The rectum is the last 12 to 15 inches of the intestine, and it has a muscular structure with mucosal coating. It leads to the opening that interfaces with the exterior, which is called the anus. The rectum is secured by the means of pelvic muscles and ligaments of the pelvis that keep it in place at the same time and provide enough room to move and perform its normal function: to propel waste materials out to the anus and therefore, out of the body.
Rectal prolapse is characterized by the rectal surface sticking out or falling down the anus and can cause constipation, incontinence, rectal ulcerations and problems in defecation if left untreated. Although the precise cause of rectal prolapse is often unknown, certain risk factors such as old age, frequent constipation, cystic fibrosis, pinworm and whipworm infestation, the stress of childbirth, anal sex, COPD, sphincter paralysis and surgical hysterectomy are identified. These lead to the weakening of the supporting structures and may contribute to the development of rectal prolapse. With time, the ligaments are so stretched that they allow the rectal tissue to collapse (internal intussusception), causing an incomplete rectal prolapse. The condition can progress to complete prolapse, with most of the rectum coming out of the anus.
Rectal prolapse is more common in females because women are exposed to more predisposing factors such as childbirth and pelvic surgery. It rarely affects infants less than three years of age. Cystic fibrosis is often the cause of rectal prolapse in the pediatric population with a 20% overall incidence rate in patients suffering from this disease. Cases in the elderly are often underreported; nonetheless, the rate among patients older than 65 years is considerable.
Upon diagnosis, the exact cause of rectal prolapse is unknown in half of the cases. However, certain conditions can give heavy intra-abdominal pressure that is transferred onto the rectum. These conditions are straining, heavy lifting, childbirth, and some physical activities. Normally, the supporting structure of the rectum is able to handle these stresses. However, certain factors can weaken these structures and make the rectum "give way" to stress and prolapse into the anus. Advanced age can weaken pelvic muscles; constant irritation to the rectum from parasites, certain spices or food chemicals (like monosodium glutamate - MSG), long term diarrhea, long term constipation, paralysis, multiple sclerosis, and frequent and prolonged anal intercourse can significantly increase the risk of having rectal prolapse.
Anyone with Rectal Prolapse may exhibit the following symptoms:
- Feeling of something protruding after wiping and retraction afterwards in the early stages of prolapse.
- The main symptom is feeling a soft mass that sticks out of the opening of the anus, especially felt upon defecation that sticks out after straining.
- Rectal bleeding
- Fecal incontinence and loss of urge to defecate in more complete prolapses.
- Mucus discharge
Rectal prolapse can easily be felt, prompting consultation to the doctor. However, because it often strikes the elderly who have decreased sensation in the anal area, it is often only discovered at later stages where complete prolapse is present.
The main procedure performed by a doctor is physical examination. The doctor instructs the patient to strain while he observes the anus to tell if the rectum is indeed prolapsed. He may also perform digital rectal examination to detect intussusception and incomplete prolapse. These procedures are usually enough to support the diagnosis.
In some cases, an x-ray while the patient is defecating (defecography) may be performed. This test enables visualization of rectal tissues while they are in strain to determine the extent of prolapse.
Initial management of rectal prolapse is normally done through changes in diet. Incomplete prolapse is usually treated with a high-fiber diet. The increase in fiber prevents constipation by making the feces soft and bulky in texture. This prevents straining while moving the bowels and promotes a regular elimination schedule. Medications that promote intestinal motility may also be ordered by the doctor to prevent constipation. This will provide rest to the rectal structures so they regain strength and alleviate incomplete prolapse.
If the prolapse is complete, surgery is often the recommended treatment option. There are two types of surgery available: abdominal and perineal. Both use either regional or general anesthesia. In the abdominal approach, an incision in the abdomen is made in order to reach the rectum. It is more dangerous, has longer recovery time and more complications, but it is associated with higher success rate and results that last longer. Nonetheless, the introduction of laparoscopic surgery has lessened these dangers because only small incisions are required. It is usually preferred for younger individuals who can tolerate surgery. The perineal approach uses an incision in the perineal area. It is an older procedure that still has significant success rate. It is less harsh for the patient and is therefore reserved for older patients who are unlikely to tolerate an abdominal surgery.
Alternative medical approaches, such as dietary changes and use of supplements to manage constipation have an important role in the treatment of incomplete prolapse.
The prognosis depends whether the prolapse is incomplete or complete. Incomplete prolapses are easily treated and prognosis is excellent. A surgery in complete prolapse can often treat the condition, but the abdominal approach has complications in about 20% of the cases. Perineal approach has recurrence rates of 25%.
The risk of rectal prolapse can be minimized by having diets rich in fiber and reducing intake of hot spices and MSG.
Sticking with a doctor's advice is usually enough to treat rectal prolapse. Reducing hot spices and MSG is recommended, and you should routinely inspect food labels for hidden culprits.
If you undergo surgery for rectal prolapse, liquid diet is usually ordered first. Clear soups and jellies are given, then a soft diet is instituted. The high fiber diet should be maintained throughout life to prevent relapses. Frequent check-ups are also advised.
Living with rectal prolapse can be quite harsh at the psychological level and some patients may experience lack of self esteem and a negative outlook. Always keep in mind that you are not alone with this condition, talk with relatives and friends about your feelings. You can also find support groups that may help through experience sharing.
Research is focused on surgery, and the use of robots is currently being tested to improve surgical procedures.