What is a rectal prolapse?

Rectal prolapse is the descent of the rectum into the anus causing pain, bleeding and incontinence. Learn about symptoms, diagnosis and treatments.

Rectal prolapse is the sliding or descent of the rectum wall outward through the anus. The rectum is the last part of the large intestine and is located before the anus; Its function is to store feces before defecation. It is surrounded by muscles, including the internal and external anal sphincter, that control the passage of feces.
Rectal prolapse is more common in women over 50 years old with a history of multiple births. It can also affect children.

It is classified into:

• Complete prolapse: the entire wall of the rectum protrudes through the anus.
• Partial prolapse: Only the inner layer (mucosa) of the rectum slides out.
• Internal prolapse (intussusception or rectal invagination): the rectum folds into itself, without protruding through the anus.

Causes

• Anatomical and structural causes.
  • Weak support of the pelvic floor muscles (due to advanced age, vaginal birth or multiple births).
  • Congenital defects in the connective tissue that affect the strength, elasticity and resistance of the tissues that support the rectum.
• Factors related to increased intra-abdominal pressure
  • Chronic constipation and repeated straining when defecating.
  • Chronic cough (e.g. in smokers or with lung diseases).
  • Any cause of sustained increase in abdominal pressure such as frequent lifting of heavy loads.
• Neuromuscular factors
  • Injuries or damage to the pelvic nerves (e.g. from surgery, trauma).
  • Paralysis or weakness of the sphincter muscles.
  • Neurological diseases (e.g. multiple sclerosis).
• History of previous pelvic surgeries.

What symptoms does it present?

• Sensation of a “mass” or “lump” protruding from the anus, especially when defecating; It can also be seen while standing or walking.
• Anal pain, itching or discomfort.
• Fecal incontinence (involuntary loss of gas or stool).
• Constipation or feeling of incomplete evacuation.
• Rectal bleeding or expulsion of mucous secretion.

Serious complications of rectal prolapse

• Ischemia and strangulation: When the prolapsed rectum is trapped outside the anus for too long, a lack of blood flow may occur, requiring urgent treatment.
• Ulceration and bleeding: The mucosa of the prolapsed rectum is exposed and may become irritated or ulcerated, causing rectal bleeding. Chronic blood loss can lead to anemia.
• Severe fecal incontinence.
• Anal narrowing (stenosis): As a result of chronic inflammation or scarring from ulcers, making defecation difficult.
• Infection: In advanced cases, necrosis or ulceration may predispose to local infections or abscesses.

Diagnosis

The diagnosis is usually clinical, through physical examination. The patient may be asked to apply pressure to check for rectal prolapse.

Complementary studies:

• Anoscopy or rectoscopy: to observe the anal canal and rectum.
• Colonoscopy: to explore the entire large intestine and rule out other causes of bleeding or the presence of other pathologies.
• barium enema: Contrast liquid is introduced into the anus and x-rays are taken.
• Defecography: Contrast in the form of a gel or paste is introduced into the rectum, and x-ray or MRI images are taken while the patient contracts and relaxes the anal muscles, as if he were having a bowel movement.
• Anorectal manometry: It is a diagnostic test that evaluates the function of the rectum and anal sphincter, measuring pressures, sensitivity and muscle coordination in that area. A narrow catheter or tube with pressure sensors is inserted through the anus and into the rectum. A small balloon can be inflated at the tip of the catheter to measure rectal capacity and sensitivity.
• MRI of the pelvic floor (in complex cases or associated with other prolapses, for example of the vagina or bladder).

Treatment

Treatment depends on the type and severity of the prolapse, the age and general condition of the patient.

In advanced cases, the prolapse may not reduce spontaneously and require medical intervention.

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Conservative treatment (in mild cases or in children)

• Pelvic floor exercises: Kegel exercises are voluntary contractions of the pelvic floor muscles, designed to strengthen them. These muscles are what support the rectum.
• Avoid straining when defecatingdietary changes (diet rich in fiber, hydration), exercise, use of mild laxatives if there is constipation.
• Treatment of underlying causes (chronic cough, neurological weakness).

Surgical treatment (in moderate to severe or recurrent cases)

The goal of surgery is to put the rectum back into place. It is usually performed with general anesthesia (more common in abdominal procedures in which the rectum is accessed through the abdomen) or with regional anesthesia (spinal or epidural) (more common in perineal processes in which the surgery is performed through the perineum, that is, the area between the anus and the genitals).

• abdominal repair: through traditional open surgery (laparotomy), or through laparoscopic surgery (minimally invasive, with small incisions and use of a camera) assisted or not by a robot.
  • Rectopexy: The rectum is fixed to the sacral wall using sutures or a mesh. In some cases, such as in patients with a history of chronic constipation, it can be combined with resection of part of the colon.
• Perineal repair: less invasive technique that is used especially in older people or people with high surgical risk:
  • Delorme procedure: The prolapsed mucosa is resected and the muscular layer is folded to shorten the rectum and keep it within the anal canal.
  • Altemeier procedure: The prolapsed rectum is resected and the remaining part is attached to the colon.
• Risks of surgery: bleeding. intestinal obstruction, damage to nearby structures, infection. fistula [una comunicación irregular entre dos partes del cuerpo (como el recto y la vagina)]recurrence of rectal prolapse, constipation.

What you should know…

• Rectal prolapse is a treatable condition, but it can significantly affect quality of life.
• Early diagnosis and a multidisciplinary approach (medical, nutritional, physiotherapeutic and surgical if necessary) offer the best results.