Definition and Overview

Rectal prolapse is a medical condition wherein the wall of the rectum or a part of it, protrudes out of the anus. When left untreated, it can lead to permanent fecal incontinence.

The rectum belongs to the lower gastrointestinal tract. It is found at the end of the large intestine and comes before the anal canal. It is directly connected to the sigmoid colon, the last section of the large intestine.

It can grow around 10 to 15 centimeters with a diameter similar to the sigmoid colon. However, the part closest to the anus is bigger and is a part of the rectal ampulla. The rectum has different types of support including the pelvic floor, fascia, and ligaments.

The rectum serves as a temporary storage for fecal matter. As part of the bowel movement, fecal matter, which is often mixed with water so it’s easy to eliminate, travels from the colon to the rectum before it exits the anus. In the rectal walls, there are several nerves that are sensitive to the wall’s expansion. As feces fill in the rectal walls, these nerves send the signal that increases the urge to expel. However, when the body delays the process, the fecal matter travels again back to the colon, where water is absorbed from it. The longer it is held, the higher the possibility of constipation.

Sometimes, however, the rectum changes its position and slides down from where it’s attached and descends into the anus (complete prolapse). In certain cases, only the lining does (partial prolapse).

Although the rectum can stick out of the anus, it’s also possible it simply moves atop or into another area, in which case it is known as intussusception. Another scenario is when the entire rectum and a part of the large intestine slide from their normal position.

Rectal prolapse is often not a medical emergency, but it can be painful and usually embarrassing for both children and adults. It does not become cancer even if it’s left untreated.

Causes of Condition

There are many possible causes of rectal prolapse. These include:

  • Overstraining during bowel movement – It is an instinct to exert effort and pressure during a bowel movement, especially if one is suffering from constipation. At this time, there’s insufficient amount of water in the feces that it becomes dry and thus makes them harder to push out. The extra pressure may not immediately weaken the attachment, but it can if constipation and exertion become chronic.

  • Cystic fibrosis – Children who develop prolapse with no other possible cause may be checked for cystic fibrosis. This is a genetic disorder characterized by the buildup of sticky mucus in different parts of the body, including the gastrointestinal tract. The body, in general, is designed to create mucus for a variety of reasons. For example, it increases immunity and traps particles that can be otherwise harmful to the body. However, a defective gene creates thick and sticky mucus instead of something that’s thin and watery.

  • Pelvic floor weaknesses – As mentioned, the pelvic floor muscle serves as one of the main supports of the rectum. There are times, though, when it becomes weak such as after a strenuous childbirth, constant lifting of heavy objects, and old age.

  • A consequence of surgery – Surgeries carry certain risks, and one of these is the possibility of infection or disturbance of the rectal walls and supports that may eventually lead to rectal prolapse.

There are also risk factors associated with rectal prolapse. It is more common among:

  • Young children more than two years old
  • Older women from 50 years old and above
  • Men from 40 years old and above
  • People with chronic constipation

It happens to more women than men.

Key Symptoms

  • Feeling of something protruding from the anus
  • More consistent mucus or bloody discharge
  • Painful bowel movement
  • Sense of not completely filling out the colon
  • Presence of lump in the anus
  • Bowel incontinence (difficulty in controlling bowel movements)
  • Damage to the pelvic nerves
  • Constipation or diarrhea

Some people are able to determine that something is wrong when they get to feel a swelling or lump in the anus especially when they’re trying to urinate or defecate. The lump can be felt when touched. It is soft enough that it can be pushed in, but a more significant prolapse would have the rectum come out again.

Who to See and Treatments Available

An internist for adults and a pediatrician for children can diagnose rectal prolapse.

One of the first steps to be undertaken is to determine that the “loose ball” in the anus is not hemorrhoid, or a swollen vein that is found in the anus. To confirm, different types of tests can be performed including a defecography, where a contrast dye is introduced into the body and is monitored while the patient goes through a bowel movement. Sometimes the patient will be observed while he or she is trying to defecate in the commode.

It’s also possible for the doctor to recommend a colonoscopy especially among older patients. It can be that a polyp or tumor in the colon is forcing the rectum to come out.

If the problem is not too severe and is related to another condition such as the weak pelvic floor or cystic fibrosis, treating or managing the condition is sometimes enough to resolve the problem.

The patient always has the option to not undergo any treatment for rectal prolapse, but this may only result in fecal and sometimes urinary incontinence. The patient also becomes more susceptible to diarrhea, which can significantly reduce the quality of life.

If the rectal prolapse is already pronounced and severe, surgical procedures can be undertaken. In general, these surgeries may be via the abdomen or the bottom (perineal). The choice depends on a number of factors such as the age, the physical condition of the patient, and other existing diseases that are directly related to the prolapse.

One of the specific techniques in belly operation is the abdominal rectopexy, where the loose rectum is pulled up and then attached to the pelvic wall found at the back (sacrum). In the perineal approach, a method known as Altemeier procedure is carried out. In this instance, the entire rectum is allowed to prolapse or stick out of the anus. What sticks out is then removed with some of the colon pulled down. An excision is performed while what remains is then attached to the anus.

References:

  • Fry RD, Mahmoud N, Maron DJ, Ross HM, Bleir JIS. Colon and rectum. In: Townsend CM Jr., Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 19th ed. Philadelphia, PA: Elsevier Saunders; 2012:chap 52.

  • Lembo AJ, Ullman SP. Constipation. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisinger & Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia, PA: Elsevier Saunders; 2010:chap 18.

  • Verma M, Rafferty J, Buie WD. Practice parameters for the management of rectal prolapse. Dis Colon Rectum. 2011;54:1339-1346.

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