Rectal Prolapse

1. Clinical Overview

Summary

Rectal prolapse is the protrusion of the rectal wall through the anal canal. It represents a spectrum of pathology ranging from internal intussusception (where the rectum telescopes into itself but does not exit the anus) to external full-thickness prolapse (procidentia) where all layers of the rectal wall protrude externally. [1,2]

Full-thickness rectal prolapse predominantly affects elderly women (6:1 female:male ratio), with peak incidence in the 7th-8th decades. Key risk factors include chronic constipation with straining, multiparity (vaginal deliveries causing pelvic floor damage), neurological conditions, and previous pelvic surgery. [3,4]

The condition causes significant morbidity through:

• Mass prolapsing through anus (initially with defecation, progressing to spontaneous prolapse)
• Faecal incontinence (affecting 50-75% of patients due to chronic sphincter stretch)
• Mucous discharge and bleeding from exposed rectal mucosa
• Obstructed defecation syndrome (particularly with internal prolapse)
• Profound impact on quality of life and social function [5,6]

Diagnosis is primarily clinical, confirmed by direct visualization during straining. Key distinguishing feature from mucosal prolapse is the presence of concentric mucosal folds (resembling tree rings) rather than radial folds. Defecating proctography or MR defecography is invaluable for assessing internal prolapse, associated pathology (enterocele, rectocele, sigmoidocele), and pelvic floor descent. [7,8]

Management is surgical for full-thickness prolapse. Two main surgical approaches exist:

1. Abdominal procedures (Laparoscopic Ventral Mesh Rectopexy [LVMR], suture rectopexy, resection rectopexy): Lower recurrence rates (5-10%), suitable for fit patients, may improve continence [9,10]

2. Perineal procedures (Delorme, Altemeier): Less invasive, suitable for frail/elderly patients, higher recurrence (10-30%), can be performed under regional anaesthesia [11,12]

Laparoscopic Ventral Mesh Rectopexy (LVMR) has emerged as the gold standard abdominal approach, offering low recurrence, improved functional outcomes (continence and constipation), and reduced mesh-related complications compared to posterior mesh techniques. [13,14]

Clinical Pearls

"Concentric Rings Distinguish Full-Thickness": Full-thickness rectal prolapse demonstrates concentric mucosal folds (like tree rings), whereas mucosal prolapse shows radial folds (like spokes of a wheel). This is the key differentiating feature on examination.

"Sulcus Sign": With full-thickness prolapse, you can palpate a sulcus (groove) between the anal verge and the prolapsed rectum – representing the intussuscepted rectal layers. This is absent in mucosal prolapse.

"The Occult Prolapse": Many patients with obstructed defecation have internal rectal intussusception visible only on defecating proctography – the "occult prolapse" that doesn't exit the anus but causes significant symptoms.

"Prolapse Begets Incontinence": Up to 75% develop faecal incontinence due to chronic sphincter stretch, pudendal neuropathy, and denervation. This may persist even after successful prolapse repair, requiring adjunctive management.

"Fit for Abdominal, Frail for Perineal": Patient fitness guides surgical approach. LVMR offers best long-term outcomes but requires GA and pneumoperitoneum. Perineal procedures suit ASA 3-4 patients and can be done under spinal/epidural.

"Mesh Anterior, Not Posterior": Ventral (anterior) mesh rectopexy reduces risk of mesh erosion into vagina/rectum compared to older posterior mesh techniques, and is associated with less postoperative constipation.

"Rectopexy May Worsen Constipation": Up to 30-50% experience worsening constipation after rectopexy (particularly posterior approaches). Consider resection rectopexy in patients with significant preoperative constipation and redundant sigmoid. [15]

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2. Epidemiology

Demographics

Risk Factors

Pediatric Rectal Prolapse

Distinct entity occurring in children less than 3 years:

• Usually mucosal prolapse only
• Associated with chronic diarrhea, malnutrition, cystic fibrosis (4-10% of CF patients), parasitic infections
• Self-limiting in 90% with conservative management (treat underlying cause)
• Surgery rarely needed [18]

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3. Classification

Types of Rectal Prolapse

Oxford Rectal Prolapse Grade

This classification (identified on defecography) helps predict progression and guides management decisions. [8]

Distinguishing Full-Thickness from Mucosal Prolapse

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4. Anatomy and Pathophysiology

Relevant Surgical Anatomy

Rectum:

• Extends from rectosigmoid junction (S3 level, ~15 cm from anal verge) to anorectal junction (levator plate)
• Three rectal valves (Houston's valves) – mucosal folds that may act as lead points for intussusception
• No serosal covering anteriorly in lower third (below peritoneal reflection)
• Blood supply: Superior rectal artery (continuation of IMA), middle rectal (internal iliac), inferior rectal (pudendal)

Pelvic Floor:

• Levator ani (puborectalis, pubococcygeus, iliococcygeus): Primary muscular support
• Puborectalis forms anorectal sling maintaining 80-90° anorectal angle
• Innervation: Pudendal nerve (S2-S4) and direct pelvic plexus branches

Rectal Fixation:

• Lateral ligaments (stalks): Condensations of endopelvic fascia containing middle rectal vessels and autonomic nerves
• Waldeyer's fascia: Rectosacral fascia – posterior fixation to sacral hollow
• Denonvilliers' fascia: Anteriorly separating rectum from prostate/vagina

Pouch of Douglas (Rectouterine/Rectovesical Pouch):

• Peritoneal reflection between rectum and bladder/uterus
• Normally extends to ~7-9 cm from anal verge
• Deep pouch of Douglas predisposes to prolapse by allowing small bowel and peritoneum to herniate behind rectum, pushing it downward

Pathophysiological Mechanisms

Rectal prolapse develops through multifactorial progressive pelvic floor failure:

1. Initial Insult: Pelvic Floor Denervation

• Chronic straining → stretching of pudendal nerves (S2-S4)
• Childbirth trauma → direct levator ani damage and pudendal neuropathy
• Neurophysiological studies show prolonged pudendal nerve terminal motor latency (PNTML) in 60-80% of patients [6]
• Progressive denervation of external anal sphincter and puborectalis

2. Loss of Rectal Fixation

• Weakening of lateral ligaments and posterior rectal attachments
• Allows abnormal rectal mobility and descent
• Diastasis of levator ani – widening of levator hiatus

3. Deep Pouch of Douglas

• Abnormally deep peritoneal reflection allows formation of enterocele or sigmoidocele
• Peritoneal sac and intra-abdominal contents push rectum anteriorly and downward
• Found in up to 70% of patients with full-thickness prolapse [7]

4. Initiation of Intussusception

• Redundant rectal wall (often with redundant sigmoid)
• Rectal valves (Houston's) may act as lead point
• Internal intussusception begins – rectum telescopes on itself
• Initially high intrarectal (Oxford Grade I), progressing distally

5. Progression to External Prolapse

• Continued straining and gravitational forces
• Intussusception progresses through anal canal
• Stretching of anal sphincter complex – progressive dilatation
• Eventually full-thickness external prolapse (procidentia)

6. Perpetuating Cycle

• Prolapse → further sphincter stretch → incontinence
• Incontinence → mucous soiling → skin excoriation → discomfort
• Discomfort → abnormal bowel habits → further straining
• Chronic prolapse → pudendal neuropathy worsens → progressive functional deterioration

Associated Pelvic Floor Defects

These represent a spectrum of pelvic organ prolapse and should be assessed preoperatively. Multidisciplinary approach (colorectal surgery + urogynecology) may be required. [17]

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5. Clinical Presentation

Symptoms

Natural History

Without surgery, full-thickness rectal prolapse is progressive and does not spontaneously resolve in adults. Untreated disease leads to progressive incontinence, worsening prolapse, and severe impact on quality of life. [5]

Examination Findings

Inspection

Key Features of Full-Thickness Prolapse on Inspection:

• Concentric mucosal folds arranged circumferentially
• Tubular/cylindrical mass protruding from anus
• Sulcus (groove) palpable between anal verge and prolapsed bowel
• Length: Can extend 5-15+ cm from anal verge
• Erythema, ulceration if chronic or incarcerated
• Reducible (early) vs irreducible (late/incarcerated)

Palpation

Digital Rectal Examination

Additional Examination

Examination Pearls

"Make Them Strain": Prolapse may not be visible at rest. Always have patient perform Valsalva maneuver, ideally sitting on commode or squatting. Examining in left lateral position may miss the diagnosis.

"The Patient's Photo": Many patients bring smartphone photographs of prolapse during episodes. These can be diagnostically invaluable for intermittent prolapse.

"Concentric vs Radial": This single examination feature distinguishes full-thickness (concentric folds) from mucosal prolapse (radial folds) with high accuracy.

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6. Differential Diagnosis

Conditions Mimicking Rectal Prolapse

Comparison Table: Prolapse vs Hemorrhoids

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7. Investigations

Diagnostic Workup

Defecating Proctography Technique

Patient Preparation:

• Rectal contrast instillation (barium paste)
• Vaginal contrast (tampons) – opacifies vagina in women
• Oral contrast (optional) – opacifies small bowel for enterocele detection

Imaging:

• Patient sits on radiolucent commode
• Lateral fluoroscopy during:
  • Rest
  • Squeeze (pelvic floor contraction)
  • Straining (Valsalva)
  • Evacuation (defecation simulation)

Key Measurements:

Preoperative Assessment Protocol

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8. Management

Management Algorithm

RECTAL PROLAPSE CONFIRMED
(Full-thickness, concentric folds, sulcus sign positive)
                    ↓
           EXCLUDE MALIGNANCY
        (Colonoscopy/Sigmoidoscopy)
                    ↓
           ASSESS FITNESS FOR SURGERY
        (ASA grade, Comorbidities, CPET if needed)
                    ↓
     ┌──────────────┴──────────────┐
     │                             │
FIT PATIENT                    FRAIL/HIGH-RISK PATIENT
(ASA 1-2, Age less than 70-75,          (ASA 3-4, Significant comorbidities,
 Good functional status)        Advanced age, Patient preference)
     ↓                             ↓
ABDOMINAL APPROACH            PERINEAL APPROACH
     ↓                             ↓
Assess constipation            Choose procedure:
     │                             │
     ├─ No/mild constipation   ├─ SHORT prolapse (less than 5cm)
     │  → LVMR                 │   → DELORME PROCEDURE
     │  (Laparoscopic Ventral  │   (Mucosectomy + plication)
     │   Mesh Rectopexy)       │
     │                         └─ LONG prolapse (> 5cm)
     └─ Severe constipation        → ALTEMEIER PROCEDURE
        + Redundant sigmoid        (Perineal rectosigmoidectomy
        → RESECTION RECTOPEXY      + coloanal anastomosis)
        (Anterior resection +           │
         mesh rectopexy)                └─ Consider levatorplasty
                                            to reduce recurrence
     ↓                             ↓
POSTOPERATIVE MANAGEMENT
- Pelvic floor physiotherapy
- Bowel management (fiber, fluids, laxatives if needed)
- Monitor for recurrence
- Address persistent incontinence (if present)

Conservative Management

Important: Full-thickness rectal prolapse in adults does NOT resolve with conservative measures and is a surgical disease.

Surgical Management: Abdominal Procedures

1. Laparoscopic Ventral Mesh Rectopexy (LVMR)

Current Gold Standard Abdominal Approach [9,13,14]

Technique:

• Laparoscopic approach (robotic increasingly used)
• Mobilization of sigmoid colon and upper rectum
• Anterior dissection only – enter rectovaginal/rectovesical space
• Mesh (biological or synthetic) placed anteriorly on rectum, avoiding posterior dissection
• Mesh secured to sacral promontory with non-absorbable sutures/tacks
• Enterocele sac excised (if present) and peritoneum closed
• NO posterior rectal mobilization – preserves pelvic autonomic nerves

Advantages:

• Low recurrence (2-5%) [13]
• Improved continence (40-60% improvement in FI scores) [14]
• Improved constipation (less worsening than posterior approaches)
• Reduced mesh erosion risk compared to posterior mesh
• Preserved sexual and urinary function

Disadvantages:

• Requires general anaesthetic and pneumoperitoneum (not suitable for severe cardiorespiratory disease)
• Mesh-related complications (rare): erosion, infection, pelvic pain
• Technically demanding – learning curve

Outcomes:

• Recurrence: 2-5% at 5 years [13]
• Continence improvement: 40-60% [14]
• Constipation improvement: 40-50%
• QoL: Significant improvement in validated scores

2. Suture Rectopexy (Wells Procedure)

Technique:

• Laparoscopic or open
• Full rectal mobilization to pelvic floor
• Lateral ligament division (risk to autonomic nerves)
• Rectum fixed to sacral promontory with non-absorbable sutures (no mesh)
• Deep pouch of Douglas obliterated

Advantages:

• No mesh (avoids mesh complications)
• Low recurrence (5-10%)

Disadvantages:

• Constipation worsens in 30-50% (due to posterior dissection and denervation) [15]
• Higher recurrence than LVMR
• Sexual/urinary dysfunction risk from autonomic nerve injury

Indications:

• Young patients (avoid lifetime mesh risk)
• Mesh contraindication (infection, immunosuppression)

3. Resection Rectopexy (Frykman-Goldberg)

Technique:

• Laparoscopic anterior resection of sigmoid +/- upper rectum
• Rectopexy (suture or mesh)
• Colorectal anastomosis

Advantages:

• Addresses severe constipation and redundant sigmoid
• Recurrence similar to LVMR (5-8%)

Disadvantages:

• Anastomotic leak risk (2-5%)
• Pelvic sepsis if leak occurs
• More extensive procedure

Indications:

• Severe constipation + slow transit on studies
• Redundant sigmoid (> 20 cm) on imaging
• Megasigmoid

Contraindications:

• Fecal incontinence (may worsen with loss of rectal reservoir)

Surgical Management: Perineal Procedures

1. Delorme Procedure

Technique:

• Perineal approach (no laparotomy)
• Mucosal stripping of prolapsed rectum (mucosectomy)
• Plication of underlying rectal muscle in longitudinal fashion
• Mucosa re-approximated

Advantages:

• Minimal invasiveness – suitable for frail/elderly
• Can be performed under spinal/epidural anaesthesia
• Short hospital stay (1-3 days)
• No mesh

Disadvantages:

• High recurrence (10-30%) [11,12]
• Limited to short prolapses (less than 5 cm)
• Does NOT address pelvic floor defects (enterocele, sigmoidocele)

Indications:

• ASA 3-4 patients
• Short prolapse (less than 5 cm)
• Advanced age (> 80 years)
• Patient preference for less invasive surgery

Outcomes:

• Recurrence: 10-30% [11]
• Continence: Variable (may improve or worsen)
• Morbidity: Low
• Mortality: less than 1%

2. Altemeier Procedure (Perineal Rectosigmoidectomy)

Technique:

• Perineal approach
• Full-thickness excision of prolapsed rectum and redundant sigmoid
• Transection of bowel at level of peritoneal reflection
• Enterocele sac excised (if present)
• Coloanal anastomosis (hand-sewn or stapled)
• +/- Levatorplasty (posterior plication of levator ani to reduce recurrence)

Advantages:

• Suitable for frail patients (can be done under regional anaesthesia)
• Addresses long prolapses (> 5 cm)
• Can treat enterocele simultaneously
• Levatorplasty reduces recurrence and may improve continence

Disadvantages:

• Higher recurrence than abdominal approaches (10-20% without levatorplasty, 5-15% with) [12]
• Anastomotic leak risk (~2%)
• Does not address deep pouch of Douglas as effectively as abdominal surgery

Indications:

• Long prolapse (> 5 cm)
• Frail/elderly patients unsuitable for laparotomy
• Failed Delorme procedure

Outcomes:

• Recurrence: 5-15% (with levatorplasty) [12]
• Continence: 30-40% improvement
• Morbidity: 10-15% (mostly minor)
• Mortality: less than 1%

3. Thiersch Procedure

Obsolete Technique – rarely performed

Technique:

• Encircling suture/silicone band around anus to narrow opening

Why Abandoned:

• Very high recurrence (> 50%)
• Fecal impaction
• Suture erosion
• Does not treat underlying pathology

Procedure Selection Summary

Management of Associated Pathology

Postoperative Management

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9. Complications

Complications of Untreated Prolapse

Surgical Complications

Abdominal Procedures (LVMR, Rectopexy)

Perineal Procedures (Delorme, Altemeier)

Recurrence Management

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10. Prognosis and Outcomes

Anatomical Outcomes (Recurrence Rates)

Functional Outcomes

Continence

Predictors of Persistent Incontinence:

• Severe preoperative incontinence (Wexner score > 15)
• Long duration of symptoms (> 5 years)
• Severe pudendal neuropathy (PNTML > 2.5 ms)
• Sphincter defect on endoanal USS
• Advanced age (> 75 years)

Constipation

Quality of Life

Multiple studies demonstrate significant QoL improvement after successful rectal prolapse surgery:

• Physical function: Major improvement (ability to leave home, social activities)
• Psychological: Reduced embarrassment, anxiety, depression
• Sexual function: Often improves (reduced avoidance)
• Overall satisfaction: > 80% report satisfaction with surgery [5]

Long-Term Outcomes

Mortality

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11. Evidence and Guidelines

Key Guidelines

Landmark Evidence

Evidence-Based Recommendations

Current Controversies

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12. Examination Focus

Common Viva Questions and Model Answers

Q1: "A 72-year-old woman presents with a mass protruding from her anus. How would you assess her?"

Model Answer: "This could represent rectal prolapse or prolapsing hemorrhoids. I would take a focused history asking about:

• Characteristics of prolapse: Timing (with defecation vs spontaneous), reducibility, duration
• Associated symptoms: Incontinence, mucous discharge, bleeding, constipation
• Risk factors: Parity, previous pelvic surgery, chronic straining, neurological disease

On examination, the key is to visualize the prolapse – I would examine her in left lateral position initially, then ask her to sit on a commode and strain (Valsalva maneuver), which reproduces physiological conditions.

Distinguishing features:

• Full-thickness rectal prolapse: Concentric folds (like tree rings), palpable sulcus between anus and prolapse, thick on palpation (double wall)
• Hemorrhoids: Radial folds from discrete pedicles, no sulcus, anal verge visible between pedicles

I would perform digital rectal examination to assess sphincter tone (often reduced in prolapse) and exclude a rectal mass.

Investigations would include:

• Colonoscopy/sigmoidoscopy (exclude malignancy, age-appropriate screening)
• Defecating proctogram or MR defecography (assess for internal intussusception, enterocele, rectocele, grade the prolapse)
• Anorectal manometry (assess sphincter function preoperatively – predicts postop continence)

This provides anatomical and functional assessment to guide surgical planning."

Q2: "What are the surgical options for full-thickness rectal prolapse?"

Model Answer: "Surgery is indicated for full-thickness rectal prolapse as it does not resolve spontaneously. There are two main approaches:

1. Abdominal Procedures – for fit, younger patients:

• Laparoscopic Ventral Mesh Rectopexy (LVMR) – current gold standard
  • Mesh placed anteriorly on rectum, fixed to sacral promontory
  • Lowest recurrence (2-5%)
  • Improves continence (40-60% improvement) and constipation
  • Lower mesh erosion risk than posterior mesh
• Suture Rectopexy – rectum sutured to sacrum without mesh; avoids mesh but higher recurrence and worsens constipation
• Resection Rectopexy – adds sigmoid resection; for patients with severe constipation and redundant sigmoid; risk of anastomotic leak

2. Perineal Procedures – for frail, elderly, high-risk patients:

• Delorme Procedure – mucosal stripping + muscle plication; for short prolapses (less than 5 cm); higher recurrence (15-30%)
• Altemeier Procedure – full-thickness perineal resection + coloanal anastomosis; for long prolapses; adding levatorplasty reduces recurrence
• Can be performed under spinal/epidural anesthesia

Choice depends on patient fitness (ASA grade, age, comorbidities), prolapse length, and constipation severity. LVMR offers best outcomes for fit patients; perineal procedures suit those unfit for laparotomy."

Q3: "What is the significance of concentric vs radial folds?"

Model Answer: "This is the key clinical sign to distinguish full-thickness rectal prolapse from mucosal prolapse or hemorrhoids:

• Concentric folds (circumferential rings, like tree growth rings): Indicate full-thickness rectal prolapse where all layers of the rectal wall have prolapsed, creating a cylindrical intussusception

• Radial folds (spoke-like pattern emanating from central point): Indicate mucosal prolapse or hemorrhoids where only mucosa/submucosa has descended from discrete vascular pedicles

Other distinguishing features:

• Full-thickness: Sulcus (palpable groove) between anus and prolapse
• Mucosal/hemorrhoids: No sulcus, continuous with anal verge

This clinical sign has high sensitivity and specificity, and can be assessed at the bedside without imaging."

Q4: "What is LVMR and why is it now the preferred abdominal procedure?"

Model Answer: "Laparoscopic Ventral Mesh Rectopexy (LVMR) is the current gold standard abdominal approach for rectal prolapse, described by D'Hoore et al. in the mid-2000s.

Technique:

• Anterior rectal dissection only – enter rectovaginal/rectovesical space
• Mesh (synthetic or biological) placed on anterior rectal wall
• Mesh fixed to sacral promontory
• Enterocele sac excised and peritoneum closed
• NO posterior mobilization – preserves autonomic nerves

Advantages over older posterior mesh/suture rectopexy:

• Lower recurrence: 2-5% (vs 5-10% for suture rectopexy)
• Improved continence: 40-60% improvement in incontinence scores – mesh supports pelvic floor and reduces sphincter stretch
• Less constipation: Avoiding posterior dissection preserves pelvic autonomic nerves and rectal compliance (posterior approaches worsen constipation in 30-50%)
• Lower mesh erosion: Ventral mesh has less than 1-2% erosion vs higher rates with posterior mesh into vagina/rectum
• Preserved sexual/urinary function: Minimal autonomic nerve injury

Evidence: Systematic reviews and large cohorts demonstrate superior functional outcomes with LVMR compared to posterior approaches, with similar or lower recurrence rates.

It is now the first-line abdominal procedure for fit patients with rectal prolapse."

Q5: "How would you manage a patient with recurrent prolapse after previous surgery?"

Model Answer: "Recurrence requires assessment of:

1. Patient fitness now (may have changed since initial surgery)
2. Type of previous surgery (perineal vs abdominal)
3. Reason for recurrence (technical failure, progression of pelvic floor disease, patient factors)

Approach:

• History: Timing of recurrence, symptoms (prolapse, incontinence, constipation)
• Examination: Confirm recurrence, assess current sphincter function
• Imaging: MR defecography – assess for missed enterocele, redundant sigmoid, extent of current prolapse
• Functional tests: Anorectal manometry (reassess sphincter function)

Management:

• Recurrence after perineal procedure:

  • If patient NOW fit → LVMR (definitive, lower recurrence)
  • If patient still frail → Repeat perineal (upgrade Delorme → Altemeier, or redo Altemeier with levatorplasty if not done previously)

• Recurrence after LVMR/abdominal:

  • "Investigate cause: Mesh failure? Inadequate mobilization? Missed enterocele?"
  • "Options: Redo LVMR with mesh revision, add sigmoid resection if redundant, ensure enterocele addressed"
  • May require conversion to open if extensive adhesions

• Multiple recurrences:

  • Consider underlying connective tissue disorder (Ehlers-Danlos, Marfan)
  • May need more extensive resection or combined approach
  • Involve MDT (colorectal + urogynecology for concurrent pelvic organ prolapse)

Key: Each recurrence requires individualized assessment; patient fitness guides approach (abdominal vs perineal)."

High-Yield Exam Points

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13. Patient and Layperson Explanation

What is Rectal Prolapse?

Rectal prolapse is a condition where part or all of the wall of your rectum (the last section of your large bowel) slides out through your anus (back passage). It can look like a lump or bulge coming out, especially when you strain to open your bowels.

What Causes It?

It is caused by weakness of the muscles and ligaments that normally hold your rectum in place. Over time, with straining or pressure, these supports fail and the rectum begins to slide downward.

Common risk factors include:

• Chronic constipation and straining to open bowels
• Having had multiple children (vaginal births can weaken pelvic floor muscles)
• Getting older – muscles and tissues naturally weaken with age
• Previous pelvic surgery (like hysterectomy)

What Are the Symptoms?

• A lump or mass coming out of your bottom – at first only when opening your bowels, but later it can come out when standing or walking
• Leakage of mucus (slime) or stool – because the prolapse stretches the muscles that control bowel movements
• Bleeding from the lump (usually minor, from rubbing)
• Difficulty emptying your bowels – feeling like you can't fully empty
• Embarrassment and impact on daily life – many people stop going out or avoid social activities

How Is It Diagnosed?

Your doctor will examine you while you strain (like you are trying to open your bowels). This usually makes the prolapse visible. Sometimes you may be asked to sit on a special commode during an X-ray (called a defecating proctogram) to see exactly what is happening.

You will also have a colonoscopy (camera test of your bowel) to make sure there is no other problem like a polyp or cancer.

What Is the Treatment?

Surgery is the main treatment for full-thickness rectal prolapse, as it does not get better on its own in adults.

There are two main types of surgery:

1. Keyhole (Laparoscopic) Surgery Through Your Abdomen:

• The surgeon uses small cuts in your tummy
• Your rectum is lifted back into place and held there with stitches or a piece of mesh (like a supportive net)
• This is called laparoscopic ventral mesh rectopexy (LVMR)
• Benefits: Low chance of it coming back (only 2-5%), may improve bowel control and constipation
• Suitable for: People who are generally fit and healthy

2. Surgery Through Your Bottom (Perineal Surgery):

• The surgeon operates through your back passage (no cuts on your tummy)
• The prolapsed part is either removed or tightened
• Benefits: Less invasive, can be done with spinal anaesthetic (you are awake but numb from waist down)
• Downsides: Slightly higher chance of the prolapse coming back (10-30%)
• Suitable for: Older or frail people with other medical problems

Your surgeon will discuss which operation is best for you based on your age, overall health, and the severity of your prolapse.

Will Surgery Cure My Symptoms?

• The prolapse: Usually cured, but there is a small chance it can come back (5-30% depending on the operation)
• Bowel control (incontinence): Often improves after surgery (40-60% improvement), but some people still have some leakage
• Constipation: May improve, stay the same, or rarely get worse depending on the type of surgery

What Happens After Surgery?

• Hospital stay: 2-5 days (longer for abdominal surgery, shorter for perineal)
• Recovery: 4-6 weeks before returning to normal activities
• Bowel management: You will be advised to eat high-fibre foods, drink plenty of fluids, and avoid straining to prevent the prolapse coming back
• Pelvic floor exercises: Physiotherapy to strengthen your pelvic floor muscles can help improve bowel control
• Follow-up: Regular check-ups to monitor for recurrence

Can It Come Back?

Yes, there is a chance of recurrence:

• Keyhole abdominal surgery (LVMR): 2-5% chance
• Perineal surgery: 10-30% chance

To reduce the risk, it is important to:

• Avoid straining
• Keep your bowels regular with good diet and fluids
• Do pelvic floor exercises

What If I Don't Have Surgery?

Without treatment, rectal prolapse gradually gets worse:

• The prolapse becomes larger and harder to push back in
• Bowel control worsens
• Impact on quality of life increases

In rare cases, the prolapse can become stuck (incarcerated) or lose its blood supply (strangulation), which is a medical emergency requiring urgent surgery.

Questions to Ask Your Surgeon

1. Which type of surgery do you recommend for me and why?
2. What are my chances of the prolapse coming back?
3. Will my bowel control improve after surgery?
4. How long will I be in hospital and off work?
5. What are the risks of the surgery?

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14. References

Primary Sources

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2. Felt-Bersma RJ, Tiersma ES, Cuesta MA. Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele. Gastroenterol Clin North Am. 2008;37(3):645-668. doi:10.1016/j.gtc.2008.06.001. PMID: 18794001.

3. Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg. 2005;94(3):207-210. doi:10.1177/145749690509400305. PMID: 16259168.

4. Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg. 2005;140(1):63-73. doi:10.1001/archsurg.140.1.63. PMID: 15655208.

5. Tou S, Brown SR, Malik AI, Nelson RL. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev. 2015;(11):CD001758. doi:10.1002/14651858.CD001758.pub3. PMID: 26558106.

6. Zbar AP, Lienemann A, Fritsch H, et al. Rectocele: pathogenesis and surgical management. Int J Colorectal Dis. 2003;18(5):369-384. doi:10.1007/s00384-003-0495-y. PMID: 12756591.

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