Experiencing a bulge or seeing tissue protruding from the anus can be an alarming and embarrassing event. While many people might immediately assume they have severe hemorrhoids, this symptom can sometimes be a sign of a more complex condition known as rectal prolapse. This is a pelvic floor disorder where the rectum, the final section of the large intestine, loses its normal attachments inside the body and turns itself inside out, protruding through the anus. While not typically a life-threatening condition, rectal prolapse can cause significant discomfort, fecal incontinence, and a profound loss of quality of life. It is crucial to understand that this is a treatable medical condition, and seeking timely care from a specialist is the first and most important step toward relief and recovery.

Rectal prolapse is a condition in which the rectum, the last part of the large intestine, slips out of its normal position and protrudes through the anus. To understand this, it helps to know the basic anatomy. The rectum is the last 6 inches of the large intestine, ending at the anus, which is the opening controlled by sphincter muscles. A complex network of muscles and ligaments, known as the pelvic floor, acts as a supportive sling, holding the rectum and other pelvic organs firmly in place.

In rectal prolapse, this supportive network weakens, and the attachments that anchor the rectum become stretched and lax. This allows the rectum to telescope down on itself and, eventually, protrude externally.

Healthcare professionals classify rectal prolapse into three main types based on its severity:

• Partial (or Mucosal) Prolapse: In this form, only the inner lining of the rectum (the mucosa) protrudes from the anus. It is typically smaller and often mistaken for hemorrhoids.
• Complete Prolapse: The entire thickness of the rectal wall protrudes through the anus. This appears as a larger, reddish, bulbous mass and is the most common type of true rectal prolapse.
• Internal Prolapse (or Rectal Intussusception): In this early stage, the rectum folds and telescopes downward on itself, but it does not yet protrude outside the anus. It can cause symptoms like a feeling of blockage or incomplete bowel movements.

It is vital to differentiate rectal prolapse from hemorrhoids. Hemorrhoids are swollen veins in the anal canal, whereas a rectal prolapse involves the protrusion of the actual wall of the bowel. A physician can easily tell the difference during an examination.

Rectal prolapse is caused by weakening of the muscles, ligaments, and tissues that normally hold the rectum in place. This weakening is typically caused by a combination of factors that put sustained pressure and strain on the pelvic floor over many years. Essentially, the anatomical “anchors” that secure the rectum fail, allowing it to slide from its normal position. Several long-standing health issues and life events can contribute to this process.

While anyone can develop rectal prolapse, it is far more common in certain populations. Understanding the risk factors can help explain why the condition develops.

The most significant risk factors for rectal prolapse include:

• Age and Gender: Rectal prolapse is overwhelmingly more common in women than men. It is most frequently diagnosed in women over the age of 50, as the natural weakening of pelvic floor muscles and ligaments accelerates with age and hormonal changes after menopause.
• Chronic Straining During Bowel Movements: This is a major contributing factor. Years of straining due to chronic constipation puts immense, repetitive pressure on the rectum and its supportive structures. Conversely, chronic diarrhea can also lead to straining and may be a factor.
• Pregnancy and Childbirth: The strain of vaginal childbirth, especially multiple deliveries or a complicated delivery involving forceps, can damage the pelvic floor muscles and the nerves that control them. This damage can manifest as a prolapse many years later.
• Previous Pelvic Surgery: Surgeries in the pelvic region, such as hysterectomy, can sometimes alter the anatomy and weaken the supportive structures around the rectum.
• Neurological Conditions: Any condition that damages the nerves that supply the muscles of the pelvic floor and anal sphincters can lead to weakness and prolapse. This includes spinal cord injuries or diseases, multiple sclerosis, and lower back problems with nerve damage.
• Cystic Fibrosis: In children, rectal prolapse can be a sign of cystic fibrosis due to the frequent, bulky stools and coughing associated with the disease.

Symptoms depend on the degree of prolapse, but they usually start subtly and become more noticeable over time.

The most obvious sign is the protrusion of tissue from the anus.

• Initially, this may only happen after a bowel movement and the tissue may retract on its own.
• As the condition progresses, the prolapse may occur with any straining, such as coughing or sneezing, and the individual may need to manually push the tissue back inside.
• In the most advanced stage, the prolapse can become permanent and remain outside the body at all times.

In addition to physical protrusion, there are several other significant symptoms:

• Fecal Incontinence: This is one of the most common and socially debilitating symptoms, affecting up to 75% of patients with complete prolapse. The constant stretching of the anal sphincter muscles by the protruding tissue weakens them, leading to leakage of stool, mucus, or gas.
• A Sensation of a Bulge or Fullness: Patients often describe feeling like they are “sitting on a ball.”
• Feeling of Incomplete Evacuation: Even after a bowel movement, the person may feel like their rectum is not empty.
• Rectal Bleeding and Mucus Discharge: The lining of the prolapsed rectum can become irritated and ulcerated, leading to minor bleeding and a constant mucus discharge.
• Pain and Itching: Discomfort and itching around the anus are common due to the protruding tissue and mucus leakage.

Diagnosis is usually straightforward, especially when the prolapse is visible during a physical exam. However, further evaluation may be needed to assess severity and rule out related conditions.

• Medical History and Physical Exam: Your doctor, preferably a colorectal specialist, will ask about your symptoms, including bowel habits, incontinence, and when the prolapse occurs. Physical examination is a key part of diagnosis. The doctor will inspect the anal area and may ask you to sit on a commode and strain as if you are having a bowel movement. This allows the doctor to see the prolapse and determine its type and severity.
• Anal Manometry: This test measures the strength and tightness of the anal sphincter muscles. It can help determine the degree of muscle weakness and predict how well bowel control might recover after surgery.
• Defecography: This is a specialized imaging test that provides a video of the rectum and pelvic floor during a bowel movement. The patient sits on a special toilet and expels a thick, paste-like contrast material while X-ray or MRI images are taken. This test can be very helpful for diagnosing an internal prolapse and evaluating the overall function of the pelvic floor.
• Colonoscopy: A colonoscopy may be performed to rule out any other conditions within the colon, such as polyps or tumors.

Treatment for rectal prolapse depends on the severity of the prolapse and the patient’s overall health.

Non-Surgical (Conservative) Management: For very minor, partial prolapses, or for patients who are too frail to undergo surgery, conservative management may be recommended. The goal is to manage symptoms and prevent worsening.

• Dietary Changes: The most important step is to avoid constipation and straining. This involves eating a high-fiber diet (25-35 grams per day) and drinking plenty of water to ensure soft, easy-to-pass stools.
• Pelvic Floor Muscle Exercises (Kegels): These exercises can help to strengthen the pelvic floor muscles and may provide some improvement in symptoms, particularly incontinence, in cases of early or mild prolapse.

Surgery: For a complete or symptomatic rectal prolapse, surgery is the only definitive and effective treatment. There are many different surgical procedures to correct rectal prolapse, and the best option depends on the patient’s age, health, and the surgeon’s expertise. The operations can be broadly grouped into two main approaches:

1. The Abdominal Approach (Rectopexy): The surgeon works through incisions in the abdomen to pull the rectum back up into its normal position. The rectum is then secured, or “fixed” (a procedure called rectopexy), to the sacrum (the bony structure at the base of the spine) using sutures or a piece of mesh. This approach can be done as a traditional open surgery or, more commonly today, through minimally invasive techniques like laparoscopic or robotic surgery. The abdominal approach generally has a lower rate of recurrence but is a more extensive operation with a longer recovery time.
2. The Perineal (or Rectal) Approach: The surgeon works directly through the anus to perform the repair. There are several types of perineal procedures, but they generally involve removing the excess, protruding portion of the rectum and sewing the remaining ends back together (a resection), or reinforcing the anal sphincter muscles. These procedures are less invasive, have a shorter recovery time, and are often preferred for older or medically frail patients. However, they are associated with a higher rate of the prolapse recurring over time.

Rectal prolapse is a physically and emotionally distressing condition that can severely impact a person’s confidence and daily life. It is a progressive disorder resulting from the long-term weakening of the pelvic floor, most commonly affecting older women with a history of childbirth and chronic straining. While the symptoms, especially fecal incontinence, can be difficult to talk about, it is vital to overcome this embarrassment and seek medical attention. Rectal prolapse is a highly treatable condition. With a proper diagnosis from a specialist, a range of effective surgical options are available to correct the problem, relieve symptoms, and significantly restore a person’s comfort, function, and quality of life.

• American Society of Colon and Rectal Surgeons (ASCRS). (2020). Rectal prolapse. Retrieved from https://fascrs.org/patients/diseases-and-conditions/a-to-z/rectal-prolapse
• Mayo Clinic. (2022). Rectal prolapse. Retrieved from https://www.mayoclinic.org/diseases-conditions/rectal-prolapse/symptoms-causes/syc-20352792
• Cleveland Clinic. (2022). Rectal Prolapse. https://my.clevelandclinic.org