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Rectal Prolapse
 

Rectal prolapse occurs when the upper portion of the rectum telescopes itself inside out and protrudes through the anus. This is found more often in older women, but it can occur in women of any age as well as in men (much more rarely). Typically the patient who presents with a rectal prolapse has a history of constipation with chronic straining at the time of bowel movement. Over time, attachments that help maintain the rectum in its normal anatomic position weaken, allowing the rectum to progressively telescope itself inside out.

Symptoms

Symptoms typically include feelings of incomplete evacuation, feeling like there is a "ball" inside the rectum, and frequently feeling the need to move your bowels, with little or no passage of stool. These symptoms may occur early in the process, before the rectum protrudes through the anus (an occult prolapse- also known as in Intussusception). Once the rectum protrudes through the anus, patients frequently experience bleeding and mucus drainage along with feeling the protrusion of the rectum. Initially the prolapse may spontaneously reduce (the prolapse returns into the rectum), however, with progression of time and ongoing straining, the prolapse may need to be manually reduced and with further progression rare cases may become incarcerated (unable to reduce without surgical intervention). Also during these time frames, the prolapse may initially occur with straining at the time of bowel movement, but may get to the point where it occurs with any activity. With progression of this problem, the prolapse itself may damage the sphincter muscle involved in control of the passage of stool. If that occurs, fecal incontinence or accidental leakage of stool could result.

Diagnosis

By taking a careful history and performing a complete anorectal examination, we are typically able to diagnose a prolapse. During the examination, we may ask you to strain as if having a bowel movement or to sit on the toilet and strain to produce the prolapse. If the prolapse is internal we may see the prolapse with an anoscope in place. If we are not sure, we will have you go for a defecating proctogram, whereby thick barium paste is placed into the rectum. You will then sit on a commode and evacuate the barium while multiple xrays are obtained. This procedure simulates what happens to you at the time of defecation and will give us information to help determine the best management of your problem. A newer procedure, MRI defecography may also give us information related to the rectum as well as the pelvic floor. Additionally, anal manometry may be used to determine whether or not the muscles around the anus are functioning normally.

Hemorrhoids vs. Rectal Prolapse

Hemorrhoidal prolapse is when the hemorrhoidal tissue composed of blood vessels along with the inner lining of the low rectum protrudes outside the anus. A true rectal prolapse includes all layers of the rectum (full thickness). Hemorrhoidal prolapse is seen to be present in separate quadrants around the anus, primarily the left lateral, right posterior and right anterior quadrants. Whereas, in the true prolapse most of the time the tissue will appear as concentric circles or "stacked coins" around the anus.

Treatment

Proper management depends on a number of factors including the age of the patient, the overall medical condition of the patient as well as the severity of the prolapse. But options are available for treatment, regardless of age or condition of the patient. It is important to use a Board Certified Colon and Rectal Surgeon in management of this problem since they will have the greatest number of options available thereby customizing your treatment. If the symptoms are mild a high-fiber diet to prevent constipation may be all that is necessary to manage the problem. On the other hand surgical correction is needed if the prolapse does not resolve by itself.

Rectal prolapse can successfully be repaired through either an abdominal or rectal procedure. Your doctor will discuss which procedure is most appropriate for you. An Altmeier procedure removes the rectum and portion of the lower colon, this is performed through the rectum. A Delorme procedure strips the lining of the prolapsing rectum while shortening the muscular layer of the rectal wall, again this is performed through the rectum. There are several surgical approaches for correction of a prolapse that are performed through an abdominal incision. This is incision is most often a Pfannenstiel or "bikini" incision, which typically causes less post operative pain. Most often the surgery involves removing a portion of the colon mobilizing then fixing the rectum to the sacral bone with mesh.

If incontinence accompanies the prolapse, this will improve in over half the patients once the prolapse is corrected. If continence does not improve, other treatment is available. We recommend a high fiber diet to all our patients with rectal prolapse.