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Rectal Prolapse

What is rectal prolapse?
Rectal prolapse is a condition where the rectum protrudes out through the anus. This condition is not common and is commonly mistaken for haemorrhoids. However, it is very important to make an accurate diagnosis as the treatment is very different. Thankfully, making the distinction is quite easy with minimal tests required.
Rectal prolapse is usually classified into 3 categories based on the degree of prolapse; rectal intussusception, rectal mucosal prolapse and full thickness rectal prolapse. Rectal intussusception describes the situation where the upper rectum prolapses into the lower rectum but does not protrude out of the anus. If only the mucosal layer (inner layer) of the rectum prolapses out of the rectum, it is called rectal mucosal prolapse. When all layers of the rectum protrude out of the anus, it is called full thickness rectal prolapse.
What causes rectal prolapse?
The rectum is held in place by its ligaments and fascia attachments to the sacrum (behind it) and vagina/prostate (in front). The pelvic floor (which consists of muscles) holds up the rectum from below. The rectum can prolapse because the supporting ligaments of the rectum have become elongated and lax or if the pelvic floor muscle weakens. Often, it is a mixture of both. Experts in pelvic floor disorders manage rectal prolapse as a physical manifestation of pelvic floor weakness and will assess your global pelvic organ supports as well.
Any disease or condition that weakens/ stretches the ligaments and fascia of the rectum or vagina can cause rectal prolapse. If the pelvic floor muscle is damaged or stretched, it can cause rectal prolapse too. Some common examples are chronic straining at bowel movements or post-menopausal women with pelvic floor descent. People with congenitally lax ligaments are more prone to developing rectal prolapse. It is also commonly seen in very young infants and toddlers due to their immature and lax ligaments but these children do not need treatment as the problem disappears spontaneously.
What are the symptoms?
In rectal intussusception, the patient feels that it is difficult to complete a bowel movement as the prolapsing rectum fools the rectal nerves into thinking there is more faeces in the rectum. The patient repeatedly strains to pass motion but is ultimately unproductive. This group of patients is difficult to diagnose as the rectum does not protrude out of the anus.
For the other 2 categories, patients often present with a prolapsing lump at the anus which can be mistaken for haemorrhoids. The prolapsed rectum looks reddish and is painless to touch. Occasionally, one may experience fresh rectal bleeding from haemorrhoids which may have prolapsed together with the rectum. There may be preceding history of long-standing constipation and use of laxatives. Constipation is associated with up to 65% of cases of rectal prolapse.
In patients with persistent prolapse, they often complain of itch around the anus (pruritis ani) or mucoid discharge due to excess mucus production and seepage from the exposed rectal mucosa. Sometimes, the chronic prolapse prevents the anus from closing properly and lead to bowel incontinence. Differentiating between rectal mucosal prolapse and full thickness rectal prolapse is based on clinical examination by an experienced doctor, preferably a colorectal surgeon or surgeon with special interest in colorectal surgery.
How is rectal prolapse diagnosed?
The diagnosis is usually made on clinical examination. When rectal intussusception is suspected, you may be required to undergo a specialized x-ray test called defaecating proctogram which studies how a person passes a bowel motion. A dynamic assessment of the pelvic floor using ultrasound or MRI is often used to assess the support structures around the rectum.
How is rectal prolapse treated?
Rectal intussusception can occasionally be controlled by treating a patient’s constipation with medication and toilet habit re-education (anorectal biofeedback). If that works well, the patient may not need surgery.
Patients with rectal mucosal prolapse and full thickness rectal prolapse require surgery. The type of surgery for each case is individualized based on the patient’s concomitant medical condition(s), age and severity of rectal prolapse. They are broadly categorized into abdominal operations (treating the prolapse using an approach through the abdomen) and perineal operations (treating the prolapse using an approach from the anus). Your doctor can explain the options in more detail during your consultation.
Do I need any tests before surgery?
Before performing surgery for rectal prolapse, you should have a colonoscopy to exclude colon cancer or polyps which require more urgent treatment. If there is a suspicion of anal muscle weakness, you may be asked to undergo anorectal physiology measurements (ARM), which provides information for your colorectal surgeon to plan your management.
What do I need to look out for after surgery?
Surgery will correct the physical rectal prolapse immediately. It is important that you follow your doctor’s advice on exercise, diet and medication after surgery as these factors affect how quickly you return to normal activity. If a patient returns to his/her previous habits (such as constipation or chronic straining), the risk of recurrent rectal prolapse increases.
If you have feedback or would like to know more about treatment for these conditions, feel free to contact us or make an appointment.