Rectal Prolapse: Symptoms, Causes & Treatment

What Is Rectal Prolapse?

Rectal prolapse is a condition where the rectum (the last 12-15 centimeters of the large intestine) slides out of its normal position and protrudes through the anal opening. It can be partial, involving only the inner lining (mucosal prolapse), or complete, involving all layers of the rectal wall (full-thickness prolapse).

The rectum is the final portion of the large intestine, connecting the sigmoid colon to the anus. Under normal conditions, it is held firmly in place by muscles, ligaments, and other supporting structures in the pelvis. When these structures weaken or become damaged, the rectum can lose its normal position and begin to protrude through the anus. This condition is known as rectal prolapse, also called procidentia when the prolapse is complete.

Rectal prolapse differs fundamentally from hemorrhoids, although the two conditions are sometimes confused. While hemorrhoids are swollen blood vessels within the anal canal that may bulge during straining, rectal prolapse involves the actual wall of the rectum protruding outward. The distinction is important because the treatment approaches are quite different, and a proper diagnosis is essential for effective management.

Understanding the anatomy helps explain why prolapse occurs. The rectum normally sits within a curve of the sacrum (lower spine) and is supported by several structures: the levator ani muscles that form the pelvic floor, the puborectalis muscle that creates a natural angle between the rectum and anus, and various ligaments and fascial attachments. When these supports fail, whether due to chronic straining, aging, childbirth trauma, or other factors, the rectum can descend and eventually protrude.

Types of Rectal Prolapse

Medical professionals classify rectal prolapse into three main types based on the extent of the prolapse and which tissues are involved. Understanding these classifications helps determine the most appropriate treatment approach.

Mucosal prolapse (partial prolapse) involves only the inner lining of the rectum, not the full thickness of the rectal wall. This type typically produces a smaller protrusion and may be confused with prolapsed hemorrhoids. Mucosal prolapse often occurs in younger patients and may respond to conservative treatment or minor procedures.

Full-thickness prolapse (complete prolapse) involves all layers of the rectal wall protruding through the anus. This creates a larger, more obvious prolapse that typically shows concentric circular folds rather than the radial folds seen with hemorrhoids. Full-thickness prolapse almost always requires surgical treatment for definitive repair.

Internal prolapse (intussusception) occurs when the rectum folds in on itself internally but does not protrude through the anus. This type can be particularly difficult to diagnose because there is no visible external prolapse, yet patients experience significant symptoms such as difficulty evacuating, sensation of incomplete emptying, and the need to use manual maneuvers to have bowel movements.

What Are the Symptoms of Rectal Prolapse?

The primary symptom of rectal prolapse is a visible mass or bulge of tissue protruding from the anus, particularly during bowel movements. Other symptoms include fecal incontinence, constipation, mucus discharge, rectal bleeding, and a sensation of incomplete bowel evacuation.

Rectal prolapse produces a range of symptoms that can significantly impact quality of life. The symptoms often develop gradually, with the prolapse initially occurring only during straining and spontaneously retracting afterward. As the condition progresses, the prolapse may become more frequent, eventually remaining outside the body even when not straining.

Many patients first notice the condition when they feel a mass or bulge while wiping after a bowel movement. Initially, this tissue may slip back inside on its own. Over time, patients may need to manually push the prolapsed tissue back inside, a process called manual reduction. In advanced cases, the prolapse may remain outside permanently, causing ongoing discomfort and hygiene challenges.

The emotional and psychological impact of rectal prolapse should not be underestimated. Many patients feel embarrassed about their condition and may delay seeking medical care. However, early diagnosis and treatment typically lead to better outcomes, making it important to overcome any hesitation about discussing symptoms with a healthcare provider.

Primary Symptoms

• Visible tissue protrusion: A reddish mass of tissue protruding through the anus, particularly during bowel movements, coughing, or straining. The tissue may initially retract spontaneously but progressively requires manual replacement
• Fecal incontinence: Difficulty controlling bowel movements, ranging from occasional leakage to complete loss of bowel control. This occurs because the prolapse stretches and damages the anal sphincter muscles
• Constipation: Difficulty passing stool, often with excessive straining. The prolapse can actually obstruct the passage of stool, creating a vicious cycle where straining worsens the prolapse
• Mucus discharge: Persistent mucus leakage from the anus, which can cause skin irritation and hygiene problems. The exposed rectal lining produces excess mucus when prolapsed
• Rectal bleeding: Blood on toilet paper or in the toilet, typically bright red. Bleeding occurs from trauma to the exposed rectal tissue or from associated ulceration

Secondary Symptoms

Beyond the primary symptoms, rectal prolapse can cause several secondary effects that further impact daily life. Understanding these symptoms helps patients recognize the condition and communicate effectively with healthcare providers.

• Sensation of incomplete evacuation: Feeling that the bowels have not been fully emptied after a bowel movement, often leading to prolonged time on the toilet and repeated straining attempts
• Pelvic pressure or discomfort: A feeling of heaviness, fullness, or pressure in the pelvic region, which may worsen with standing or physical activity
• Anal pain or discomfort: Aching, burning, or sharp pain in the anal region, particularly when the prolapse is outside the body
• Skin irritation: Redness, itching, and soreness around the anus due to constant exposure to mucus and difficulty maintaining hygiene
• Urinary symptoms: In women, rectal prolapse often coexists with other pelvic organ prolapse, potentially causing urinary incontinence or difficulty emptying the bladder

What Causes Rectal Prolapse?

Rectal prolapse results from weakening of the muscles and ligaments that support the rectum. Major causes include chronic constipation and straining, multiple vaginal childbirths, aging and tissue degeneration, neurological conditions, and previous pelvic surgery. The condition often develops from a combination of these factors.

The development of rectal prolapse typically involves multiple contributing factors working together over time. Understanding these causes can help identify individuals at higher risk and guide prevention strategies. While some risk factors like age and genetics cannot be modified, others such as straining and dietary habits can be addressed to reduce risk.

The fundamental problem in rectal prolapse is failure of the normal supporting structures that keep the rectum in position. The pelvic floor muscles, which form a supportive sling under the pelvic organs, can become weakened or stretched. The ligaments and fascial attachments that anchor the rectum to surrounding structures can loosen or tear. When these supports fail, gravity and increased abdominal pressure during straining push the rectum downward and eventually out through the anus.

Research has shown that patients with rectal prolapse often have anatomical differences that predispose them to the condition. These may include a deeper than normal pouch between the rectum and uterus or bladder, a longer than normal sigmoid colon, and a more mobile rectum with less firm attachments. These anatomical variations, combined with environmental factors, create the conditions for prolapse to develop.

Primary Risk Factors

Several key factors significantly increase the risk of developing rectal prolapse. Understanding these risk factors can help individuals and healthcare providers take preventive measures.

Chronic constipation and straining is perhaps the most modifiable risk factor for rectal prolapse. Years of straining during bowel movements creates repeated downward pressure on the rectum and progressively stretches the supporting tissues. This chronic mechanical stress eventually overwhelms the pelvic floor's ability to resist, allowing the rectum to descend. Treating constipation with dietary changes, fiber supplements, and proper toilet habits can significantly reduce this risk.

Childbirth and pregnancy significantly increase risk in women, particularly with multiple vaginal deliveries. The process of vaginal birth stretches and can tear the pelvic floor muscles and nerves. Additionally, the weight of the pregnant uterus places prolonged pressure on the pelvic structures. Episiotomies and forceps deliveries may further increase risk by causing additional tissue damage.

Advanced age is a major risk factor because tissues naturally lose elasticity and strength over time. The muscles of the pelvic floor atrophy with age, and the ligaments become more lax. This explains why rectal prolapse is most common in people over 50 years old, with peak incidence in the 60s and 70s.

Additional Contributing Factors

• Previous pelvic surgery: Hysterectomy and other pelvic procedures can disrupt the normal support structures and increase prolapse risk
• Neurological conditions: Diseases affecting the nerves to the pelvic floor, such as multiple sclerosis, spinal cord injuries, or diabetic neuropathy, can impair muscle function
• Chronic cough: Conditions causing prolonged coughing, such as COPD or chronic bronchitis, create repeated increases in abdominal pressure
• Connective tissue disorders: Conditions like Ehlers-Danlos syndrome that affect collagen can weaken the supportive tissues
• Obesity: Excess weight increases chronic pressure on the pelvic floor
• Parasitic infections: In some regions, infections such as schistosomiasis can contribute to prolapse

How Is Rectal Prolapse Diagnosed?

Diagnosis typically begins with a physical examination where the doctor observes the prolapse during straining. Additional tests may include defecography (imaging during defecation), colonoscopy to rule out other conditions, anorectal manometry to assess muscle function, and MRI of the pelvis for detailed anatomical evaluation.

Diagnosing rectal prolapse usually starts with a careful medical history and physical examination. The doctor will ask about symptoms, their duration, bowel habits, and any factors that make symptoms better or worse. Information about past surgeries, childbirth history, and other medical conditions helps paint a complete picture.

The physical examination is the cornerstone of diagnosis. In many cases, the prolapse is immediately visible when the patient is examined. If the prolapse is not visible at rest, the doctor will ask the patient to strain as if having a bowel movement. This may be done in different positions, sometimes including sitting on a commode, to reproduce the conditions under which prolapse occurs. The doctor will note the size of the prolapse, whether it involves the full thickness of the rectal wall, and how easily it can be pushed back inside.

A digital rectal examination is performed to assess the strength of the anal sphincter muscles and to feel for any masses or abnormalities inside the rectum. The doctor checks the resting tone of the sphincter and asks the patient to squeeze to evaluate voluntary muscle strength. This information helps predict whether fecal incontinence may be an issue after surgery.

Diagnostic Tests

Several specialized tests may be ordered to fully evaluate rectal prolapse and plan treatment:

Defecography (also called evacuation proctography) is a specialized X-ray or MRI study that images the rectum and anus during defecation. The patient is given a contrast material to fill the rectum, then asked to evacuate while images are captured. This dynamic study shows exactly how the rectum behaves during straining and defecation, revealing the extent of prolapse and any associated problems like rectocele or pelvic floor dyssynergia.

Colonoscopy examines the entire colon and rectum using a flexible camera. While not specifically diagnosing prolapse, colonoscopy is important to rule out other conditions that might be causing symptoms or that could complicate treatment, such as colorectal cancer, polyps, or inflammatory bowel disease. Most patients with rectal prolapse will have a colonoscopy as part of their workup.

Anorectal manometry measures the pressures generated by the anal sphincter muscles. Sensors are placed in the anal canal to record resting pressure, squeeze pressure, and the rectal sensation threshold. This test helps predict which patients are at risk for incontinence and guides surgical planning.

Anal electromyography (EMG) assesses the nerve supply to the pelvic floor muscles. This test can identify nerve damage that might affect surgical outcomes or indicate the need for additional therapies.

How Is Rectal Prolapse Treated?

Treatment options range from conservative measures like dietary changes and pelvic floor exercises for mild cases, to surgical repair for complete prolapse. Surgical approaches include abdominal procedures (rectopexy) offering 90-95% success rates, and perineal procedures (Delorme or Altemeier) for higher-risk patients with 70-80% success rates.

The treatment of rectal prolapse depends on several factors including the type and severity of prolapse, the patient's overall health, symptoms such as incontinence, and patient preferences. While conservative measures may help mild cases or patients unfit for surgery, most complete rectal prolapses ultimately require surgical repair for definitive treatment.

The goals of treatment extend beyond simply correcting the anatomical problem. Effective treatment should also address bowel function, control symptoms like incontinence and constipation, and improve quality of life. For many patients, achieving these goals requires a combination of surgical repair and ongoing management of bowel habits.

Conservative Treatment

Non-surgical approaches can be effective for mucosal prolapse, internal prolapse, or patients who are not surgical candidates. These measures can also help prevent recurrence after surgical repair.

Dietary modifications form the foundation of conservative treatment. A high-fiber diet with 25-30 grams of fiber daily helps create soft, bulky stools that are easier to pass without straining. Fiber sources include whole grains, fruits, vegetables, and legumes. Adequate hydration with 8-10 glasses of water daily is equally important, as fiber absorbs water to work effectively.

Bowel habit training teaches patients to respond promptly to the urge to defecate, avoid prolonged sitting on the toilet, and refrain from straining. Elevating the feet on a small stool during bowel movements can help achieve a more favorable position that requires less straining.

Pelvic floor rehabilitation includes exercises to strengthen the pelvic floor muscles (Kegel exercises) and biofeedback training. Biofeedback uses sensors to help patients learn to coordinate their pelvic floor muscles properly during defecation. This therapy can be particularly helpful for patients with pelvic floor dyssynergia, where the muscles paradoxically contract instead of relaxing during bowel movements.

Surgical Treatment

Surgery is the definitive treatment for complete rectal prolapse and is indicated when conservative measures fail for partial prolapse. Two main surgical approaches exist: abdominal procedures and perineal procedures. The choice depends on patient factors including age, overall health, bowel function, and surgeon expertise.

Abdominal procedures (Rectopexy) approach the rectum through the abdomen, either with traditional open surgery or laparoscopically. These procedures mobilize the rectum and fix it in the proper position, often with mesh reinforcement. Types include:

• Ventral mesh rectopexy: Places mesh along the front of the rectum to support it. This technique has become popular as it avoids the back of the rectum where nerves run, reducing constipation risk
• Posterior suture rectopexy: Sutures the rectum to the sacrum without mesh. Lower risk of mesh complications but potentially higher recurrence
• Resection rectopexy: Removes a portion of the sigmoid colon along with rectopexy. May be preferred when significant constipation or redundant colon exists

Perineal procedures approach through the anus without abdominal incisions, making them suitable for elderly or high-risk patients who may not tolerate abdominal surgery. Options include:

• Delorme procedure: Removes only the mucosa of the prolapsed segment and plicates the muscle layers. Less invasive but higher recurrence rate
• Altemeier procedure (perineal rectosigmoidectomy): Removes the prolapsed rectum and sigmoid colon through the anus. More definitive than Delorme but still avoids abdominal surgery

When Should You See a Doctor for Rectal Prolapse?

Seek medical attention if you notice tissue protruding from your anus, experience rectal bleeding, have difficulty controlling bowel movements, or feel a constant sensation of incomplete evacuation. Seek emergency care immediately if the prolapsed tissue becomes dark, extremely painful, or cannot be pushed back in.

Many people delay seeking medical care for rectal prolapse due to embarrassment or the mistaken belief that nothing can be done. However, early evaluation and treatment typically lead to better outcomes. The condition rarely improves on its own and usually progresses over time if left untreated.

A consultation with a healthcare provider is recommended when you first notice tissue protruding from the anus, even if it goes back in on its own. The doctor can determine whether it is truly rectal prolapse or another condition like hemorrhoids, and can advise on treatment options. Early intervention may allow for more conservative treatment approaches.

Routine evaluation becomes more urgent when symptoms progress. If you find yourself needing to manually push tissue back inside after bowel movements, if you are experiencing fecal incontinence or increasing constipation, or if you notice bleeding or persistent discharge, these are signs that the condition is advancing and professional evaluation is needed.

Can Rectal Prolapse Be Prevented?

While not all cases can be prevented, you can reduce risk by avoiding constipation and straining, eating a high-fiber diet (25-30g daily), staying well hydrated, performing regular pelvic floor exercises, maintaining healthy weight, and using proper toilet positioning. Prompt treatment of chronic constipation is particularly important.

Prevention of rectal prolapse focuses primarily on reducing chronic straining during bowel movements and maintaining strong pelvic floor muscles. While some risk factors like age and childbirth history cannot be changed, many contributing factors can be modified through lifestyle changes.

The cornerstone of prevention is maintaining healthy bowel habits. This means ensuring regular, soft bowel movements that pass easily without straining. A diet rich in fiber from whole grains, fruits, vegetables, and legumes provides the bulk needed for easy passage. Adequate water intake helps fiber work effectively. When dietary changes alone are insufficient, fiber supplements like psyllium can help.

Proper toilet habits also matter significantly. Responding promptly to the urge to defecate prevents stool from becoming harder and more difficult to pass. Avoiding reading or phone use on the toilet discourages prolonged sitting. Using a small footstool to elevate the feet puts the body in a more natural squatting position that allows easier evacuation with less straining.

Prevention Strategies

• Dietary fiber: Consume 25-30 grams of fiber daily from whole foods and supplements if needed
• Adequate hydration: Drink 8-10 glasses of water daily to help fiber work properly
• Pelvic floor exercises: Regular Kegel exercises strengthen the muscles supporting the rectum
• Avoid straining: Never strain forcefully during bowel movements; if stool does not pass easily, try again later
• Limit toilet time: Spend no more than a few minutes on the toilet; prolonged sitting increases pressure
• Maintain healthy weight: Excess weight increases pressure on pelvic floor structures
• Treat chronic cough: Persistent coughing creates repeated strain on pelvic floor; seek treatment for underlying causes
• Post-pregnancy care: After childbirth, pelvic floor physical therapy can help restore muscle function

Living With Rectal Prolapse

Managing rectal prolapse between diagnosis and treatment involves learning to reduce the prolapse manually, maintaining excellent hygiene, using protective pads if needed, continuing bowel management strategies, and attending regular follow-up appointments. Many patients maintain good quality of life while awaiting or recovering from treatment.

For patients awaiting surgery or those who cannot undergo surgical treatment, living with rectal prolapse requires ongoing management strategies. While the condition can significantly impact daily life, most patients can maintain reasonable function and comfort with proper care.

Learning to manually reduce the prolapse is an important skill. When the rectum protrudes, gentle pressure can usually push it back inside. This is best done after washing hands, applying lubricant, and lying on your side with knees bent toward the chest. Steady, gentle pressure allows the tissue to slip back through the anal opening. If the prolapse is difficult to reduce or causes significant pain during attempts, medical attention should be sought.

Maintaining good hygiene helps prevent complications like skin breakdown and infection. After bowel movements, gentle cleaning with moistened wipes followed by thorough drying helps protect the sensitive perianal skin. Barrier creams can protect against moisture and irritation from mucus discharge. Absorbent pads may be needed if there is significant leakage.