Rectal prolapse

• A rectal prolapse is the protrusion of mucosal or full-thickness layer of rectal tissue out of the anus.
• There are two main types of rectal prolapse:

  • Partial thickness – the rectal mucosa protrudes out of the anus
  • Full thickness – the rectal wall protrudes out the anus
• Pathophysiology:

  • Full prolapse - form of sliding hernia, through a defect of the fascia of the pelvic region. May be caused by chronic straining secondary to constipation, a chronic cough, or multiple vaginal deliveries
  • Partial thickness - loosening and stretching of the connective tissue that attaches the rectal mucosa to the remainder of the rectal wall. Often occurs in conjunction with long standing haemorrhoids
• Risk factors:

  • Increasing age
  • Female sex
  • Multiple deliveries
  • Straining
  • Previous traumatic vaginal delivery
• Clinical features:

  • Rectal mucus discharge
  • Faecal incontinence
  • Per rectum bleeding or visible ulceration
  • Full thickness prolapses will begin internally and thus can initially present with a sensation of rectal fullness, tenesmus or repeated defecation
  • May not always be visible - ask the patient to strain
  • DRE - weakened anal sphincter
• Conservative management of rectal prolapse is more common in those unfit for surgery, with minimal symptoms, or in children (as most prolapses in children will resolve spontaneously).

  Initial management often involves increasing dietary fibre and fluid intake. Minor mucosal prolapses may be banded in clinic, although this is prone to recurrence.
• Surgical repair is the only definitive management and can be done by 2 approaches:

  • Perineal approach
  • Abdominal approach - rectum is mobilised and fixed via sutures or mesh