Rectal Prolapse - Podcast Version 0:00 / 0:00 1x 0.25x 0.5x 0.75x 1x 1.25x 1.5x 1.75x 2x A rectal prolapse is the protrusion of mucosal or full-thickness layer of rectal tissue out of the anus. It is a relatively uncommon condition, affecting about 2.5 per 100 000 individuals each year in the UK, mainly affecting older females. There are two main types* of rectal prolapse: Partial thickness – the rectal mucosa protrudes out of the anus Full thickness – the rectal wall protrudes out the anus In this article, we shall look at the pathophysiology, clinical features, and management of rectal prolapse. *Internal intussusception is the prolapse of the rectum into the distal rectum or anal canal but without its protrusion outside of the anus Pathophysiology The current theories surrounding full prolapse suggest that is a form of sliding hernia, through a defect of the fascia of the pelvic region. This may be caused by chronic straining secondary to constipation, a chronic cough, or from multiple vaginal deliveries. In contrast, partial thickness prolapses are associated with the loosening and stretching of the connective tissue that attaches the rectal mucosa to the remainder of the rectal wall. This often occurs in conjunction with long standing haemorrhoidal disease. By Mohit Achanta, TeachMeSurgery [CC-BY-NC-ND 4.0] Figure 1Schematic demonstrating a rectal prolapse Risk Factors The main risk factors for rectal prolapse are increasing age, female gender, multiple deliveries, straining, anorexia, and previous traumatic vaginal delivery. Clinical Features Patients with a rectal prolapse will typically present with rectal mucus discharge, faecal incontinence, per rectum bleeding, or with visible ulceration. Full thickness prolapses (Fig. 2) will begin internally and thus can initially present with a sensation of rectal fullness, tenesmus, or repeated defecation. On examination, the prolapse may not always be evident, but can be identified by asking the patient to strain. A digital rectal examination should be performed, often on which a weakened anal sphincter is identified. For a suspected internal prolapse, defecating proctography and examination under anaesthesia may be the only means to diagnose clinically. By Mohit Achanta, TeachMeSurgery [CC-BY-NC-ND 4.0] Figure 2Appearances of a full thickness rectal prolapse Management Conservative management of rectal prolapse is more common in those unfit for surgery, with minimal symptoms, or in children (as most prolapses in children will resolve spontaneously). Initial management often involves increasing dietary fibre and fluid intake. Surgical Management Surgical repair is the only definitive management. The mainstay of treatments is between the abdominal approach and the perineal approach: Perineal approach The two more commonly performed operations are the Delormes operation* (the prolapsed lining of the rectal mucosa is removed and the underlying muscle reinforced with plicated sutures) and the Altemeier’s operation (resection of the redundant prolapsed bowel to restore the original anatomy) Abdominal approach Performed laparoscopically (most common), robotically, or open, the procedure will involve a rectopexy, whereby the rectum is mobilised and fixed onto the sacral prominence via sutures or mesh Overall, whilst studies have shown no difference in the post-operative outcomes between abdominal and perineal procedures, the perineal procedures are preferred in older patients as they are considered safer operations. Also, previous operations in the region of the respective approach may make the procedure more difficult (for instance, a patient who had a recurrence following a Delormes procedure may be more suitable for an abdominal approach. *Delormes procedure can be considered for smaller prolapses or frail patients, but it may have a higher rate of recurrence compared to an Altemeier’s operation Key Points Rectal prolapse can be either partial or full thickness prolapse Symptoms may include rectal mucus discharge, faecal soiling, or rectal bleeding Definitive management is via surgical repair, either by an abdominal or perineal approach Do you think you’re ready? Take the quiz below Pro Feature - Quiz Rectal Prolapse Question 1 of 3 Submitting... Skip Next Rate question: You scored 0% Skipped: 0/3 Keep your streak going Unlock the full question bank You’ve made a great start. Continue with over 1,200 MRCS-style MCQs, two full mock papers, and ad-free revision with TeachMeSurgery Pro. Continue with Pro Frequent questions What is rectal prolapse? Rectal prolapse is a condition where the rectal tissue protrudes through the anus, which can be either partial thickness, involving just the mucosa, or full thickness, where the entire rectal wall is involved. It predominantly affects older females and occurs at a rate of approximately 2.5 per 100,000 individuals annually in the UK. What causes rectal prolapse? Rectal prolapse is thought to result from a sliding hernia due to pelvic fascia defects, often triggered by chronic straining from constipation, chronic cough, or multiple vaginal deliveries. Partial thickness prolapse is typically linked to the stretching and loosening of connective tissue, often seen in patients with longstanding haemorrhoidal disease. What are the common symptoms of rectal prolapse? Patients with rectal prolapse may experience symptoms such as rectal mucus discharge, faecal incontinence, rectal bleeding, and visible ulceration. Full thickness prolapse may also present initially with a sensation of rectal fullness or tenesmus, which can be assessed during a physical examination. How is rectal prolapse diagnosed? Diagnosis of rectal prolapse can often be made through a physical examination, especially when the patient is asked to strain, revealing the prolapse. In cases of suspected internal prolapse, additional diagnostic methods like defecating proctography or examination under anaesthesia may be required. What are the treatment options for rectal prolapse? The definitive treatment for rectal prolapse is surgical repair, which can be performed via either an abdominal or perineal approach. The choice of procedure often depends on the patient's overall health and the specifics of the prolapse, with perineal methods being preferred for older patients due to their lower risk profile. Rate This Article