Rectal Prolapse

The term “prolapse” is used in the medical field to describe any body part that has shifted from its normal position due to weakened or deteriorated supporting muscles. While some muscle weakening is a natural part of aging, factors like childbirth, chronic constipation, or diarrhea can expedite this process, leading to rectal prolapse.

Your rectum, the final part of your large intestine before reaching your anus, plays a crucial role in preparing waste, commonly known as poop, for elimination from your body. When poop reaches your rectum, it signals the urge to defecate, and a network of muscles kicks into action, pushing the waste out through your anus. However, in cases of rectal prolapse, a condition where the rectum slips from its usual position, it can descend into the anal canal, sometimes protruding through the anus. Though not typically an urgent medical situation, prolonged presence of rectal prolapse can exacerbate the condition, leading to discomfort and impacting daily life.

Rectal prolapse affects approximately 2.5 individuals per 1,000, with a higher incidence among those assigned female at birth. While it’s more commonly observed in individuals over 50, it can also occur in children, particularly those dealing with chronic diarrhea or cystic fibrosis.

Noticing any unusual sensations during bowel movements or experiencing difficulty passing stool should not be ignored. Consulting a doctor for diagnosis and treatment is essential in such cases.

Types

Rectal prolapse manifests in three main forms:

1. External prolapse: The entire rectum protrudes from the anus.
2. Mucosal prolapse: Part of the rectal lining protrudes from the anus.
3. Internal prolapse: The rectum begins to descend but hasn’t yet protruded from the anus.

Causes of Rectal prolapse

Several factors can contribute to rectal prolapse, such as:

1. Digestive Issues: Persistent diarrhea or constipation over time can strain the rectal area, increasing the risk of prolapse.
2. Cystic Fibrosis: This condition, known for its impact on breathing and digestive functions, can also predispose individuals to rectal prolapse.
3. Intestinal Parasites: Infections caused by intestinal parasites can weaken the rectal area, potentially leading to prolapse.
4. Chronic Straining: Long-term habits of straining during bowel movements can weaken the muscles and ligaments supporting the rectum.
5. Aging: As people age, the muscles and ligaments in the rectal area may weaken, making prolapse more likely.
6. Previous Trauma: Injuries to the anal or hip area can increase the risk of rectal prolapse.
7. Nerve Damage: Damage to nerves controlling muscle function, possibly due to factors like pregnancy, difficult vaginal childbirth, or spinal injuries, can contribute to this prolapse.
8. Neurological Disorders: Conditions affecting the spinal cord, such as diseases or trauma, may also increase the risk of prolapse.

Risk factors

Certain factors elevate the risk of developing rectal prolapse:

• Gender and Age: Rectal prolapse is more prevalent in individuals assigned female at birth, particularly as they age.
• History of Pelvic Issues: Individuals with a history of constipation or pelvic floor problems, especially in older age, are at higher risk.
• Chronic Straining: Regularly straining during bowel movements increases the likelihood of rectal prolapse.
• Back Injuries or Disorders: Lower back injuries or diseases affecting spinal discs can contribute to prolapse.
• Neurological Conditions: Conditions like dementia or stroke can impair muscle function, potentially leading to prolapse.
• Previous Medical Interventions: Surgeries like hysterectomy or conditions such as benign prostatic hypertrophy can increase the risk.
• Family History: Having a family member with rectal prolapse may indicate a genetic predisposition.
• Other Medical Conditions: Conditions like chronic obstructive pulmonary disease (COPD) or congenital bowel disorders can also raise the risk.

Rectal prolapse symptoms

Symptoms of this prolapse include:

• Sensation of sitting on a ball after bowel movements.
• Presence of a protrusion from the anus, which may retreat back inside initially but later becomes persistent.
• Additional symptoms may include:
• Feeling a bulge outside the anus.
• Observing a red mass outside the anal opening.
• Pain in the anus or rectum.
• Anal itching.
• Constipation.
• Fecal incontinence (loss of bowel control).
• Rectal bleeding.
• Leakage of blood, stool, or mucus from the anus.

While rectal prolapse might resemble hemorrhoids in its early stages, these are distinct conditions. Hemorrhoids are swollen blood vessels in the anus or lower rectum, often causing itching, pain, and bleeding during bowel movements. A proper diagnosis from a healthcare professional can differentiate between rectal prolapse and hemorrhoids.

Children with Rectal prolapse

Rectal prolapse is relatively uncommon in children, but it can occur in certain cases, such as:

• Chronic Constipation or Straining: Children who regularly strain during bowel movements may be at risk.
• Chronic Diarrhea: Persistent diarrhea can weaken the rectal area, increasing the likelihood of prolapse.
• Poor Nutrition: Inadequate nutrition can contribute to weakened muscles and tissues in the rectal area.
• Cystic Fibrosis: This condition, which affects breathing and digestion, can predispose children to rectal prolapse.
• Spinal Cord Injury or Tethered Cord: Injuries to the spinal cord or conditions like tethered cord syndrome can impact muscle function in the rectal area.
• Issues with Colon and Pelvis: Conditions such as Hirschsprung’s disease, characterized by a lack of nerve cells in the bowel, can lead to blockages and increase the risk of prolapse.
• Anal Penetration: In cases of potential sexual abuse, anal penetration can result in rectal prolapse.

If a child experiences rectal prolapse, treatment is typically provided by their pediatrician. However, if the child has an underlying chronic condition like cystic fibrosis, they may require specialized care from a specialist or even surgical intervention.

Diagnosis

Diagnosing this prolapse can sometimes be challenging for doctors, as it may resemble other conditions like hemorrhoids. To confirm the diagnosis, various tests may be recommended, including:

1. Digital Rectal Exam: This involves the insertion of a gloved finger into the anus to assess muscle strength.
2. Anal Electromyography (EMG): This test evaluates nerve function in the anal sphincter.
3. Anal Manometry: A thin tube inserted into the rectum measures muscle strength.
4. Anal Ultrasound: This procedure uses a probe inserted into the anus and rectum to examine muscles and tissues.
5. Pudendal Nerve Terminal Motor Latency Test: It assesses the function of the pudendal nerves involved in bowel movements.
6. Proctography (Defecography): This test uses MRI or X-ray videos to observe rectal function during bowel movements.
7. Colonoscopy: A long tube with a camera examines the inside of the intestines for any abnormalities.
8. Proctosigmoidoscopy: Similar to colonoscopy, this test looks for inflammation, scarring, or tumors in the lower intestines.
9. MRI: This imaging scan assesses pelvic organs for any abnormalities.
10. Lower GI Series (Barium Enema): X-rays are taken to visualize the lower gastrointestinal tract.

These diagnostic tests help doctors determine the cause of symptoms and plan appropriate treatment for the prolapse in children.

Treatments

Treatment for this prolapse depends on the severity of the condition and individual factors. Here’s what you need to know about rectal prolapse treatment:

1. Self-Care and Conservative Measures:
   • In mild cases detected early, self-care methods may suffice. These include using stool softeners to ease bowel movements and manually pushing the rectum’s tissue back into the anus.
   • Children may find relief through treating the underlying cause, such as chronic diarrhea or constipation.
2. Surgery:
   • Surgery becomes necessary for rectal prolapse that doesn’t improve with conservative measures, particularly in adults where muscle repair doesn’t occur naturally.
   • The type of surgery recommended depends on factors like overall health, age, and the severity of the condition.
   Rectopexy:
   • This surgical procedure involves accessing the rectum through the abdominal area, either through a large incision or laparoscopy.
   • During rectopexy, the surgeon secures the rectum back in place using stitches or mesh. General anesthesia is typically administered for this procedure, especially for severe cases.
   • Rectopexy boasts a success rate of about 97% in treating rectal prolapse.
   Perineal Surgery:
   • Also known as rectal repair, perineal surgery may be recommended for older individuals, those with minor prolapse, or if the rectum is adhered to the skin outside the body.
   • Two main types of perineal surgery are performed:
     • Altemeier Procedure: Involves removing the prolapsed part of the rectum and stitching the remaining large intestine to the anus. However, there’s a risk of recurrence with this procedure.
     • Delorme Procedure: Suitable for minor prolapse cases, this procedure entails removing the rectal lining, folding the muscle wall back in, and stitching it to the anal canal.

Risks of Surgery

General Complications:

1. Bleeding: There is a risk of bleeding during or after surgery.
2. Infection: Surgical sites can become infected, leading to complications.
3. Blood Clots: Blood clots may form in the veins, potentially causing serious complications if they travel to other parts of the body.
4. Injury to Nearby Organs: During surgery, nearby organs may be accidentally injured.
5. Anesthesia Complications: Adverse reactions to anesthesia can occur, although they are rare.

Additional Risks Specific to Rectal Prolapse Surgery:

1. Anastomotic Leak: This complication arises if the two ends of the bowel that were cut and reconnected fail to heal properly, leading to a leakage of bowel contents into the abdomen. Another surgery may be required to repair this.
2. Constipation: Some individuals may experience worsened constipation after rectal prolapse surgery, or they may develop constipation even if they didn’t experience it before surgery. Scar tissue in the bowels could contribute to this issue.
3. Sexual Dysfunction: Rectopexy, a common surgery for rectal prolapse, carries a small risk (1% to 2%) of damaging a nerve connected with male sexual function, potentially resulting in sexual dysfunction.

Recovery

Hospital stay is typically short, possibly overnight, with a gradual progression from liquids to solid foods.

Monitoring bowel movements is crucial post-surgery, with emphasis on hydration, fiber intake, and stool softeners to prevent constipation and recurrence.

Normal activities can usually be resumed within 4-6 weeks post-surgery.

Prevention

Preventing rectal prolapse involves adopting healthy habits to reduce strain during bowel movements. Here’s what you can do to prevent rectal prolapse:

1. Avoid Straining: Refrain from straining during bowel movements, as this can exacerbate the condition. To ease or prevent constipation, consider the following:
   • Increase Fiber Intake: Aim for a minimum of five servings of fruits and vegetables each day to boost fiber intake, which promotes healthy bowel movements.
   • Stay Hydrated: Drink 6-8 glasses of water daily to maintain proper hydration levels, aiding in digestion and bowel regularity.
   • Regular Exercise: Engage in regular physical activity to promote overall digestive health and bowel function.
   • Maintain a Healthy Weight: Keep your weight within a healthy range or work on losing weight if necessary, as excess weight can contribute to constipation and strain during bowel movements.
2. Consult Your Doctor: If you experience frequent constipation, consult your doctor. They may recommend stool softeners or laxatives to alleviate symptoms.
3. Avoid Heavy Lifting: Steer clear of heavy lifting activities, as they can exert pressure on the muscles surrounding the bowel, potentially leading to strain.

Complications of untreated rectal prolapse

The complications arising from untreated rectal prolapse include:

• Rectal Damage: Untreated rectal prolapse can cause rectal damage such as ulceration or bleeding.
• Inability to Manually Reduce Prolapse: Over time, the ability to manually push the rectum back into the body may diminish.
• Strangulation: In severe cases, the blood supply to the rectum may become compromised, leading to strangulation.
• Gangrene: Strangulated rectal tissue may decay and die, resulting in gangrene.
• Difficulty Controlling Gas and Stool: Many individuals with rectal prolapse experience difficulty in controlling gas and stool, occurring in about 50%-75% of cases.
• Constipation: Chronic constipation may worsen if rectal prolapse is left untreated.

Outlook

Rectal prolapse may start mildly but worsen over time, especially if you have existing bowel issues. Surgery is often effective in correcting it, but recurrence is possible in some cases. Bowel complications may persist after surgery, requiring additional treatment. Regular follow-up care is essential for monitoring and managing the condition effectively. Overall, early intervention and tailored medical care can improve the outlook for rectal prolapse and associated complications.

Sources

• University of Massachusetts Memorial Medical Center:
• Cedars-Sinai Hospital
• Johns Hopkins Medicine
• Foundation of the American Society of Colon and Rectal Surgeons
• Cleveland Clinic
• Mayo Clinic
• American Congress of Obstetricians and Gynecologists: “Laparoscopy.”
• CDC: “Cystic Fibrosis.”
• Cedars-Sinai
• Boston Children’s Hospital
• Children’s Mercy Hospital
• American Society of Colon and Rectal Surgeons
• Victoria State Government Better Health