Rectal prolapse

Rectal Prolapse: When the Rectum Slips Out

Rectal prolapse is a condition where all or part of the rectal wall "turns itself inside out" and can protrude through the anal opening. It is often a source of embarrassment and is easily confused with haemorrhoids - but the two conditions are very different and require their own specific treatments.

In a Finnish regional series of patients operated for complete rectal prolapse between 1988 and 2002, the condition was diagnosed in a mean of 2.5 per 100,000 inhabitants per year, and 89 of 99 patients (90%) were women with a median age of 69 [1]. The figures come from one region and cannot simply be transferred to Denmark.

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Three types of prolapse

1. Complete rectal prolapse (procidentia) - the entire wall of the rectum turns inside out, usually protruding 4-10 cm
2. Internal/hidden prolapse (intussusception) - the rectum folds in on itself but does not come out
3. Mucosal prolapse - only the lining of the rectum (mucosa) comes loose (resembles large haemorrhoids)

It is important to get the correct diagnosis, as the treatment varies for each type.

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Symptoms

• A soft "lump" that comes out during a bowel movement or physical exertion
• Mucus or blood on your underwear
• A feeling of incomplete emptying
• Faecal incontinence - seen in a large proportion of patients at the time of diagnosis [2]
• Constipation - paradoxically common, as the prolapse can block the passage of stool
• Pain is rare (unlike with thrombosed haemorrhoids)

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Risk factors

• Being female and aged over 50
• Multiple vaginal births
• Chronic constipation and straining during bowel movements
• Pelvic floor weakness
• Previous pelvic surgery
• Neurological diseases (MS, spinal cord injuries)
• Cystic fibrosis in children [3]

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Investigation

The diagnosis is often made during a clinical examination, where the patient is asked to "bear down" while sitting on a toilet or lying on their left side. Additional investigations include:

• Defaecography (MRI or X-ray) for internal prolapse or suspected pelvic floor dysfunction [4]
• Anorectal manometry to assess the function of the sphincter muscle
• Colonoscopy to rule out a tumour or other cause, especially for first-time symptoms in those over 50

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Treatment

Conservative treatment is rarely sufficient for a complete prolapse but can improve symptoms in cases of mucosal or internal prolapse:

• A fibre-rich diet and lactulose to combat constipation
• Pelvic floor exercises with a specialist physiotherapist
• Biofeedback training for concurrent incontinence

Surgery is the definitive treatment for complete prolapse and is divided into:

• Abdominal procedures (laparoscopic ventral mesh rectopexy, the D'Hoore procedure): Good long-term results. In an observational study of 919 patients operated with this specific technique the 10-year recurrence rate for external rectal prolapse was 8.2% (95% CI 3.7-12.7). The figure applies to that series and cannot be transferred to rectal prolapse surgery in general. The procedure is often chosen for younger and fitter patients [5,6]
• Perineal procedures (Altemeier's or Delorme's procedure): Less invasive, shorter operating time, and typically used for older or more frail patients; in the randomised PROSPER trial 24 of 102 patients (24%) had a recurrence after Altemeier's procedure and 31 of 99 (31%) after Delorme's. These are trial-level figures for the two techniques, not an individual patient's risk [7]

The choice between techniques is individualised and based on age, general health, concurrent incontinence/constipation, and the surgeon's experience. For ventral mesh rectopexy, the Pelvic Floor Society and ACPGBI recommend that every patient considered for surgery is discussed at a multidisciplinary pelvic floor meeting, and that the procedure is carried out by adequately trained surgeons within a multidisciplinary framework [8].

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Prognosis and follow-up

After surgery many patients experience improvement in both the prolapse and any incontinence, but the result varies. However, constipation can remain a problem and requires ongoing dietary and pelvic floor therapy. Recurrence can happen years after the operation, and a follow-up with a surgeon is recommended if new symptoms appear [9].

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When should you see a doctor?

• If you feel something "coming out" of your rectum
• Persistent faecal incontinence
• New symptoms from the rectum after the age of 50
• Bleeding that cannot be explained by haemorrhoids or an anal fissure

An uncomplicated rectal prolapse is not in itself dangerous, and it is nothing to be ashamed of. A prolapse that becomes stuck and cannot be pushed back, and that turns painful, swollen or discoloured, is by contrast an emergency. Seek medical help the same day, because the blood supply to the bowel may be threatened. The condition does not resolve on its own, and persistent or progressive symptoms should be assessed by a colorectal surgeon. The choice of treatment depends on the type of prolapse, on the symptoms and on the risk of surgery, and the course cannot be predicted for the individual patient.

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References

1. Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg 2005;94(3):207-10.
2. Madiba TE, et al. Surgical management of rectal prolapse. Arch Surg 2005;140(1):63-73.
3. Bordeianou L, et al. Clinical practice guidelines for the treatment of rectal prolapse. Dis Colon Rectum 2017;60(11):1121-31.
4. El Sayed RF, et al. Magnetic resonance imaging of pelvic floor dysfunction - joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group. Eur Radiol 2017;27(5):2067-2085. PMID: 27488850
5. D'Hoore A, et al. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg 2004;91(11):1500-5.
6. Consten ECJ, et al. Long-term outcome after laparoscopic ventral mesh rectopexy: an observational study of 919 consecutive patients. Ann Surg 2015;262(5):742-7.
7. Senapati A, et al. PROSPER: a randomised comparison of surgical treatments for rectal prolapse. Colorectal Dis 2013;15(7):858-68.
8. Mercer-Jones MA, Brown SR, Knowles CH, Williams AB. Position statement by the Pelvic Floor Society on behalf of the Association of Coloproctology of Great Britain and Ireland on the use of mesh in ventral mesh rectopexy. Colorectal Dis. 2020;22(10):1429-1435. DOI: 10.1111/codi.13893. PMID: 28926174
9. Hotouras A, et al. Recurrence of full-thickness rectal prolapse following surgical repair: a systematic review. Colorectal Dis 2018;20(11):974-86.