Rectal prolapse

What is a rectal prolapse?

Rectal prolapse happens when your rectum, the last section of your large bowel, loses its normal support and slips down through your anus. It's caused by weakening in the muscles and tissues that would normally hold it in place, and in adults it will not correct itself without treatment.

What are the symptoms of rectal prolapse?

In the early stages, you might only notice a lump coming down when you go to the toilet, which then slips back by itself. Over time, this tends to happen more often and may stop going back in on its own. Common signs include:

• a reddish lump or mass that comes out of your anus, sometimes needing to be pushed back in with your hand
• a feeling of pressure, fullness, or that you haven't fully emptied your bowels
• leaking mucus, liquid stool or blood from your anus
• needing to use a lot of toilet paper to feel clean
• difficulty controlling wind or bowel movements (faecal incontinence)
• constipation or straining to pass a motion
• discomfort or pain low in your tummy, especially when opening your bowels
• soreness or itching around your anus.

These symptoms can also happen with piles (haemorrhoids), so it's easy to confuse the two. One helpful difference: piles usually settle down within a week or so by themselves, while a true rectal prolapse is a long-term problem that keeps returning and tends to get worse without treatment.

What causes rectal prolapse, and who is at risk?

There's no single, clear-cut cause. Rectal prolapse develops when the pelvic floor muscles, ligaments and the anal sphincter that normally support the rectum become weak, letting it slip out of place.

Rectal prolapse affects women far more often than men. It's also more common with increasing age, particularly from the mid-60s onwards. Other conditions linked to a higher chance of rectal prolapse include:

• long-term constipation, diarrhoea, or straining on the toilet
• pregnancy, childbirth, or previous pelvic surgery or injury
• a family history of rectal prolapse, suggesting some people may be more genetically prone to it
• conditions that raise pressure inside your tummy over the long term, such as chronic coughing or an enlarged prostate
• nerve or spinal cord problems, or conditions such as dementia that affect bowel control
• connective tissue disorders, such as Ehlers-Danlos syndrome
• cystic fibrosis or a bowel parasite infection.

In young children, rectal prolapse is uncommon and usually appears before the age of 4, often alongside chronic diarrhoea, straining, or an underlying condition such as cystic fibrosis, so children with a prolapse are usually tested for this too.

Are there different types of rectal prolapse?

Doctors describe rectal prolapse by how much of the rectum is affected, ranging from milder to more severe:

• internal prolapse (also called intussusception): the rectum starts to drop but hasn't yet come through the anus
• mucosal prolapse: only the inner lining of the rectum turns inside out and pokes through
• full-thickness (external) prolapse: the whole thickness of the rectal wall pushes all the way out through the anus.

Prolapse can also happen alongside other pelvic floor problems caused by the same underlying weakness, such as a bulge of the bladder, small bowel or vaginal wall, so your doctor may check for these at the same time.

How is rectal prolapse diagnosed?

Your doctor will ask about your symptoms and bowel habits, then examine the area. If the prolapse isn't visible while you're resting, you may be asked to strain as though opening your bowels so it can be seen. A gloved, lubricated finger examination (a digital rectal exam) is often part of this.

Depending on what your doctor finds, further tests may include:

• anorectal manometry, which measures the strength and coordination of your anal muscles
• an endoanal ultrasound or MRI/X-ray defecography, which look at the muscles and check for any structural damage while you're passing a motion
• a colonoscopy, flexible sigmoidoscopy or lower GI series (barium enema), to view inside your bowel and rule out other causes
• blood tests, and in children, a test for cystic fibrosis, since this is linked to prolapse in a meaningful number of cases.

How is rectal prolapse treated?

Treatment depends on your age, general health, and how severe the prolapse is.

Non-surgical treatment

In young children, treating the underlying cause, such as constipation or an infection, is often enough on its own; as the child grows, the muscles usually strengthen and the prolapse resolves. In adults, non-surgical measures won't cure a prolapse on their own, but they help manage symptoms, reduce strain on the area, and lower the chance of it coming back after surgery. This includes:

• eating enough fibre (around 18 to 30g a day) and drinking 1.5 to 2 litres of fluid, aiming for a soft, well-formed stool that's easy to pass without straining
• learning a toileting technique that avoids straining, such as leaning forward with your feet raised and gently bracing rather than pushing hard
• pelvic floor exercises: squeezing and lifting the muscles around your anus for 5 to 10 seconds, then relaxing for 10 seconds, repeated several times, three times a day; consistency over around 3 months tends to bring the best results
• biofeedback or supervised pelvic floor physiotherapy
• for a minor mucosal prolapse, a doctor may sometimes secure the area with surgical rubber bands
• gentle skin care around the anus, such as patting rather than rubbing dry, using non-scented products, and wearing cotton underwear, to prevent soreness from any leakage.

Surgical treatment

For most healthy adults, surgery is the main way to correct rectal prolapse permanently, and there are two broad approaches.

The abdominal approach (rectopexy) fixes the rectum back into its normal position, stitching it to the bone at the back of your pelvis, sometimes with a supporting mesh. It can be done as open surgery or as keyhole (laparoscopic) surgery, occasionally with robotic assistance, and generally has strong long-term results. If chronic constipation has contributed to the prolapse, your surgeon may also remove a short section of bowel at the same time.

The rectal (perineal) approach works through the anus rather than the tummy, which can mean a shorter, easier recovery, and may suit older patients or those not well enough for abdominal surgery. Two common versions are the Altemeier procedure, where the prolapsed section is removed and the bowel rejoined, and the Delorme procedure, where only the prolapsed lining is removed and the muscle layer folded and stitched to reinforce it.

As with any operation, there are risks: bleeding, infection, blood clots, and a small chance of injury to nearby organs or nerves. Surgery-specific risks can include the two ends of bowel not healing together properly, constipation, difficulty passing urine for a day or two, and, if mesh is used, a small chance (around 2 in 100) of the mesh eroding through nearby tissue over time. Rectopexy also carries a small (1 to 2%) chance of affecting male sexual function. Even after successful surgery, the prolapse can return in some people.

Afterwards, you'll usually be encouraged to stay mobile, avoid heavy lifting for several weeks, and take laxatives for a while to avoid straining while everything heals. Most people can drive again after about 2 weeks and return to work within 4 to 8 weeks, depending on the type of work and surgery.

When should I see a doctor?

See a doctor if you notice a lump or any of the symptoms above, even if it goes back in by itself, since early treatment can help prevent things from getting worse.

Get urgent medical attention if:

• the prolapse cannot be pushed back inside
• you have heavy or persistent bleeding from your bottom
• you develop severe pain in your lower tummy, back passage or lower back
• you have a high temperature, or persistent nausea or vomiting.

A prolapse that won't go back in can cut off its own blood supply, which is a medical emergency, so don't wait to get this checked.