What is rectal prolapse?
Rectal prolapse occurs when the rectum (the last portion of the large bowel) slides through the anus to the outside. It is important to distinguish a complete rectal prolapse from a mucosal prolapse [Figure 1]. A mucosal prolapse contains hemorrhoids and redundant mucosal tissue (a small portion of the inner lining of the bottom part of the rectum). The treatment of a complete rectal prolapse is different from a mucosal prolapse. Rectal prolapse can occur from early childhood to older age but is commonly seen in women older than age 50 years. The presence of the prolapse negatively impacts the quality of life, especially in patients with a large prolapse and Anal Incontinence.
Figure 1 – Mucosal prolapse compared to complete rectal prolapse (right of the picture)
What causes rectal prolapse?
Despite extensive scientific studies, our understanding of what causes rectal prolapse remains limited. A history of severe constipation with excessive straining or the opposite loose diarrheal stools have been noted in patients. Rectal prolapse occurs in both genders but it is more common in women. A woman is at risk regardless whether she had prior childbirth or not. Children with congenital abnormalities such as cystic fibrosis are at increased risk.
What are the symptoms of rectal prolapse?
The severity of the symptoms in patients with rectal prolapse can vary from mild to severe depending on various factors including the size of the prolapse, the frequency of its occurrence, and the presence of other disorders. Patients with rectal prolapse experience 1 or more of the following symptoms:
- Anal incontinence
- Constant moisture and mucous leakage
- Difficulty with evacuation or incomplete evacuation of feces
- External protrusion of tissue
- Pain in the anus, rectum, or pelvis
How is a rectal prolapse diagnosed?
The most important part of the evaluation is the history provided by the patient and the office-based examination performed by Dr. Maher Abbas. Visual inspection of the exterior aspect of the pelvis and anus, a brief testing of the sensation, an evaluation of the anal muscles, palpation of the rectal and vaginal wall, and Anoscopy is performed to check the inside of the anus. When there is a question whether there is complete or mucosal prolapse [Figure 2], the patient is asked to strain while sitting on the toilet for 3 to 5 minutes and is examined in such position. The diagnosis is made in the majority of patients during the initial office visit.
Figure 2 – Complete rectal prolapse with circular folks (left of the picture) compared to mucosal prolapse with hemorrhoids (right of the picture)
Additional testing may be necessary to further investigate contributing factors such as constipation, anal incontinence, the overall status of pelvic musculature, the presence of internal prolapse of the rectum, or other pelvic organs such as the bladder and uterus. These tests include:
- Blood tests: thyroid hormone and calcium level in cases of new onset of severe constipation
Imaging studies: an endoanal ultrasound to look at the anal muscles or alternatively an MRI scan of the pelvis to assess the anus and pelvic floor muscles. In patients with abnormal defecation, a dynamic MRI (magnetic resonance imaging) defecography to check for pelvic floor function. During this procedure, gel material is inserted into the rectum and in some cases the vagina. MRI pictures are obtained at rest and when the patient tries to defecate. This test provides the opportunity to visualize the internal pelvic organs in action. In addition, the presence of other disorders such as cystocele (prolapse of the bladder), uterine prolapse, internal rectal prolapse (intussusception), and/or enterocele (herniation of small bowel into the deep pelvis) is documented
Procedures: Flexible sigmoidoscopy or Colonoscopy to visualize the inside of the rectum and colon. Such procedures are indicated to further investigate constipation or other gastrointestinal symptoms which maybe present such as bleeding or abdominal pain. Anorectal manometry with testing of rectal compliance and a balloon expulsion test to evaluate the anal sphincter muscle function and coordination of the pelvic floor musculature. Pudendal nerve testing and anal electromyography (EMG) can evaluate the function of the nerve supply to the anus
It is important to note that in most patients, additional testing is not needed. Dr. Maher Abbas personalizes the care of each patient based on the clinical history, symptoms, and physical examination during the initial visit.
What treatment options are available for rectal prolapse?
Most patients with rectal prolapse do benefit from surgical correction of the prolapse. However, patients with small prolapse with minimal symptoms can be initially managed with conservative medical treatment which consists of several options including the following:
Dietary modifications. The patient is advised to maintain a diet and bowel diary for a couple of months to identify factors that exacerbate the symptoms and food products that relieve them. A review of a properly maintained diary can provide valuable information for dietary modification which can significantly control the symptoms. Relieving Constipation with increasing dietary fiber consumption, fiber supplements, the judicious use of laxatives, and a higher fluid intake is customized based on the patient’s degree of constipation. Patients with diarrhea can benefit from anti-diarrheal pills such as Imodium (loperamide hydrochloride). The medication should be titrated to the degree of the patient’s symptoms and is best taken 30 minutes prior to a meal
Lifestyle modifications. Losing weight, avoidance of severe straining or bearing down, and controlling chronic cough can be helpful when present
Physical therapy. Biofeedback/Kegel Exercises strengthen the anus and pelvic floor musculature. A prolonged course of daily therapy is needed for a minimum of 2 to 3 months to see a significant improvement. Working with a physical therapist specialized in pelvic floor disorders is very important
Surgical intervention remains the most effective way to treat a rectal prolapse. The decision of which operation to perform is based on an individual patient’s findings including the bowel function, the presence of other conditions such as bladder or uterus prolapse, the presence and severity of anal incontinence, and the age of the patient and medical fitness for surgery. Dr. Maher Abbas individualizes the care of every patient. In general, there are 2 approaches for the treatment of rectal prolapse:
Abdominal approach. Rectal prolapse correction through the abdomen is performed by making an incision or with the use of minimally invasive laparoscopic camera surgery (keyhole surgery) which is the preferred method of Dr. Maher Abbas for his patients. During the operation, excessive large bowel is resected in patients with severe constipation issues and the rectum is suspended and anchored to the pelvis to minimize the risk of recurrence. In some patients, lifting and anchoring the rectum to the pelvis (rectopexy) is sufficient. Minimally invasive surgery is associated with less risks and faster recovery
Perineal approach. Removal of the prolapsed rectum from a “bottom” approach is reserved for some patients with a small prolapse or elderly patients with significant medical issues who may not be able to tolerate an abdominal operation. During the perineal repair, the pelvic floor musculature can be tightened to improve anal incontinence
Dr. Maher Abbas customizes the care of each individual patient. Patients with other pelvic organs prolapse (bladder and/or uterus) often require multidisciplinary care with a gynecologist and/or a urologist. In such cases, Dr. Maher Abbas involves a trusted colleague from the needed specialty so that all the repairs are done in one setting.
Why seek care with Dr. Maher Abbas?
Dr. Maher Abbas is an American Board Certified Colon and Rectal Surgeon with special interest in rectal prolapse and pelvic floor disorders. He provides the entire spectrum of operations for rectal prolapse. Dr. Maher Abbas is a leader in Minimally Invasive Laparoscopic Surgery (Camera Keyhole Surgery).
If you would like to schedule a consultation with Dr. Maher Abbas to discuss and evaluate your condition, click here. If you have previously undergone any operation or tests related to your condition, kindly bring all outside reports for Dr. Maher Abbas to review the day of your consultation.