Rectal prolapse- Definition, Causes, Types, and Treatment

Definition

Rectal prolapse is when part of your rectum sticks out through your anus (back passage) to form a lump. The rectum is the last part of your bowel. You may notice the rectal prolapse when you’re having a bowel movement. But it can also happen when you cough or sneeze, or even when you’re doing everyday activities, such as walking or standing up. Having a rectal prolapse can be uncomfortable and it may affect your daily life. You may feel embarrassed about it, but it’s important to see your GP if you think you may have a rectal prolapse.

Epidemiology

The annual incidence of rectal prolapse in Finland was found to be 2.5 per 100,000 population.

Age-related demographics

Although all ages can be affected, peak incidences are observed in the fourth and seventh decades of life. Pediatric patients usually are affected when younger than 3 years, with peak incidence in the first year of life. Mucosal prolapse is more common than complete prolapse (possibly because of poor fixation of the submucosa to the mucosa in pediatric patients). The incidence of the prolapsed rectum in children with cystic fibrosis approaches 20%.

Types of Rectal prolapse

There are three types of rectal prolapse.

Partial prolapse (also called mucosal prolapse): The lining (mucous membrane) of the rectum slides out of place and usually sticks out of the anus. This can happen when you strain to have a bowel movement. Partial prolapse is most common in children younger than 2 years.

Internal prolapse (intussusception): One part of the wall of the large intestine (colon) or rectum may slide into or over another part, like the folding parts of a toy telescope. The rectum does not stick out of the anus. (See a picture of intussusception.) Intussusception is most common in children and rarely affects adults. In children, the cause is usually not known. In adults, it is usually related to another intestinal problem, such as a growth of tissue in the wall of the intestines (such as a polyp or tumor).

Complete prolapse: The entire wall of the rectum slides out of place and usually sticks out of the anus. At first, this may occur only during bowel movements. Eventually, it may occur when you stand or walk. And in some cases, the prolapsed tissue may remain outside your body all the time.

Rectal prolapse risk factors

In children, rectal prolapse may be associated with cystic fibrosis, Ehlers-Danlos syndrome, Hirschsprung’s disease, congenital megacolon, malnutrition, and rectal polyps.

• Increased intra-abdominal pressure- eg, constipation, diarrhea, benign prostatic hypertrophy, pregnancy, severe or chronic cough (eg, chronic obstructive pulmonary disease, cystic fibrosis, whooping cough).
• Previous surgery.
• Pelvic floor dysfunction.
• Parasitic infections- eg, amoebiasis, schistosomiasis.
• Neurological disease- eg, previous lower back or pelvic trauma, lumbar disc disease, cauda equina syndrome, spinal tumors, multiple sclerosis.
• Psychiatric disease.

Causes of Rectal prolapse

Rectal prolapse can occur as a result of many conditions, including:

• Chronic (long-term) constipation or chronic diarrhea
• The long-term history of straining during bowel movements
• Older age: Muscles and ligaments in the rectum and anus naturally weaken with age. Other nearby structures in the pelvis area also loosen with age, which adds to the general weakness in that area of the body.
• The weakening of the anal sphincter: This is the specific muscle that controls the release of stool from the rectum.
• Earlier injury to the anal or pelvic areas
• Damage to nerves: If the nerves that control the ability of the rectum and anus muscles to contract (shrink) are damaged, rectal prolapse can result. Nerve damage can be caused by pregnancy, difficult vaginal childbirth, anal sphincter paralysis, spinal injury, back injury/back surgery, and/or other surgeries of the pelvic area.
• Other diseases, conditions, and infections: Rectal prolapse can be a consequence of diabetes, cystic fibrosis, chronic obstructive pulmonary disease, hysterectomy, and infections in the intestines caused by parasites – such as pinworms and whipworms – and diseases resulting from poor nutrition or from difficulty digesting foods.

Symptoms

The symptoms of rectal prolapse depend on the severity, but can include:

• Pain and discomfort felt deep within the lower abdomen
• Blood and mucus from the anus
• The feeling of constipation, or that the rectum is never completely emptied after passing a motion
• Difficulties passing a bowel motion
• Protrusion of the rectum through the anus
• The need to use huge quantities of toilet paper to clean up following a bowel motion
• Leakage of liquefied feces, particularly following a bowel motion
• Fecal incontinence or reduced ability to control the bowels.

Protrusion of the rectum through the anus

Complications of Rectal prolapse

Complications include:

Strangulated prolapse: This occurs when part of the rectum becomes trapped and cuts off the blood supply, causing the tissue to die. This can develop gangrene, and the area will turn black and drop off. It is rare and requires surgery.

Solitary rectal ulcer syndrome: Present in mucosal prolapse, ulcers can develop on the part of the rectum sticking out. This complication often requires surgery.

Recurring prolapse: People who have surgery for rectal prolapse may have another prolapse at some point in the future.

Diagnosis and test

Your doctor or nurse should be able to tell if you have the problem by doing an exam. If the tissue has moved back inside your body, your doctor might ask you to squat or sit on the toilet. He or she will check to see if the tissue has come back out of your body.

You might need other tests. These tests can also show if you have a different problem. They include:

Cystocolpoproctography- A doctor fills your bladder, vagina, and rectum with a substance called “contrast material.” This allows these body parts to show up on X-rays and gives your doctor a view into how they are working.

Defecography- Contrast material is placed in the rectum. Care experts take X-rays while you have a bowel movement.

Manometry- A test that measures the pressure inside the rectum. It can show if the muscles that control bowel movements are working correctly.

Treatment and medications

Treatment will depend on your symptoms, your age, and your general health. It will also depend on how severe the condition is. Treatment often begins with steps to prevent constipation and straining.

If your rectal prolapse is severe and interferes with your quality of life, your healthcare provider may advise surgery. Types of surgery include:

Repair through the abdomen: A cut is made through the lower belly. The rectum is attached to the lower part of the backbone to support it and keep it in place.

Repair through the rectum: Your surgeon removes the part of the rectum that has prolapsed and reconnects the remaining parts.

Repair with both these methods: These 2 methods may be combined to treat your prolapse.

Talk with your healthcare providers about the risks, benefits, and possible side effects of all treatments.

Rectal prolapse prevention

Preventing rectal prolapse isn’t always possible. You can reduce your risk if you maintain good intestinal health. To help avoid constipation, in particular:

• Make high-fiber foods part of your regular diet, including fruits, vegetables, bran, and beans
• Reduce the amount of processed food in your diet
• Drink plenty of water and fluids every day
• Exercise most, if not all, days of the week
• Manage your stress with meditation or other relaxation techniques