Rectal Prolapse

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Overview

Rectal prolapse can present in a variety of forms and is associated with a range of symptoms including pain, incomplete evacuation, bloody and/or mucous rectal discharge, and fecal incontinence or constipation. Complete external rectal prolapse is characterized by a circumferential, full-thickness protrusion of the rectum through the anus, which may be intermittent or may be incarcerated and poses a risk of strangulation. There are multiple surgical options to treat rectal prolapse, and thus care should be taken to understand each patient's symptoms, bowel habits, anatomy, and pre-operative expectations. Preoperative workup includes physical exam, colonoscopy, anoscopy, and, in some patients, anal manometry and defecography. With this information, a tailored surgical approach (abdominal versus perineal, minimally invasive versus open) and technique (posterior versus ventral rectopexy +/- sigmoidectomy, for example) can then be chosen. We propose an algorithm based on available outcomes data in the literature, an understanding of anorectal physiology, and expert opinion that can serve as a guide to determining the rectal prolapse operation that will achieve the best possible postoperative outcomes for individual patients.

Symptoms

If you feel like you’re sitting on a ball after pooping, or if you notice that you have something sticking out of the opening (your anus) where you poop, you could have rectal prolapse.

Typically, you’ll first experience rectal prolapse after you have a bowel movement. The first time, or first few times, the rectum may return inside on its own. Later, you may feel like something has fallen out of your body, or you just feel something down there that isn’t normal. In those cases, you may be able to push the rectum back in yourself.

Additional symptoms of rectal prolapse can include:

Feeling a bulge outside your anus

Seeing a red mass outside your anal opening

Pain in the anus or rectum

Bleeding from the rectum

Leaking blood, poop, or mucus from the anus

Early on, rectal prolapse may look like hemorrhoids slipping out of your anal opening, but these are two different conditions. Hemorrhoids are swollen blood vessels in your anus or lower rectum that may cause itching, pain, and blood on the toilet paper when you wipe after you poop. Your doctor can diagnose whether you have rectal prolapse or hemorrhoids.

Causes

A variety of things can cause the condition, including:

Long-term history of diarrhea or constipation

Long-term history of having to strain when you poop

Old age, which weakens muscles and ligaments in the rectal area

Previous injury to the anal or hip area

Nerve damage that affects your muscles’ ability to tighten and loosen, which could be caused by pregnancy, vaginal childbirth complications, anal sphincter paralysis, or injury to your spine or back

Neurological problems, such as spinal cord disease or spinal cord transection

Risk factors

More women develop rectal prolapse than men, especially women older than 50. In general, older people who have had a history of constipation or problems with their pelvic floor have a higher chance of having the problem.

Any of these health conditions could put you at higher risk for rectal prolapse:

Chronic constipation

Always have to strain to poop

Lower back injury or disc disease

Muscle weakness in your anus or pelvic floor

Someone in your family also had rectal prolapse

Parasitic infections like schistosomiasis

Chronic obstructive pulmonary disorder (COPD)

Benign prostatic hypertrophy

Any injury or problems with ligaments that keep your rectum attached to the intestinal wall

Congenital bowel disorders like Hirschsprung’s disease or neuronal intestinal dysplasia


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Complications

Rectal prolapse, if it’s not treated, could lead to these complications:


Rectal damage like ulceration or bleeding

Your rectum can’t be manually pushed back up inside you

Strangulation, or the blood supply in your rectum is reduced

Gangrene, or the strangulated rectal tissue decays and dies

Prevention

Treat chronic bowel disorders. Don’t let chronic constipation or diarrhea persist. Ask your healthcare provider about treatment options, including lifestyle changes and medications.

Strengthen your pelvic floor. Kegel exercises can help keep your pelvic muscles fit and strong. They have been shown to prevent incontinence as well as possible pelvic organ prolapse.