Rectal Prolapse

What is rectal prolapse?

Rectal prolapse is a condition where the rectum looses its normal attachments inside the body allowing it to protrude out through the anus. There are three main types of prolapse:

• Mucosal prolapse – only the lining of the rectum is prolapsing.
• Internal prolapse – the rectum is prolapsing but is not yet protruding through the anus.
• Complete prolapse – full thickness external prolapse of the rectum through the anus.

Why does rectal prolapse occur?

The precise cause in not known. There are a number of factors associated with prolapse including female, advancing age, chronic constipation with straining at stool as well as medical conditions such as connective tissue disorders. Possible explanations include a weak pelvic floor or inadequate fixation of the rectum. Prolapse affects women 6 times more commonly than men.

What are the symptoms of prolapse?

Commonly, patients first notice protrusion of the rectum through the anus initially during defecation. The prolapse may need to be pushed back by hand. Later, there can be discomfort, bleeding, mucous discharge and incontinence. The incontinence becomes more severe the longer the prolapse has been present.

Is prolapse the same as haemorrhoids?

Although some of the symptoms can be the same, haemorrhoids only involve the inner layer of the bowel near the anal opening.

How is rectal prolapse diagnosed?

A careful history and examination is usually all that is required to diagnose rectal prolapse. Sometimes it might be necessary to sit on the toilet to demonstrate the prolapse. Mucosal prolapse and internal prolapse may sometimes require further tests to diagnose accurately. These may include a defecating proctogram or an examination under a general anaesthetic. A colonoscopy may sometimes be required.

How is rectal prolapse treated?

Mucosal prolapse can be treated by rubber band ligation or sometimes by surgery. Incomplete prolapse is usually treated with bulking agents / laxatives but surgery is sometimes required.

Full thickness rectal prolapse usually needs surgery.

There are a variety of surgical options to treat prolapse. This includes both abdominal and trans-anal approaches. Most patients that are fit for surgery would be candidates for abdominal surgery.

This usually involves rectopexy and may be performed robotically. The trans-anal (perineal) procedures involve either stripping the mucosa (Delorme’s procedure) or a full thickness resection of the bowel (Altemeier’s procedure). After correcting the prolapse, patients with incontinence may be candidates for sacral nerve neuromodulation to improve their function (see Faecal Incontinence).

How successful is treatment?

The prolapse is generally well treated with either abdominal or trans-anal approaches. The abdominal approaches tend to be longer lasting with lower long-term recurrence rates. Bowel function can be considerably improved following surgery. For patients with prolapse that have had incontinence, it may take some time (up to 1 year) to regain optimum strength and function.

What is a colorectal surgeon?

A colorectal surgeon is an expert in the surgical and non-surgical treatment of colon and rectal conditions. In Australia, a colorectal surgeon has completed general surgical training to be a specialist general surgeon (FRACS). A minimum of 2 years of clinical post-fellowship training is then undertaken in high volume accredited institutions through the Colorectal Surgical Society of Australia and New Zealand (CSSANZ). There is also a research requirement and a written examination on colon and rectal conditions. An equivalent domestic or international experience may qualify a surgeon for CSSANZ accreditation.