Rectal Prolapse: Symptoms, Causes, and Surgical Treatment

What is Rectal Prolapse?

Rectal prolapse is a condition in which the rectum, or a portion of it, descends from its normal anatomical position and protrudes through the anal opening. In simpler terms, part of the large intestine slides out of place and becomes visible or palpable outside the body.

The condition encompasses a broad spectrum of severity. At one end, there may be mild internal displacement that the patient does not even notice. At the other extreme, complete external prolapse can occur, where a significant length of the rectum protrudes through the anus and cannot be reduced without medical assistance.

Rectal prolapse is more common in older adults and affects women significantly more than men, likely due to the cumulative impact of childbirth, hormonal changes, and age-related pelvic floor weakening on the supportive structures of the pelvis. However, it can occur in any individual at any age, including children (usually in association with specific underlying conditions).

Key Symptoms

The most commonly reported symptoms include:

• Discomfort and pain in the anorectal region
• Mucous discharge from the rectum
• Rectal bleeding
• A persistent or frequent urge to defecate (tenesmus)
• Anal itching (pruritus ani)
• Fecal incontinence
• Visible or palpable protrusion of rectal tissue through the anus

Treatment Approach

A wide range of treatment options is available. These include conservative lifestyle measures for mild or early cases and definitive surgical repair for advanced presentations. The optimal approach is selected based on:

• The patient’s age, sex, and general health status
• The severity and type of prolapse
• The presence of associated bowel dysfunction (constipation or incontinence)
• The patient’s surgical fitness and personal preferences

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Definition and Types of Rectal Prolapse

Anatomy of the Rectum

The rectum is the final segment of the large intestine. It measures approximately 12 cm in length and is positioned between the sigmoid colon above and the anal canal below. It acts as a temporary reservoir for stool before defecation and plays a critical role in maintaining continence.

The rectal wall is composed of three distinct layers (tunics):

1. Mucosa: The innermost layer, lining the rectal lumen and producing mucus
2. Submucosa: A loosely organized connective tissue layer beneath the mucosa. This layer is particularly susceptible to displacement in cases of prolapse
3. Muscularis: The muscular layer responsible for rectal motor function

The rectum is held in its correct anatomical position by pelvic floor muscles, endopelvic fascia, lateral ligaments, and the rectosacral fascia. When these supporting structures weaken or fail, the rectum can descend and protrude.

Classification of Rectal Prolapse

By Tissue Layers Involved

• Full-thickness (complete) rectal prolapse: All three rectal layers (mucosa, submucosa, and muscularis) slide downward and protrude through the anus. This is the most clinically significant form, more common in older adults and associated with a higher risk of complications.

• Partial (mucosal) prolapse: Only the innermost mucosal layer descends and protrudes. This less severe form tends to occur in younger individuals and may be associated with prolapsing hemorrhoids, which it can closely resemble clinically.

By Degree of External Descent

• External prolapse: The prolapsed tissue protrudes visibly through the anal opening, making it the most obvious and recognizable form. May be reducible (spontaneously or manually) or irreducible.

• Internal prolapse (intussusception): The rectum telescopes inward on itself, but it does not protrude through the anus. Instead, it remains contained within the rectum or anal canal. This form is often occult (not visible on external examination) and diagnosed only with specific investigations such as defecography.

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Causes

At the root of both complete and mucosal rectal prolapse lies weakness and dysfunction of the pelvic floor. This area serves as the anatomical foundation that supports and correctly positions the rectum, bladder, urethra, and, in women, the uterus.

The pelvic floor is a complex, integrated structure composed of:

• Muscles: Particularly the levator ani complex (puborectalis, pubococcygeus, iliococcygeus) and the external anal sphincter
• Fasciae and ligaments: Including the endopelvic fascia, uterosacral and cardinal ligaments, and the Waldeyer’s fascia connecting the rectum to the sacrum
• Connective tissue: Providing tensile strength and elasticity

When any of these components deteriorates, the rectum loses adequate support and may descend progressively.

The exact causes of pelvic floor failure are not fully understood, but several factors appear to contribute:

• Aging: Progressive loss of muscle mass, elasticity, and connective tissue integrity
• Obstetric trauma: Vaginal delivery, especially when labor is complicated or prolonged, involves the use of instruments like forceps, or occurs in multiple pregnancies, can stretch, tear, or denervate the pelvic floor and its innervation, such as the pudendal nerve
• Prior pelvic surgery: Previous anorectal, gynecological, or urological procedures may disrupt supporting structures
• Genetic predisposition: Some individuals have an inherent weakness of connective tissue that predisposes to pelvic organ descent

Risk Factors

Elevated Intra-abdominal Pressure

Any condition that chronically raises intra-abdominal pressure transmits mechanical stress to the pelvic floor, gradually overwhelming its supportive capacity:

• Chronic constipation with excessive straining: Prolonged, forceful straining during defecation stretches and weakens the pelvic floor over time. This is especially true for the pudendal nerve, which provides motor innervation to the external anal sphincter and pelvic muscles. Straining-induced pudendal neuropathy (stretch injury to the nerve) is a recognized contributing mechanism.
• Obesity: Excess abdominal weight chronically increases intra-abdominal pressure
• Multiple pregnancies: The cumulative mechanical load of repeated pregnancies progressively strains pelvic support structures
• Chronic cough (e.g., from smoking or chronic respiratory disease): Repeated forceful cough episodes increase intra-abdominal pressure

Prior Pelvic Trauma or Surgery

• Obstetric injuries: Tears of the levator ani, perineal lacerations, pudendal nerve injury, or damage to the anal sphincters during vaginal delivery significantly increase long-term prolapse risk
• Previous pelvic or anorectal surgery: Operations in the pelvis may inadvertently damage supporting ligaments, fasciae, or nerves

Neurological and Muscular Disorders

Conditions affecting the nervous system or musculature supplying the pelvic floor can impair its supportive function:

• Spinal cord lesions: Tumors, disc herniation, traumatic injury, or spinal stenosis affecting sacral nerve roots
• Peripheral neuropathies: Diabetic neuropathy and other systemic neuropathies can impair pudendal nerve function
• Myopathies: Conditions weakening pelvic floor muscles directly

Pediatric-Specific Risk Factors

In children, rectal prolapse is more commonly associated with specific underlying conditions:

• Ehlers-Danlos syndrome: Inherited connective tissue disorder causing generalized hyperlaxity
• Hirschsprung’s disease: Congenital absence of enteric ganglion cells causing functional obstruction and straining
• Cystic fibrosis: Malnutrition, chronic cough, and increased straining all contribute to prolapse
• Malnutrition and chronic diarrheal diseases: In resource-limited settings, these remain important pediatric causes

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Symptoms

The clinical presentation of rectal prolapse varies considerably depending on the type and severity of prolapse. Symptoms may range from barely noticeable in early or internal prolapse to severely debilitating in complete external prolapse.

Characteristic Symptoms

• Anal and rectal pain: Ranging from mild discomfort to severe pain, particularly during defecation or with prolonged prolapse

• Rectal bleeding: Fresh blood on the stool or toilet paper, resulting from mucosal trauma, ulceration, or congestion of the prolapsed segment

• Mucous discharge: Excess mucus production from the prolapsed, inflamed rectal mucosa

• Sensation of incomplete evacuation: A persistent feeling that defecation is not fully accomplished, often prompting repeated, unproductive attempts (tenesmus)

• Protrusion of rectal tissue through the anus: The defining symptom of external prolapse. Initially occurs only during straining (defecation, coughing, sneezing) and the prolapsed tissue spontaneously reduces after the effort ceases. In more advanced stages, reduction may require manual repositioning by the patient. Ultimately, the prolapse may become irreducible, remaining permanently protruding.

• Anal itching (pruritus ani): Caused by mucus soiling and perianal skin irritation

• Mucosal ulceration: Chronic friction and vascular compromise of the prolapsed segment may lead to ulcer formation. These ulcers are visible on endoscopy

• Fecal incontinence: Particularly common in complete (full-thickness) prolapse, because the constant distension of the anal sphincter by the prolapsed rectum weakens and fatigues the sphincter muscle over time. This is one of the most distressing symptoms and significantly impacts quality of life.

Important clinical note: Many symptoms of rectal prolapse, such as bleeding, pruritus, mucous discharge, and prolapsing tissue, closely resemble those of hemorrhoidal disease. Careful clinical examination and, when necessary, endoscopy are required to distinguish between the two.

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Progression and Complications

Natural History and Progression

Rectal prolapse is a progressive condition if left untreated. The typical course follows a predictable pattern:

1. Early stage: Prolapse occurs only during defecation or other activities that transiently increase intra-abdominal pressure (coughing, sneezing, lifting). At this stage, the prolapsed segment spontaneously reduces after the triggering event.

2. Intermediate stage: The prolapse becomes more frequent and more easily triggered. Manual reduction is required after episodes. Symptoms such as mucous discharge, bleeding, and soiling become more prominent.

3. Advanced stage: The prolapse occurs spontaneously, even with simple postural changes such as standing upright. It may become chronically irreducible, meaning it remains permanently prolapsed. Fecal incontinence worsens progressively due to chronic sphincter stretching and distension.

Complications

• Mucosal ulceration: Chronic trauma and vascular congestion of the prolapsed tissue lead to ulcer formation, contributing to bleeding and pain

• Vascular compromise and necrosis: In severe or irreducible prolapse, blood supply to the prolapsed segment may be interrupted, which can lead to ischemia and tissue necrosis. This is a rare but potentially catastrophic complication, presenting with severe pain, fever, and signs of systemic toxicity. It constitutes a surgical emergency.

• Worsening fecal incontinence: Progressive sphincter damage leads to increasingly severe incontinence

• Anal fissures and skin excoriation: From chronic mucous soiling

Associated Pelvic Floor Disorders

Weakness of the pelvic floor, which is the common underlying mechanism, frequently results in concurrent pelvic organ prolapse across multiple compartments.

• Cystocele (bladder prolapse): Descent of the bladder base below the pubococcygeal plane into the anterior vaginal wall, causing urinary symptoms.

• Uterine prolapse: Descent of the uterus, which can vary in severity. It may range from minor descent within the vaginal canal to complete procidentia, where the uterus protrudes externally.

• Rectocele: Protrusion of the anterior rectal wall into the posterior vaginal wall, often causing difficulty with defecation (need to digitally splint the vagina to facilitate stool passage).

• Enterocele: Herniation of the peritoneal sac (containing small bowel) into the rectovaginal space.

The coexistence of multiple pelvic floor defects is common and should be systematically assessed before planning treatment.

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Diagnosis

Clinical Examination

In obvious (external, fully prolapsed) cases, the diagnosis is established by visual inspection and physical examination alone, performed by a proctologist or colorectal surgeon. The patient may be asked to perform the Valsalva maneuver, which involves straining as if attempting to defecate, to reproduce and demonstrate the prolapse during the examination. This is particularly useful when the prolapse reduces spontaneously at rest.

The physical examination also assesses:

• Degree and reducibility of the prolapse: Is it reducible spontaneously? Manually?
• Sphincter tone: Digital rectal examination reveals sphincter laxity, which correlates with fecal incontinence risk
• Mucosal condition: Presence of ulceration, erythema, congestion, or necrosis
• Concurrent perianal pathology: Hemorrhoids, fissures, or fistulae

Instrumental Investigations

When the diagnosis requires confirmation (particularly for internal prolapse) or when surgical planning is needed, additional tests are performed:

• Anorectoscopy (proctoscopy): Direct endoscopic visualization of the rectal lumen, used to diagnose internal intussusception and assess mucosal condition

• Colonoscopy and barium enema: To evaluate the entire colon, exclude neoplastic or inflammatory lesions that may contribute to prolapse, and assess colonic transit

• Defecography (dynamic proctography): A fluoroscopic imaging study in which the patient defecates contrast material on a specially designed commode while X-ray images are obtained. This is the most valuable test for diagnosing internal prolapse (occult intussusception) and can simultaneously reveal concurrent pelvic floor abnormalities including rectocele, cystocele, and enterocele. MRI defecography provides superior soft tissue resolution and avoids radiation exposure.

• Anorectal manometry: Measures the functional pressures of the anal sphincters (resting and squeeze pressures) and the rectoanal inhibitory reflex. This test is particularly important before surgical planning, as it quantifies pre-existing sphincter dysfunction and helps predict functional outcomes after repair. It also allows assessment of rectal compliance and sensation.

• Pudendal nerve terminal motor latency (PNTML): This test evaluates the integrity of pudendal nerve conduction. It is particularly useful for patients with significant fecal incontinence, as it helps assess neuropathic damage.

• Transanal ultrasound: Assesses the structural integrity of the internal and external anal sphincter muscles, particularly important in patients with fecal incontinence

Differential Diagnosis

Several anorectal conditions may mimic or be confused with rectal prolapse:

• Prolapsing hemorrhoids: These can protrude through the anus, causing bleeding, mucous discharge, and discomfort. Their symptoms closely resemble those of partial (mucosal) prolapse. Distinguished by the absence of concentric mucosal folds (characteristic of full-thickness prolapse), the radial arrangement of hemorrhoidal cushions, and typically harder consistency on palpation.

• Mucosal polyps: Large rectal polyps may prolapse through the anal opening during defecation; distinguished by their stalk and localized origin.

• Proctitis: Rectal inflammation causing erythema and mucosal changes may be visually confused with prolapse mucosa. In doubtful cases, mucosal biopsy can definitively exclude inflammatory or infectious proctitis.

• Hypertrophied anal papillae: Benign fibrous polyps arising from the dentate line; may protrude externally but are easily distinguished by palpation and anoscopy

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Treatment

The choice of treatment depends on several factors: the type and severity of prolapse, the patient’s age and general health status, the presence of associated symptoms (particularly fecal incontinence or constipation), and the patient’s functional goals and expectations.

Conservative Management

In early or mild cases, particularly those involving partial (mucosal) prolapse, internal intussusception, or prolapse in elderly patients with significant surgical risk, conservative measures may temporarily improve symptoms and slow progression. However, these approaches are unlikely to achieve a definitive cure.

• Dietary fiber and hydration: Increasing dietary fiber intake to 25–30 g/day and drinking adequate fluids (1.5–2 L/day) softens stools and reduces straining. This is the cornerstone of conservative management.

• Bulk-forming laxatives: Agents such as psyllium or methylcellulose reduce straining associated with chronic constipation

• Defecation retraining and biofeedback: Teaching correct defecation technique (avoiding prolonged straining) and biofeedback therapy for pelvic floor rehabilitation can improve symptoms, particularly fecal incontinence

• Manual reduction of acute episodes: Patients with reducible prolapse can be taught to gently reduce prolapsed tissue manually

• Protective ointments and perianal skin care: To manage irritation and skin breakdown from mucous soiling

Surgical Intervention

For advanced, complete, or symptomatic prolapse, surgery remains the only definitive treatment. No medication or conservative measure can correct the anatomical defect of full-thickness rectal prolapse. It is important to counsel patients that even after surgical repair, recurrence is possible. The likelihood of recurrence depends on several factors: the surgical approach, the surgeon’s experience, and the patient’s underlying risk factors.

Most surgical procedures for rectal prolapse are performed under general anesthesia. In elderly or medically frail patients, epidural or spinal anesthesia may be preferred to reduce the systemic physiological burden of anesthesia.

Surgical approaches are broadly classified into two categories:

Abdominal Approach (Rectopexy)

The abdominal approach accesses the pelvis through the abdomen (via open laparotomy or laparoscopic/robotic surgery). The primary goals are:

1. Mobilization and reduction of the prolapsed rectum
2. Rectopexy: A procedure to fix the mobilized rectum to the presacral fascia or sacral promontory. This restores the normal anatomical position and prevents re-prolapse
3. Sigmoid resection (resection rectopexy): In patients with associated constipation, simultaneous removal of the redundant sigmoid colon helps address constipation-related straining that contributed to the prolapse

Advantages of the abdominal approach:

• Lower recurrence rate: The most durable repair, particularly for laparoscopic ventral mesh rectopexy
• Better functional outcomes: Particularly for fecal incontinence, which resolves in the majority of patients
• Indicated for younger patients in good general health

Modern minimally invasive variants:

• Laparoscopic rectopexy: Equivalent outcomes to open surgery with smaller incisions, less postoperative pain, and faster recovery
• Robotic-assisted rectopexy: Offers superior precision and dexterity in the narrow pelvis
• Laparoscopic ventral mesh rectopexy (D’Hoore technique): A mesh-augmented repair that avoids extensive posterior mobilization of the rectum (reducing the risk of autonomic nerve injury and constipation), while providing excellent recurrence rates. Currently one of the most widely adopted approaches in experienced centers.

Perineal Approach

Perineal procedures access the rectum through the perineum (the area between the genitals and the anus), avoiding any abdominal incision. They are preferred for:

• Partial (mucosal) prolapse
• Elderly or medically frail patients in whom abdominal surgery carries unacceptable risk
• Patients with severe cardiorespiratory comorbidities

Common perineal procedures:

• Altemeier procedure (perineal proctosigmoidectomy): The prolapsed rectum and a portion of the sigmoid colon are resected through the perineum, and a coloanal anastomosis is fashioned. Suitable for complete prolapse; may be combined with a levatorplasty to improve sphincter function.

• Delorme procedure: The mucosal layer is stripped from the prolapsed segment, and the underlying muscular wall is plicated (folded and sutured) to shorten the bowel and reduce the prolapse, after which the mucosa is repaired. Less radical than the Altemeier; generally better tolerated in frail patients.

• Thiersch procedure (anal encirclement): A subcutaneous wire or mesh is placed around the anal canal to mechanically narrow it and prevent prolapse. Now largely of historical interest due to high complication rates.

Advantages of perineal approach:

• Avoids abdominal entry, reducing physiological stress. This makes it suitable for high-risk patients
• Less postoperative pain and shorter hospital stay
• Faster recovery

Disadvantages:

• Higher recurrence rate compared to abdominal approaches
• Functional outcomes (particularly for incontinence) may be less favorable

Choosing the Right Approach

Postoperative Considerations and Potential Complications

Rectal prolapse surgery is generally well-tolerated, but like any operation, it carries inherent risks.

• General surgical risks: Bleeding, infection, wound complications, deep vein thrombosis, anesthetic risks
• Specific functional complications (uncommon):
  • De novo or worsening constipation: More common after posterior rectopexy without sigmoid resection; less common with ventral mesh rectopexy
  • Fecal incontinence: Usually improves after successful repair, but may persist if sphincter damage is severe
  • Anastomotic complications: Leak or stricture after resection-based procedures (rare)
  • Mesh-related complications (erosion, infection): A recognized risk with mesh-augmented repairs, though uncommon with correct surgical technique
• Recurrence: The rate varies by procedure. It is lower with abdominal approaches, at 5–10%, while perineal approaches have higher rates. For example, the Delorme procedure has a recurrence rate of up to 30–40% at 5 years, and the Altemeier procedure is slightly lower.

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Sources and Bibliography

• Dionigi R. Chirurgia, 3rd Edition. Masson.
• Bordeianou L et al. Rectal prolapse: an overview of clinical features, diagnosis, and patient-specific management strategies. J Gastrointest Surg. 2014;18(5):1059-1069. PubMed
• Formijne Jonkers HA et al. European consensus statement on the diagnosis and treatment of rectal prolapse. Colorectal Dis. 2017;19(11):972-984. PubMed
• D’Hoore A et al. Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients. Colorectal Dis. 2006;8(5):372-377. PubMed
• Tou S et al. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev. 2015;(11):CD001758. PubMed
• American Society of Colon and Rectal Surgeons (ASCRS): Rectal Prolapse
• NHS: Rectal Prolapse
• Mayo Clinic: Rectal Prolapse