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.

The condition affects approximately 2.5 in every 100,000 people annually, and 80-90% of patients are women over the age of 50 [1].

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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 50-75% 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, low recurrence rate (5-10%), and best suited 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; recurrence rate 10-25% [7]

The choice between techniques is individualised and based on age, general health, concurrent incontinence/constipation, and the surgeon's experience. The ESCP (European Society of Coloproctology) recommends that the decision be made within a multidisciplinary pelvic floor team [8].

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Prognosis and follow-up

After a successful operation, most patients experience a significant improvement in both the prolapse and any incontinence. 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

Rectal prolapse is neither life-threatening nor something to be ashamed of - but left untreated, the condition will worsen and significantly affect your quality of life. An early referral to a colorectal surgeon provides the best outcomes.

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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. Pannu HK, et al. MR imaging of pelvic floor dysfunction. Radiographics 2003;23(1):e1.
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, et al. Consensus on ventral rectopexy: report of a panel of experts. Colorectal Dis 2014;16(2):82-8.
9. Hotouras A, et al. Recurrence of full-thickness rectal prolapse following surgical repair: a systematic review. Colorectal Dis 2018;20(11):974-86.