Gastroenterology & Nutrition

Rectal prolapse

Rectal prolapse is descent of rectal tissue through or within the anal canal, ranging from internal intussusception to external full-thickness prolapse; it causes a proluding mass, mucus, bleeding, obstructed defaecation or faecal incontinence and needs urgent review if it is irreducible, dusky or heavily bleeding.

In a nutshell

Rectal prolapse is descent of rectal tissue through or within the anal canal. External full-thickness prolapse usually shows concentric folds; mucosal prolapse and haemorrhoids have a different appearance. Symptoms include a protruding mass, mucus, bleeding, obstructed defaecation and faecal incontinence. Treat bowel dysfunction and refer symptomatic full-thickness prolapse to a colorectal service; urgent review is needed if the prolapse is irreducible, dusky or heavily bleeding.

Classic presentation

An older person reports a lump coming through the anus during defaecation that may need manual reduction, with mucus, bleeding, constipation or leakage of stool.

Key points

External full-thickness prolapse typically has circumferential or concentric folds; distinguish it from mucosal prolapse and prolapsing haemorrhoids.
Examine while the person strains and ask whether the tissue is reducible; an intermittent prolapse may need a position or manoeuvre that reproduces symptoms.
An irreducible, dusky, necrotic or heavily bleeding prolapse needs urgent surgical assessment; do not force reduction.
Treat constipation, diarrhoea, straining, pelvic-floor weakness and incontinence, but conservative care does not reliably correct established external full-thickness prolapse.
Surgery may be abdominal or perineal; choice depends on anatomy, bowel function, fitness, previous surgery, recurrence risk and patient preference.
Continence may improve after repair but can persistently require pelvic-floor and continence support.

First-line investigation

Perineal and anorectal examination during straining to classify the prolapse and assess viability, reducibility and sphincter function.

Management

Assess viability and reducibility

An irreducible, dusky, necrotic, severely painful or heavily bleeding prolapse needs urgent colorectal or emergency review; protect exposed tissue with moist gauze and avoid forceful manipulation.^1,3

Classify the prolapse and treat bowel dysfunction

Examine during straining to distinguish full-thickness, mucosal and internal prolapse, then address constipation, diarrhoea, straining, pelvic-floor weakness and incontinence.^1,4,5

Refer symptomatic full-thickness prolapse for surgery

Choose an abdominal rectopexy or a perineal operation such as Delorme or Altemeier through specialist shared decision-making based on anatomy, fitness, bowel function, previous surgery and patient preference.^4,6,3

Continue continence and pelvic-floor support

Monitor for recurrence, bleeding, pain, bowel-emptying difficulty and persistent incontinence; continue pelvic-floor rehabilitation and bowel-function care after repair.^5,3

Exam traps

Concentric folds suggest full-thickness prolapse; haemorrhoids usually appear as separate cushions rather than a circumferential rectal wall.
Do not label every prolapsing mass as rectal prolapse: mucosal prolapse, intussusception, haemorrhoids and a rectal tumour can mimic it.
Do not force an oedematous or dusky prolapse back in; urgent surgical review takes priority.
Colonoscopy or flexible sigmoidoscopy is selective, guided by bleeding, altered bowel habit, a suspected lead point or another indication.
Repair may not restore continence if sphincter or pelvic-floor injury is established.

Illustrations

Sensitive clinical image, hidden — Full-thickness rectal prolapseA clinical photograph of a full-thickness rectal prolapse: a dark red, oedematous, globular mass of rectal wall protruding through the anus, used with a sensitive-content warning and clear clinical context.Dr. K.-H. Guenther, Klinikum Main Spessart, Lohr am Main, Wikimedia Commons · CC-BY-3.0

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.