Rectal Prolapse – Causes, Symptoms, Diagnosis, Treatment

The rectum is the final part of the digestive system, which sits just before the anus. It’s the area that holds faeces before you pass a bowel movement. It is made up of rectal wall lining (the mucosa), a layer of strong muscle, and some fatty tissue.

Although rectal prolapses are most common in older women (six times more likely to occur in women over 50 years old than in men of the same age), rectal prolapse can occur in men and women of all ages. In men, rectal prolapses are more common in those under 40 years old.

As with most medical problems, it’s important not to put off treatment. Allowing your prolapse to go untreated for a long period of time leads to weakened pelvic muscles and damage to your anal sphincter and associated nerves – increasing the risk of it reoccurring. So avoid unnecessary delays and speak to your doctor if you have any concerns.

Stages of  Rectal Prolapse

There are various stages of rectal prolapse, which generally affect different ages:

• Full-thickness (complete) rectal prolapse – When part or all of the rectum falls out of place and protrudes from the anus. This is the most common type of rectal prolapse for all ages.
• Internal rectal prolapse (intussusception) – Occurs when the rectum has weakened sufficiently to fold in on itself as sections higher up fall down. This happens inside your body and your rectum will not poke out of your anus. An internal rectal prolapse is most common in children. In adults, this grade of prolapse is usually related to other intestinal problems such as tumour? growths.
• Partial (mucosal) rectal prolapse – It is possible to also have a partial (mucosal) rectal prolapse, where only the mucosal lining of the rectum protrudes from the anus. A partial (mucosal) rectal prolapse is most common in children under 2 years old.

In the most severe? cases of rectal prolapse, the large intestine may also fall from its natural position and, with the rectum, fall down. The stretching of tissue and straightening of the intestine, resulting in severe faecal incontinence?. If your rectal prolapse protrudes from your anus when passing stool, in the early stages you may be able to push it back up into your anus or simply standing up may cause it to retract. Eventually, however, gently pushing it back up may only work temporarily or you may not be able to get it to retract at all. Therefore it is important to get your condition diagnosed early and seek treatment.

Causes of Rectal Prolapse

Any of the following may cause a rectal prolapse:

• Constipation? – Continued straining to pass a stool will put extra pressure on the pelvic floor and could cause it to weaken.
• Childbirth – Again, around 50% of women who give birth vaginally will experience some level of prolapse. A large baby or a difficult birth where you’ve had to push a lot or forceps were used may increase your risk. More than one birth also increases your risk of experiencing a vaginal prolapse.
• Previous pelvic surgeries – A hysterectomy or previous vaginal prolapse surgery can weaken the pelvic floor muscles, and is likely to be part of the cause of any future pelvic organ prolapses.
• Bodyweight – Being overweight or obese can increase your chances of suffering a rectal prolapse due to the weight on your pelvic area.
• Persistent coughing – Constant heavy coughing can add pressure to the pelvic floor. If you smoke and have a persistent smokers cough? or if you have a lung condition that results in a cough, such as asthma? or bronchitis?, then you could be at a higher risk.
• Strenuous activity – Heavy, high impact exercises such as running or plyometric training (jump training) can cause the pelvic floor muscles to weaken.
• Chronic? diarrhoea? – Parasitic infections that result in chronic diarrhoea such as amoebiasis or schistosomiasis.
• Neurological conditions – Certain neurological conditions such as multiple sclerosis?, spinal tumours or lumbar? disc disease that put pressure on the nerves of the lower back?, bowel and rectum.
• Certain medications – Certain medications increase the likelihood of developing a rectal prolapse, always read the information leaflet that accompanies your medication.
• Genetics and physical development problems – Certain genetics increase the likelihood of developing a rectal prolapse, including autism and others associated with a developmental delay.
• Cystic fibrosis? – Children who develop a rectal prolapse should be tested for cystic fibrosis when the cause of the prolapse is not obvious.

Symptoms of  Rectal Prolapse

If you have a rectal prolapse, you may experience some or all of the following symptoms:

• faecal incontinence or stools uncontrollably leaking from the anus
• leaking mucus or blood from the anus
• a constant feeling of a full bowel
• an urgent need to have a bowel movement
• constipation
• passing many small stools
• a feeling of not having fully emptied the bowel
• a feeling of sitting on a ball
• inability to control gas/flatus incontinence
• anal irritation including pain?, itching? and bleeding
• red tissue that extends out of the anus that may or may not retract when you stand up
• red tissue that extends out of the anus when coughing, sneezing or heavy lifting

With the number of different prolapse conditions and their close proximity to each other in the body, it can be difficult to know which symptoms point to which condition. Visiting your doctor to get a diagnosis? is important and can help you decide which course of treatment is best for you.

Diagnosis of Rectal Prolapse

Medical history?

A health care professional may ask about your

• symptoms, such as bulges or lumps in the vagina?, pelvic pressure or heaviness, and urinary incontinence
• pregnancy and childbirth history
• current and past medical problems, including surgeries
• family history?
• over-the-counter and prescription? medicines
• bowel habits

History

Rectoceles have a broad range of symptoms. Some patients may present as asymptomatic? while others may demonstrate a significant impact on the quality of life, including the following symptoms[rx]:

• Pelvic pain?/pressure
• Posterior vaginal bulge
• Obstructive defecation
• Incomplete defecation
• Constipation
• Dyspareunia
• Erosions and bleeding of mucosa if there is tissue exposure to the outside environment

Physical Exam

A thorough examination will include a vaginal exam, rectal exam, abdominal exam, and focused neurological exam.

The focused neurological exam consists of levator ani muscle tone and contraction strength.

The vaginal exam can be evaluated using the Baden-Walker or POP-Q exam. The Baden-Walker system utilizes one measurement. The distance of the most distal portion of the prolapse from the hymen while the patient is completing the Valsalva manoeuvre.[rx]

Treatments for Rectal Prolapse

Depending on how severe your rectal prolapse is, there are a number of treatment options to treat the accompanying symptoms. It is wise to consider all non-surgical treatments before discussing surgery with your doctor. Targeted pelvic floor muscle exercises are a popular choice for seeing a quick and effective improvement in your prolapse. Non-surgical treatments will reduce your symptoms and lead to a faster recovery if you are advised to undergo surgery.

• Avoid constipation – Eating a healthy diet, rich in fibre, and ensuring you drink plenty of water will help to keep your bowels regular. High fibre foods include fruit, vegetables and wholegrain cereals. Regular, gentle exercise will also help to keep things moving as they should.
• Avoid straining – Straining on the toilet when trying to empty your bowels will put unnecessary pressure on your pelvic floor area. Causing the pelvic floor muscles to weaken and eventually allow a rectal prolapse. Going to the toilet using a toilet stool will bring your knees up and force you into the ideal posture for fully eliminating your bowels. For children, using a potty-training toilet can offer this support.
• Keep to a healthy weight – The National Institute for Heath and Care Excellence (NICE) recommend keeping your BMI under 30.
• Kegel exercises – Regularly performing Kegel / pelvic floor exercises will help to strengthen the pelvic floor muscles. The stronger these muscles, the more the organs in the whole pelvic region are likely to stay in place and avoid moving downwards and prolapsing.
• Treat chronic diarrhoea – If you have a persistent stomach bug and/or you’re constantly passing loose stools, seek medical help to resolve the problem.
• Lifestyle treatments – Change your diet to include more fibre, stay hydrated and avoid constipation and straining. Dietary changes can be enough to reverse a minor partial (mucosal) rectal prolapse, when in conjunction with pelvic floor exercises.
• Stool softeners – Stool softeners may be prescribed to treat constipation.
• Prescribed bulking laxatives – Your doctor may suggest a bulking laxative, such as Fybogel. This group of laxatives help you pass a bowel movement without needing to strain.
• Pelvic floor strengthening exercises and toners – A tried and true method is getting into the habit of performing regular pelvic floor strengthening exercises. These can make a real difference in reducing the symptoms of a rectal prolapse and can be made even more effective through the use of pelvic floor toners such as the Kegel8 Ultra 20 Electronic Pelvic Toner.
• Pushing your prolapsed rectum back up – Your doctor may teach you how to safely and gently push your prolapsed rectum back up inside your anus. To do this, it’s a good idea to add a water-based lubricant to your finger, to allow a smoother passage and cause less discomfort.
• Surgery – Your doctor will only look into surgical options following a physical examination and where they are satisfied by your medical history. If there is any uncertainty, it is likely that you will be recommended to try non-surgical treatments before proceeding down the path of surgery. If surgery is determined to be a suitable solution, your surgery will follow a colonoscopy and will aim to restore the positioning of the rectum to correct functionality as a secondary outcome. There are two ways in which a surgeon can repair a prolapsed rectum; either through the anus (also known as perineal), or through the abdomen. Your surgeon will decide which method is best for you, based on your age, gender, other medical complications and the severity of your rectal prolapse. Depending on the type of surgery you have, you will either have a general anaesthetic, a local anaesthetic with muscle relaxing medications, or a spinal block to numb the area, which is similar to an epidural given during childbirth. If x-rays show that lifelong constipation will continue to be an issue, your surgeon may also remove a portion of your colon at the same time as the rectal prolapse repair to further improve bowel function. If you do opt for surgery, it is important to note that surgery cannot repair your pelvic floor muscles. You will need to perform pelvic floor exercises after you recover from your surgery, to prevent the rectal prolapse from recurring and to support any synthetic or biological mesh from stretching.

How Long Does It Take to Recover from Rectal Prolapse Surgery?

A hospital stay following surgery to correct a rectal prolapse can be anywhere from six days to two weeks. Perineal surgery (through your anus), generally leads to a shorter hospital stay than any abdominal surgery. With recovery being the fastest for keyhole surgery (laparoscopic) to the abdomen over open abdominal surgery.

It is important to note that surgery is unable to repair your pelvic floor muscles, so you will need to perform pelvic floor exercises after your recovery to prevent the rectal prolapse from reoccurring. Other non-surgical treatments should also be followed to prevent future prolapses; such as eating well to avoid constipation and using a toilet stool to reduce straining.

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