Will a Mucosal Rectal Prolapse Continue to Get Worse if Not Treated

Expert reviewer, Mr Stephen Pollard, Consultant Surgeon
Next review due June 2023

A rectal prolapse is when part of your rectum (back passage) slides out through your anus (the opening in your bottom), forming a lump. You may only get the rectal prolapse when you're having a bowel movement at first, but eventually it might be there all the time.

Having a rectal prolapse can be uncomfortable and interfere with your daily life. You may feel embarrassed about it, but it's important to see your GP if you think you may have one.

About rectal prolapse

If you have a rectal prolapse, your rectum (back passage) isn't kept in place inside your body as it usually is. It may slide out through your anus (the opening in your bottom).

There are three types of rectal prolapse.

• Full-thickness rectal prolapse is when the entire thickness of the wall of your rectum slides out through your anus.
• Partial, or mucosal prolapse is when just the lining (mucosa) of your rectum slides down inside your rectum and comes out through your anus.
• Internal rectal prolapse is when the lining of your rectum slides down inside your rectum but doesn't reach as far as your anus. This is also known as an internal intussusception.

People of any age can get a rectal prolapse, but it's most common in women older than 60, and in young children under three.

Symptoms of rectal prolapse

If you have a rectal prolapse, the most obvious symptom is having a lump or swelling coming out of your anus. At first, you may only notice this after you've had a poo – it may go away when you stand up. But if your prolapse gets worse, it may also happen when you strain – for instance, when you cough or sneeze, and then just when you're walking or standing up. Eventually it may be there all the time.

Other symptoms of a rectal prolapse may include:

• being unable to control your bowel movements (when you poo), due to stretching of the muscles around your anus – you might not be able to hold it in until you reach the toilet
• constipation – feeling like you're unable to have a poo
• having bright red blood or slimy mucus coming from your rectum
• feeling some discomfort or pain

If you have an internal rectal prolapse you may feel as though you're not fully emptying your bowels, rather than noticing a lump.

These symptoms don't necessarily mean you have a rectal prolapse. But if you have any of them, contact your GP.

Diagnosis of rectal prolapse

GP examination

Your GP may be able to diagnose a rectal prolapse by asking about your symptoms and examining you. They'll need to examine your anus (the opening in your bottom) and the area around it. They may ask you to stand up or squat and strain (as if you were having a bowel movement) while they examine you.

Your GP may also ask to carry out a rectal examination to gently feel inside your back passage. A rectal examination can feel uncomfortable but shouldn't hurt. Your GP will ensure your privacy, and you can ask to have someone with you during the test.

Referral

If your GP thinks you have a rectal prolapse, they'll usually refer you straight to a colorectal surgeon – a doctor who specialises in conditions that affect the bowel. Your colorectal surgeon may recommend further tests. These might be to check the rest of your colon (large intestine) for any other problems before surgery. Or, they may be to find out what type of prolapse you have or to try to find the underlying cause. Some of the tests you may be offered include the following.

• Colonoscopy – this uses a narrow, flexible, tube-like telescopic camera called a colonoscope to allow a doctor to look inside your large bowel.
• Barium enema – this is an X-ray examination of your lower bowel. A special fluid is passed through your anus to show up the lining of your bowel when X-ray pictures are taken.
• Proctography (defecography) – this is a type of X-ray or magnetic resonance imaging (MRI) scan that shows your rectum and anal canal when you're having a bowel movement.
• Rigid proctosigmoidoscopy – this uses a rigid tube with a light to look at the inside of your rectum.
• Other tests that look at how the muscles or nerves around your anus are working – such as an anal manometry.

Treatment for rectal prolapse

The best treatment for you will depend on the type of prolapse you have, as well as other things like your age and your overall health. In young children, especially those under the age of four, rectal prolapse usually gets better by itself, without any specific treatment. But for a full-thickness rectal prolapse, adults usually need an operation to fix it.

Non-surgical

There are certain things you can do before or instead of surgery, to help manage your symptoms and stop your prolapse getting any worse. These measures are often enough for a partial prolapse.

Your doctor may gently push the prolapse back in, which is called 'reducing' the prolapse. They may show you how to do this yourself too. For more information, see FAQ: Should I push a rectal prolapse back in myself?

If you have constipation or diarrhoea, your doctor will give you advice on managing this, as it could be a factor in causing the prolapse. For constipation, this includes eating more high-fibre foods, such as fruit and vegetables and wholegrain carbohydrates, and make sure you're drinking enough. Try not to strain when you have a bowel movement. Your doctor may also prescribe a laxative if necessary, to soften your poo.

Your doctor may also recommend that you use barrier creams around your anus, such as ones containing zinc or castor oil, as the mucus from the prolapse can irritate your skin. Your doctor will advise you what creams to use. They may also suggest specific exercises you can do to strengthen your pelvic floor muscles and prevent any worsening of the prolapse. If you choose not to have surgery or it's not recommended for you, your doctor may suggest some support garments you can wear to stop the prolapse from coming out all the time.

Rectal prolapse surgery

It's your choice whether to have any type of surgery that's been recommended to you. But it's important to realise that in adults, it's unlikely that a full-thickness rectal prolapse will go away on its own. Surgery might sometimes be recommended for a partial relapse too. Children who have a complicated rectal prolapse, or whose prolapse hasn't gone away within a year, may also need surgery.

If left untreated, a rectal prolapse is likely to get larger and come out more easily, and symptoms such as incontinence (losing control of your bowels) will continue to get worse. And the longer you leave it before seeking treatment, the more likely it is that you'll get another rectal prolapse in the future. There can be other long-term problems too – see complications section below.

There are many different procedures which surgeons can use to treat a rectal prolapse. Your surgeon will discuss which one they recommend for you. Surgery for full-thickness rectal prolapse is carried out in one of the following two ways.

• Through your abdomen (tummy). This involves cutting into your abdomen to reach your rectum, and fix it in place (rectopexy) so that it doesn't prolapse again. It may be an option to have this done with keyhole (laparoscopic) surgery, where your surgeon performs the procedure using instruments passed through tiny cuts in your abdomen.
• Through your perineum (the area around your anus). This is called perineal surgery – it can involve removing part of the prolapsed rectum and sewing in place the remaining section to prevent it happening again. Examples include the Delorme procedure and the Altemeir procedure. Your surgeon may be more likely to recommend perineal surgery if you're not fit enough for abdominal surgery, as you don't need to have a general anaesthetic. You can have this type of surgery with anaesthetic into your spine, which numbs the area.

If you have a partial (mucosal) prolapse, your surgeon will use different techniques to treat it. This may include cutting away the lining that has pushed through your anus or pulling the lining back into place, using a stapling instrument.

It's possible to have another rectal prolapse after you've had surgery. This happens to around one in five people who have surgery for a rectal prolapse. How long it will take you to recover from surgery depends on many things, including the type of operation you had and your general health. For more information, read our FAQ, How long does it take to recover after surgery?

Causes of rectal prolapse

It's not clear exactly why some people get a rectal prolapse. However, it's often linked to having a long-term history of constipation and straining when you poo. Anything else that increases the pressure inside your abdomen can increase your risk of getting a rectal prolapse too. This includes:

• pregnancy
• diarrhoea
• conditions that make you cough a lot, such as cystic fibrosis, chronic obstructive pulmonary disease (COPD) or whooping cough
• an enlarged prostate
• being overweight or obese

Rectal prolapse is also occasionally linked to neurological (nerve) conditions, including:

• multiple sclerosis (MS)
• lumbar (low back) disc disease
• an injury to your lower back or pelvis
• spinal tumours

Another factor often seems to be having weak pelvic floor muscles. Your pelvic floor is the supportive sling of muscles and ligaments that keep all your pelvic organs in place. In women, the muscles of your pelvic floor may become weak after you have a baby. You may be more likely to get rectal prolapse if you're a woman who's given birth vaginally several times, or if you've had an injury to your perineum during childbirth. Rectal prolapse can happen at the same time as a prolapsed uterus (womb) or bladder in women.

Complications of rectal prolapse

If a rectal prolapse isn't treated, it can go on to cause complications. These may include the following.

• Ulcers forming on the lining (mucosa) of your prolapsed rectum, which might bleed and make your skin sore.
• Incarceration and strangulation of the prolapse – this is when the prolapse gets trapped and its blood supply gets cut off. If this happens, the prolapse may become dark red, painful and much more swollen. You may no longer be able to push your prolapse back in. You must seek medical advice straightaway if this happens, as you'll need surgery.

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Source: https://www.bupa.co.uk/health-information/digestive-gut-health/rectal-prolapse

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