What is Rectal Prolapse?

By Brooke Gurland, MD

Rectal prolapse occurs when the rectum falls from its normal position within the pelvic area and extends out of the anus. Rectal prolapse is more common in postmenopausal women but occurs in younger people too. People who suffer from long-term history of constipation, laxative abuse or functional bowel disorders are more likely to develop rectal prolapse. Rectal prolapse can be associated with bladder and vaginal prolapse as a result of generalized pelvic floor muscle weakness (AKA pelvic floor dysfunction).

The symptoms of rectal prolapse include the feeling of a bulge or the appearance of intestine that extends outside the anus. This can occur during or after bowel movements and can be a temporary condition. However, over time the rectum may extend out of the anal canal and needs to be pushed back up into the anus by hand. Mucus discharge, pain and rectal bleeding are common symptoms associated with rectal prolapse. Fecal incontinence with leakage of mucus and stool from the anus can occur as a result of the rectum stretching the anal muscles and stretch injuries to the pelvic floor nerves. Rectal prolapse is not life threatening but can impact quality of life.

How is rectal prolpase diagnosed?
A detailed medical history and physical examination is required. A patient may be asked to "strain" while sitting on a commode to mimic an actual bowel movement. Being able to see the prolapse helps their doctor confirm the diagnosis and plan treatment.

Other conditions could be present along with rectal prolapse such as urinary incontinence, bladder prolpase and vaginal/uterine prolapse. Because of the variety of potential problems, urologists, urogynecologists and other specialist 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.

How is rectal prolapse treated?

For 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 the only way 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 prolpase, results of the exam and other tests and the surgeon's preference and experience with certain techniques.

Abdominal and rectal (also called perienal) 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 under general anesthesia. Abdominal repair involves rectopexy (fixation [reattachement] of the rectum). Rectopexy can also be performed laparoscopically through small keyhole incisions or robotically. Ventral rectopexy involves using a mesh material sewed to the top of the rectum with fixation to the sacrum (backbone) to suspend the rectum. In selected patients with severe constipation, removal of a segment of intestine followed by rectopexy is recommended.

Rectal (perineal) repair approaches
Rectal procedures are often used in older and sicker patients. Spinal anesthesia or epidural may be used instead of general anesthesia in these patients. The two most common rectal approaches are the Altemeir and the Delorme procedures.

  • Altemeir 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 sewed back together.

  • 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.

How successful is surgery?
Success can vary depending on the condition of supporting tissues, degree of prolapse and health of the patient. Abdominal procedures are associated with a 5 percent chance of prolpase reoccurrence. Perineal procedures are associated with 14 percent risk of reoccurrence.

Recovery After Rectal Surgery
The average length of hospital stay is three to five days but this varies depending on the procedure and patient's other exsisting health conditions. Complete recovery can usually be expected in three months; however, patients should avoid straining and heavy lifting for at least six 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.

About The Author
Brooke Gurland, MD, is a general laparoscopic and colorectal surgeon at Cleveland Clinic in Ohio. Dr. Gurland has special interests in evaluation and treatment of patients with functional bowel and complex pelvic floor disorders. She is board certified in colon and rectal surgery. After receiving her medical degree from Hahnemann, she trained at Mount Sinai in New York City and subsequently at Florida's Cleveland Clinic. She is currently on the NAFC Board of Directors.