Rectal Prolapse ✅

Rectal prolapse is protrusion of the rectum through the anus. It may be: mucosal (partial) — prolapse of mucosa only, or full-thickness (complete/external) — protrusion of the full rectal wall. It can cause major distress, mucus leakage, bleeding, obstructed defaecation, and faecal incontinence.

📖 About

• Full-thickness rectal prolapse is more common in older women, but can occur in men and younger adults.
• Mucosal prolapse is more limited and may overlap clinically with prolapsing haemorrhoids.
• Symptoms often worsen over time as the prolapse becomes larger, more frequent, and harder to reduce.
• Repeated prolapse may stretch the anal sphincter and contribute to faecal urgency, leakage, or incontinence.

⚠️ Aetiology & Risk Factors

• Pelvic floor weakness and impaired rectal support.
• Chronic constipation, prolonged straining, and disordered defaecation.
• Multiparity and other causes of pelvic floor dysfunction.
• Neurological disease affecting pelvic floor or continence mechanisms.
• Frailty and connective tissue laxity.
• In children, prolapse is usually due to a different mechanism and often relates to bowel disturbance, malnutrition, or underlying conditions.

🩺 Clinical Features

• Visible protruding rectal mass on straining or after defaecation.
• Initially self-reducing, but later may require manual reduction.
• Mucus discharge, rectal bleeding, tenesmus, or a feeling of incomplete evacuation.
• Faecal urgency, seepage, or incontinence due to pelvic floor/sphincter dysfunction.
• Advanced prolapse may become oedematous, ulcerated, painful, or difficult to reduce.

🚩 Red flags / urgent features

• Irreducible prolapse, marked oedema, dusky colour change, severe pain, or concern about strangulation/ischemia.
• Systemic illness or sepsis.
• Associated rectal mass, significant bleeding, weight loss, iron-deficiency anaemia, or change in bowel habit suggesting malignancy.

🔎 Assessment

• Diagnosis is often clinical, based on history and examination; asking the patient to strain may demonstrate the prolapse.
• Assess bowel habit, constipation, incontinence, straining, manual reduction, and pelvic floor symptoms.
• Examine for associated haemorrhoids, mucosal prolapse, skin changes, ulceration, and sphincter tone.
• Evaluate for coexisting pelvic floor dysfunction and faecal incontinence.

🧪 Investigations

• Routine blood tests are not needed to diagnose rectal prolapse.
• FBC if significant bleeding or anaemia is suspected.
• Bloods for operative fitness only if surgery is being planned or comorbidity/systemic illness is relevant.
• Flexible sigmoidoscopy/colonoscopy/proctoscopy may be needed if the diagnosis is uncertain or to exclude other colorectal pathology, including malignancy.
• Defecating proctography or MRI defecography can be useful in complex, recurrent, or internal prolapse and in suspected multicompartment pelvic floor dysfunction.

🧾 Differential Diagnosis

• Haemorrhoids — tend to appear as discrete prolapsing cushions rather than circumferential concentric folds.
• Mucosal prolapse.
• Rectal polyp or tumour.
• Anal skin tags.
• Prolapsing intussusception/internal rectal prolapse.

💊 Management

• Acute reduction of prolapsed tissue:
  • Positioning, analgesia, and gentle manual reduction may be attempted if the prolapse is recent and viable.
  • Applying granulated sugar can help reduce oedema osmotically in an oedematous prolapse before attempted reduction.
  • If irreducible, very painful, dusky, ulcerated, or ischemic → urgent colorectal/surgical review.
• Conservative/supportive treatment:
  • Optimise bowel habit: treat constipation, use stool softeners where needed, reduce straining, and improve toileting technique.
  • Pelvic floor physiotherapy/biofeedback may help associated pelvic floor dysfunction and faecal incontinence symptoms.
  • In children, many cases resolve with treatment of the underlying bowel issue and conservative measures.
• Definitive management in adults:
  • Full-thickness external rectal prolapse is usually treated surgically, especially when symptomatic.
  • Abdominal procedures such as laparoscopic ventral mesh rectopexy are often preferred in fitter adults because recurrence may be lower and functional outcomes can be better in selected patients.
  • Perineal procedures (for example, Delorme’s or Altemeier’s) are often considered in frailer or higher-risk patients because they are less physiologically demanding, though recurrence may be higher.
  • Procedure choice depends on frailty, comorbidity, continence, constipation, and surgeon expertise.

🌟 Exam pearl: Rectal prolapse has concentric circular folds; haemorrhoids prolapse as separate cushions, classically at 3, 7, and 11 o’clock.

🧑‍⚕️ When to refer

• Urgent same-day surgical review: irreducible prolapse, suspected ischemia/strangulation, severe pain, or ulceration.
• Routine colorectal referral: symptomatic adult rectal prolapse, especially full-thickness prolapse, recurrent prolapse, or prolapse associated with incontinence/obstructed defaecation.
• Urgent cancer pathway assessment: if there are red-flag colorectal symptoms such as unexplained rectal bleeding, weight loss, anaemia, change in bowel habit, or a suspicious mass.

Case examples

• 🚺 Case 1 – Age 76: Older woman with chronic constipation, mucus discharge, and faecal leakage develops a circumferential full-thickness prolapse after defaecation. Management: bowel habit optimisation, continence assessment, and colorectal referral; perineal repair may be preferred if frail. Teaching point: In older adults, prolapse often coexists with faecal incontinence and wider pelvic floor dysfunction.
• 🏃‍♂️ Case 2 – Age 42: Recurrent reducible prolapse during straining with obstructed defaecation symptoms. Management: treat constipation and straining, then consider specialist assessment for definitive surgery if symptoms persist. Teaching point: Conservative treatment may reduce symptoms, but established symptomatic full-thickness prolapse in adults often ultimately needs surgery.
• 🧒 Case 3 – Age 5: Reducible prolapse during bowel motions with diarrhoea and poor nutrition. Management: treat underlying bowel disturbance, optimise nutrition, and monitor. Teaching point: Paediatric prolapse is often secondary and commonly settles with conservative management.

📚 References

• NICE NG210: Pelvic floor dysfunction – prevention and non-surgical management
• NICE CG49: Faecal incontinence in adults
• NICE CKS: Faecal incontinence in adults – underlying causes
• NHS patient information: Rectal prolapse
• Guy’s and St Thomas’ NHS Foundation Trust: Rectal prolapse and perineal repair