Rectal Prolapse

Related Subjects: |Rectal Prolapse |Anal Cancer |Anal Fissure |Perianal symptoms |Perianal abscesses and fistulae |Pilonidal Abscess (sinus) |Haemorrhoids (Piles) |Faecal Incontinence |Rectal Pain (Proctalgia) |Rectal Foreign Body

Rectal prolapse = protrusion of rectal wall through the anus. It can cause major anxiety for patients and carers. Partial prolapse – mucosa only, a few cm outside anus. Complete prolapse – full thickness rectum; often elderly women, sometimes protruding 10–12 cm. Anal sphincter often becomes lax over time → worsening symptoms and possible incontinence.

⚠️ Aetiology & Risk Factors

• Weak pelvic floor / ligaments – e.g. multiparity.
• Chronic cough, constipation, prolonged straining.
• Neurological disease affecting pelvic innervation.
• Psychiatric disorders (sometimes associated with neglect of bowel care).
• Seen in both frail elderly and children (different mechanisms).

🩺 Clinical Features

• Commonest in older women.
• Protruding rectal mass on straining; initially self-reduces, later requires manual reduction.
• Advanced prolapse → ulcerated, painful, irreducible, risk of strangulation.
• Lax sphincter → faecal leakage or urgency.
• In severe cases rectum protrudes 10–12 cm, difficult to reduce.

🔎 Investigations

• FBC, U&E, LFTs → pre-operative fitness.
• Endoscopy or proctoscopy if diagnosis uncertain / to exclude malignancy.
• Defecating proctogram or MRI defecography in complex/recurrent cases.

🧾 Differential Diagnosis

• Haemorrhoids – usually cushion-like, not concentric rings.
• Rectal polyps or tumours.
• Anal skin tags.

💊 Management

• Acute prolapse reduction:
  • Lay patient in Trendelenburg position, apply sugar or salt granules → osmotically reduces oedema → attempt gentle manual reduction after ~15 min.
  • If irreducible → risk of necrosis/ulceration → urgent surgical review.
• Conservative measures (esp. in children): Improve bowel habits, high-fibre diet, stool softeners, avoid straining.
• Surgical options (depends on age & frailty):
  • Laparoscopic ventral rectopexy – preferred in fit adults; low recurrence, preserves continence.
  • Perineal approaches (Delorme’s, Altemeier’s) – used in frail elderly, less invasive but higher recurrence.
  • Thiersch procedure – anal encirclement with nylon/silicone; palliative option in frail/high-risk patients.

🌟 Exam Pearl: Haemorrhoids prolapse as discrete cushions at 3/7/11 o’clock, while rectal prolapse appears as concentric folds of mucosa.

Case examples

• 🚺 Case 1 – Age 76: Elderly woman with long-standing constipation and chronic straining presented with a full-thickness rectal prolapse visible after defaecation. She reported mucus discharge and faecal incontinence. Examination confirmed circumferential mucosal folds. Management: Optimised bowel habit (fibre, laxatives), pelvic floor physiotherapy, and referral for elective Delorme’s procedure due to frailty. Teaching point: In older women, pelvic floor weakness and chronic constipation are the key risk factors.
• 🏃‍♂️ Case 2 – Age 42: Manual labourer complained of a “bulge from the anus” during heavy lifting, reducible but recurrent. No bleeding or incontinence. Examination confirmed partial mucosal prolapse. Management: Advised stool softeners, avoidance of straining, and pelvic floor exercises. Surgical options (rectopexy) discussed for persistent symptoms. Teaching point: Younger adults may develop mucosal prolapse due to increased intra-abdominal pressure or connective tissue laxity.
• 🧒 Case 3 – Age 5: Child presented with a protruding rectal mass noticed by parents during bowel movement. History of chronic diarrhoea and undernutrition. Examination showed reducible mucosal prolapse, no ulceration. Management: Nutritional support, treatment of underlying diarrhoeal illness, and stool regulation. Most paediatric cases resolve conservatively. Teaching point: In children, prolapse often reflects systemic factors (malnutrition, diarrhoea) rather than true pelvic floor weakness.