Date issued: August 2023
Review date: August 2025
A-581/AC/Colorectal/Managing a Rectal Prolapse
What is rectal prolapse?
A rectal prolapse occurs when there is insufficient support of the rectum, and this results in the rectum dropping outside of the back passage (anus). This often happens because the anal sphincter muscle has become weakened. A rectal prolapse usually presents as a lump protruding from the back passage and can be uncomfortable. The lump can pop in and out initially, however, can progress to protruding all the time, especially when in standing. This can cause problems with daily activities that involve walking or standing for any length of time.
How common is Rectal Prolapse?
The exact number of cases is unknown, as is thought to be under-reported, however, is currently thought to affect 2.5 per 100,000 people in the UK. It is known to happen most frequently with increasing age and more common in women.
What are the Causes of Rectal Prolapse?
Constipation due to prolonged straining
Childbirth, multiple vaginal deliveries and / or traumatic vaginal deliveries resulting in injury and weakness to the pelvic floor muscles.
Neurological problems affecting the brain, spinal cord and nerves may lead to a prolapse.
Symptoms of Rectal Prolapse
A lump protruding from the anus
Initially, the lump can protrude during or after you have had a poo or strained to open your bowels. It may disappear on standing.
With time, it may protrude with other forceful activities, such as coughing or sneezing.
Eventually, the lump may be noticeable most of the time and interfere with day-to-day activities, such as walking.
You may have to push the lump back inside using your hand.
You may notice pain, constipation, and bleeding from the back passage. The lump may rub against underwear, leading to the prolapse becoming ulcerated.
The muscles around the anus (anal sphincters) may become weak, leading to the leakage of poo or sometimes mucus, a jelly-like substance produced by the bowel wall.
What else looks like rectal prolapse?
A Prolapsed Intussusception: An intussusception occurs when a section of bowel folds into the next section, a bit like the way a telescope folds up. Sometimes the folded bowel pokes outside the back passage and can look like a rectal prolapse.
A Rectal Polyp: A rectal polyp is a thickening of the lining of the bowel that comes to resemble a finger-like structure, growing out of the side wall of the gut. However, if this appears outside the anus, it can resemble a rectal prolapse.
A haemorrhoid (Piles): These can develop because of straining whilst going to the loo. This is yet another condition that can look like a rectal prolapse if protruding from the back passage. However, a prolapse has concentric rings around the outside, whereas piles are usually smooth.
Do I need any tests for rectal prolapse?
You may be offered a colonoscopy or flexible sigmoidoscopy. These examinations involve passing a thin flexible tube containing fibre-optic channels, through the anus and into the lower part of your bowel.
Anal Physiology Tests may be offered to evaluate the function and strength of the muscles of the back passage muscles.
Defaecating Proctogram may be requested to determine how well the bowel empties using x-ray and can identify whether there are some other prolapses, for example a prolapse involving the small bowel, otherwise known as an enterocele.
Colonic transit Study is an x-ray examination that shows how quickly food passes through your digestive system.
Treatment for a Rectal Prolapse
There are various strategies to help manage a rectal prolapse conservatively. A partial prolapse (in which it's only the lining of the bowel that pops out) can usually be treated without surgery, although sometimes the extra tissue may need to be banded / suture repaired. However, a rectal prolapse may need to be surgically repaired, and there are two approaches either abdominally or via the back passage. The suitability of surgery and type will depend on various factors and will be discussed with your Consultant Surgeon, if necessary.
Hints and Tips to help you to Manage a Rectal Prolapse
A small prolapse may be easily reduced (pushed gently back inside) using the pressure from your hand. We suggest using a gloved finger and KY jelly or gauze pads can help with this. Most people can cope with pushing the prolapse back, however if it cannot be pushed back, bleeds excessively or becomes dusky or purple in colour, please seek a medical review urgently, as it may be necessary for you to be reviewed by the surgeon.
Address any underlying causes, such as constipation or diarrhoea. Sometimes a laxative or stool bulking agent may be required to avoid straining.
The use of Supportive Underwear can be very helpful in providing support with a reinforced gusset and abdominal support. Examples include Marks & Spencer’s Shapewear range, V-Brace by Fembrace and EVB Support underwear, available at Win Health.
The use of perineal support by placing the index finger and middle finger either side of the anus, when opening the bowels. This can help reduce the prolapse protruding further and provide support.
Avoid heavy lifting where possible. When lifting, perform a pelvic floor contraction before this increase in abdominal pressure, such as before coughing, sneezing, or laughing. This is known as ‘The Knack’. Please see ‘Improving your Bowel Function’ leaflet at the rear of this booklet.
A rectal prolapse can feel more uncomfortable as the day progresses due to gravity. It can be helpful to spend some time in antigravity resting positions, such as lying with a cushion placed under your pelvis. This is also an ideal opportunity and position to do pelvic floor exercises.
If using an incontinence pad to manage leakage, it may be helpful to rub a small amount of Vaseline over the prolapse to stop the pad sticking and rubbing against the pad.
Improve the function and strength of the pelvic floor to provide support. The following leaflets on ‘Pelvic Floor Exercises for Men and Women’ on the POGP webpage www.thepogp.co.uk/resources
Ilex Skin protection Barrier Cream can be used on both intact and broken skin around the prolapse to form a protective barrier. Please refer to the manufacturer instructions before using.
If Surgery is necessary, which option is best for me?
Your surgeon will discuss the most appropriate surgical option for you, if required. These will consider your age, general health, any previous anaesthetic issues and how long you have had the prolapse.
NICE recommendations for Treatment
2.2 Conservative treatment of internal rectal prolapse may include pelvic floor exercises and advice to improve defaecatory habits, reduce constipation and improve incontinence. These are often termed biofeedback or pelvic floor re‑training. Surgical treatment of internal rectal prolapse is classified into perineal (Delorme's operation) and abdominal procedures. Open abdominal surgery and laparoscopic procedures, with or without robotic assistance, use mesh or direct suturing and may involve resection of the sigmoid colon.
Laparoscopic ventral mesh rectopexy for internal rectal prolapse.
Interventional procedures guidance [IPG618] Published: 20 June 2018