out, how often. Does it come out with every bowel movement? Is this just something that happened once? Then examine the patient. The physical exam would include a digital rectal exam, and in women also vaginal exam, and to examine the entire perineum to see what is happening anatomically, what is coming out. I would also put the patients on the toilet and have them strain because oftentimes the prolapse just comes out with straining. So evaluate in a sitting position as well.

And then, as far as the testing goes, it depends. If it's a very, very obvious big prolapse, might they... no testing might not be necessary. If it is something where they're accompanying perhaps incontinence or constipation, we will definitely do anorectal physiology testing, such as manometry. It is something that we do in the office. And this is a procedure where the pressures of the anal sphincter, as well as capacity of the rectum are examined. It's a very quick test. It's done with a tiny catheter in the bottom. Like I said, we do it in the clinic.

And then another test that is sometimes possible that the patient would need, especially if it's an internal prolapse, something that doesn't come out when the patient sits down, they would need a defecography, which is an evaluation by radiology. It's a very, very useful test because it gives me a very good picture on the anatomy on the inside, but rather annoying for the patient. So you do need to do bowel prep for that. And then the patients present to radiology on the appointment.

They're given contrast to drink, contrast is placed in the rectum and in women in the vagina, and then the patient is placed on the radiolucent commode, and the defecation of the contrast happens under the x-ray guidance. And I get essentially a video of organs moving during defecation. So this tells me what happens on the inside. Is something telescoping? Is something bulging? Is something not moving normally? Are the muscles relaxing the way they're supposed to relax?

It's an incredibly useful test and gives us a lot of information how to proceed with management. Other than that, I would say the very important thing to remember is that if you've never had a colonoscopy and this is the first thing that something is falling out, definitely we need a colonoscopy to evaluate the colon and make sure that there is no other underlying problem that's going on that causes the prolapse.

Dr. Scott Steele: So Anna, who is most likely to develop rectal prolapse? Are there age groups or genders? Can men get rectal prolapse? And why is this?

Dr. Anna Spivak: So we see... most commonly, we see the rectal prolapse in older women. And like I said, the risk factors are being a woman, having children, and maybe having a history of episiotomy, maybe a history of constipation, straining, or any kind of defecatory dysfunction or toileting habits where the patients have very quick bowel movements, strained for short amounts of times, but with a very significant push.

So the older women are the largest group of patients that would get the rectal prolapse, but we definitely see that rectal prolapse in men, and just not that common. I would say, probably of all patients, out of 100 patients, maybe five or six men would be with rectal prolapse. So, not as common, but certainly happens most of the time, it's related again to longstanding history of straining, maybe constipation as well. And then we see the rectal prolapse now more and more common in younger patients.

And some of it correlates to, again, constipation, straining, pelvic trauma, but also to the connective tissue disorders. We certainly see increasing number of patients with connective tissue disorders who develop rectal prolapse. And in younger patients, what I tend to see is that it's not just the rectum that's falling out, everything is falling out, and that certainly does happen.

Dr. Scott Steele: So let's look at two things. First of all, if I'm out there and I'm like, "Man, I don't want to get rectal prolapse." Is there anything I can do out there to reduce the risk for developing? And second, if I'm somebody that it's actually happened to, are there ways to be able to prevent it from happening again?

Dr. Anna Spivak: Absolutely. And the ways to prevent it from happening is, again, the biggest thing is constipation and straining. So, not sitting in the toilet for a long time, making sure that you drink enough water, take the fiber. If laxatives are necessary, taking on laxatives. It could be something as simple as prune juice. It could be something like magnesium or over-the-counter laxatives, or even, if necessary, prescription laxatives, but making sure that the bowel movements are somewhat regular. I can be... It's variable in people.

It can be anywhere between one and three days, whatever is your normal, but the bowel movements are soft, and that you really don't strain. You don't spend a long time on the toilet, sitting more than five minutes on the toilet, and excessive straining, that can certainly cause the prolapse. And as far as the patients after surgery, the same thing. We make sure that constipation is corrected, that the patients are on the appropriate bowel regimen after surgery. And another huge component also, just like having any surgery, for example, for shoulder.

You get physical therapy after shoulder to learn to use your new joint, to make sure that you exercise it and work the muscles after the operation. The same thing for the pelvic floor. Anytime you have any kind of anatomic change, which repair for the rectal prolapse is, it's changing anatomy back to how it's supposed to be, we also recommend pelvic floor physical therapy to make sure that the muscles are optimized and function is optimized. And again, that the patient does not strain to move the bowels.

Dr. Scott Steele: And so, how important are proper nutrition and maybe even hydration in preventing this condition? Or are there exercises? You mentioned physical therapy, strengthening a floor. What about that nutritional and that hydration aspect?

Dr. Anna Spivak: Yeah, I mean, nutrition and hydration, I think, goes along the lines of constipation. And thank you for bringing that up, because hydration is very important because proper water intake would play the role in stool consistency. So it's very important to be drinking at least six to eight cups of water a day. And as far as nutrition goes, it's sort of the same thing, right. So you wouldn’t want to have too little.

So being on the spectrum of eating disorders can put somebody at increased risk, but also being in a spectrum of sort of overeating and being overweight can also put the patients to the increase the risk of putting a lot more pressure on those muscles, on the pelvic floor muscles, and set up patients on a sort of negative trajectory to potentially be at a higher risk to developing any kind of prolapse.

Dr. Scott Steele: So you mentioned it a little bit earlier in terms of treatment options, and specifically, you spoke about external prolapse being a surgical disease, and you mentioned a little bit about internal prolapse. But can you talk a little bit about these treatment options in more detail? And how, as a surgeon, do you know when surgery is needed?

Dr. Anna Spivak: So when I look at a prolapse, and the rectum is hanging out, that is always a surgical diagnosis. There's no amount of physical therapy or muscle strengthening that will get the rectum to go back in and stay up. If I do have a patient who, in addition to having a prolapse, has muscle dysfunction, we may optimize them with physical therapy, but once the prolapse is out, it's a surgical diagnosis that would need surgery.

So, the way we approach rectal prolapse, there are ways to... different ways to fix it, certainly. And there are two big categories. One is to fix the prolapse through the bottom or do a perineal repair, and there's several procedures that are allowed to do that. And then there is a second way to do the surgeries through the belly or abdominal procedures. So the procedures through the bottom or perineal procedures are really reserved for patients who cannot tolerate abdominal surgery, and that can be age, frailty.

They maybe have a high-risk condition that will allow... not allow them to stay under general anesthesia for several hours to tolerate the abdominal procedure, because what we do know from our data is that abdominal procedure really gives us an optimal repair. It's the best kind of repair with the longevity of it. So it's less likely to recur in the future. And when the prolapse is repaired through the belly, there're ways to do it with mesh and without the mesh.

And that depends on the degree of prolapse, exactly which part of the rectum is prolapsing. If there is another organ that is prolapsing, it could be bladder or the vagina, it's sometimes necessary to do surgery with mesh. And in other situations, it's possible to just do what's called a tissue repair or just suspend the organs themselves without utilization of the mesh. And same way, through the bottom, there are different ways to do it.

So there are types to do it where no rectum is resected. It's sort of plicated or sewn up, or a different way to do it when part of the rectum is essentially amputated to fix the prolapse. But that is really dependent on each particular patient. And one thing that I would say is that there's no one approach to every single prolapse. It's every patient gets evaluated, and you really see what would be the best operation fit for each patient. And we talk about options and decide together what would be the best fit for them.

Dr. Scott Steele: Anna, I like how you said earlier about a defecography. You're looking for bulging and following... and falling down and all sorts of different things that you can see on that.

What you're really talking about is many of these patients, as you say, may have other concomitant issues at the same time, whether it be bladder or vaginal prolapse, urinary incontinence, fecal incontinence, constipation, if you said.

So I know you also kind of hinted at that sometimes you do these operations with other people, but will these conditions improve after rectal prolapse surgery, or is this a multidisciplinary or what do these patients expect?

Dr. Anna Spivak: As you mentioned, there's another Butts & Guts that we've done in the past, actually, that talks about multicompartment. I do a lot of prolapse surgery together with urology and urogynecology. We work together to fix everything at the same time because the pelvic floor is kind of like a basket, the muscles themselves. And then we have different organs in there. So we have the bladder, the urethra, we have the vagina with the uterus and the rectum.

So if I'm just going to lift up the rectum, but the uterus and the vagina is still dragging everything down, it really puts my repair in jeopardy as well. In addition, the patient may still feel just as miserable because something else is falling down, and they're feeling it a lot more. So that's the situations when we do surgery concurrently with urology, urogynecology, and fix everything at the same time.

Constipation can certainly be affected by organ prolapsing because it becomes a matter of space in the pelvis, and things just cannot function the way they're supposed to function. There's no... Because things are prolapsing, rectum doesn't have a good ability to empty completely. And fecal incontinence is also something that's quite common because I usually compare the sphincter to the rubber band. And if you have a very stretched-out rubber band because something is pushing rectum is prolapsing.

So it's constantly coming out. It's stretching that rubber band that doesn't do a good job with holding things in place. So, once we lift everything up and fix the prolapse, that sphincter really has a chance to then improve with exercise. And that is certainly something that gets better. We also asked about urinary incontinence. That can or cannot be related in prolapse to different kind of urinary incontinence.

And that is something, when the patient has the symptoms, I would evaluate them together with my urogynecology colleagues, and they would do their part of testing and see if something else is necessary to address the problem at the same time, or is this something to be expected to improve once that, perhaps bladder or the vaginal prolapse, is fixed?

Dr. Scott Steele: Yeah. And as Anna hinted at for all our listeners out there, we did do a special episode on multi-compartment prolapse and multi-compartment disorder. So please look back in our library for that one to get more information. And so, finally, finishing up here, a lot of these patients are very active. They're not just all moribund and laying down and everything. And they want to know how can they get back to resuming regular activities, work, exercise if they are or required to undergo surgery?

Dr. Anna Spivak: So the rectal prolapse surgery can be a very minimal invasive operation. Most of the surgeries are done robotically, so very small incisions. Many patients are able to even go home the same day. So, from an impact of recovery in a sense of going back to activities or just even taking care of yourself and the activities of daily living, most patients able to go back pretty quickly to those activities.

The only restriction that I really ask the patients to do is to avoid heavy lifting because we want everything to scar in really well. So for several months, I ask them not to lift. And if the patients are runners or they do yoga, avoid certain type of exercises like lunges, squats, that sort of things.

But it's just for a few months. Once everything heals, which is about three months, patients can really go back to their regular exercise, their regular activities, and hiking and enjoying all the different exercises and activities that they would like to do.

Dr. Scott Steele: That's fantastic. And so now it's time for our quick hitters, a chance to get to know you just a little bit better. So first of all, what was your first car?

Dr. Anna Spivak: Oh, first car, Mazda. Don't remember the model, very small one. It was early college.

Dr. Scott Steele: There's probably a lot of listeners out there that have never been to St. Petersburg, Russia. Anna, can you give us maybe something that they... a fun fact about that, or a place that's just been beautiful, is something to know.

Dr. Anna Spivak: Yeah, it's actually a beautiful city, and it's a very unique city because it's a largest city north enough where you have white nights. So for a couple of months in the summer, the sun essentially doesn't go down. It's about an hour or so of twilight. And as a child, it was a very interesting experience because you have no idea when to go to sleep and when to wake up. It just light all the time.

And also, in the winter, the day is very short. The day can be about an hour, hour and a half. So if you think it's sad in Cleveland in the winter when you go wake up in the morning, and you come home in the morning, and it's still dark outside, imagine being a kid and living like that for four or five months a year. So it's a... And it didn't matter. It could have been two o'clock, but it was already dark.

Dr. Scott Steele: Fantastic. And so now onto foods. Are you salt or sweet?

Dr. Anna Spivak: Sweet.

Dr. Scott Steele: And finally, if you could go back to your 18-year-old self and give yourself a piece of advice, what advice would you give yourself?

Dr. Anna Spivak: Just maybe enjoy things a little bit more and not always run to accomplish something.

Dr. Scott Steele: And I would just add to that, you are probably the one person that can say, "Hey, you're going to go into finance, but you're eventually going to be a colorectal surgeon." And yourself would've said, "What? What? There's no way that's going to happen."

Dr. Anna Spivak: Very true.

Dr. Scott Steele: So give us a final take-home message for our listeners about rectal prolapse.

Dr. Anna Spivak: If you have a rectal prolapse, please come see us and get evaluated. If you suspect that you think you may have a rectal prolapse and you're not sure, you can still get evaluated. We have a very robust team, and I can certainly do that.

And for listeners out there who do not want to get the rectal prolapse or maybe it's younger patients who are worried, and they're having children and worried about what if things start falling out, keep doing...

There's a lot of resources out there for pelvic floor physical therapy. And the biggest thing, avoid straining, sitting in a toilet for a long time, and keep your pelvic floor healthy, and avoid constipation that will prevent problems in the future.

Dr. Scott Steele: Fantastic. And so for more information on the Digestive Disease Institute here at the Cleveland Clinic, please call 216.444.7000. That's 216.444.7000. You can also visit clevelandclinic.org/digestive for more information. That's clevelandclinic.org/digestive. Anna, thanks for joining us on Butts & Guts.

Dr. Anna Spivak: Thank you so much for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.