Rectal Prolapse

Rectal prolapse occurs when your rectum, part of your large intestine, slips down inside your anus. It’s caused by a weakening of the muscles that hold it in place. Rectal prolapse may look or feel like hemorrhoids, but unlike hemorrhoids, it doesn’t go away on its own. You’ll eventually need surgery to fix it.

Rectal Prolapse

Prolapse is when any body part slips or falls down from its normal position. Rectal prolapse is when your rectum — the last section of your large intestine — drops down or slides out of your anus. While that may sound scary, it’s typically not considered a medical emergency. However, the longer you have the condition, the worse it can get. Living with rectal prolapse can cause embarrassment and affect your quality of life.

If you feel like something just isn’t right when you go to the bathroom, or try to poop, you shouldn’t ignore it or make light of it. Your doctor can diagnose rectal prolapse and suggest treatment to fix it.

Types of Rectal Prolapse

There are three types of prolapse:

• External prolapse: The entire rectum sticks out of your anus.
• Mucosal prolapse: Part of the rectal lining pokes out of your anus.
• Internal prolapse: The rectum has started to drop but is not yet sticking out of your anus.

Rectal Prolapse Symptoms

If you feel like you’re sitting on a ball after pooping, or if you notice that you have something sticking out of the opening (your anus) where you poop, you could have rectal prolapse.

Typically, you’ll first experience rectal prolapse after you have a bowel movement. The first time, or first few times, the rectum may return inside on its own. Later, you may feel like something has fallen out of your body, or you just feel something down there that isn’t normal. In those cases, you may be able to push the rectum back in yourself.

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Additional symptoms of rectal prolapse can include:

• Feeling a bulge outside your anus
• Seeing a red mass outside your anal opening
• Pain in the anus or rectum
• Bleeding from the rectum
• Leaking blood, poop, or mucus from the anus

Early on, rectal prolapse may look like hemorrhoids slipping out of your anal opening, but these are two different conditions. Hemorrhoids are swollen blood vessels in your anus or lower rectum that may cause itching, pain, and blood on the toilet paper when you wipe after you poop. Your doctor can diagnose whether you have rectal prolapse or hemorrhoids.

Rectal Prolapse Causes

A variety of things can cause the condition, including:

• Long-term history of diarrhea or constipation
• Long-term history of having to strain when you poop
• Old age, which weakens muscles and ligaments in the rectal area
• Previous injury to the anal or hip area
• Nerve damage that affects your muscles’ ability to tighten and loosen, which could be caused by pregnancy, vaginal childbirth complications, anal sphincter paralysis, or injury to your spine or back
• Neurological problems, such as spinal cord disease or spinal cord transection

Rectal Prolapse Risk Factors

More women develop rectal prolapse than men, especially women older than 50. In general, older people who have had a history of constipation or problems with their pelvic floor have a higher chance of having the problem.

Any of these health conditions could put you at higher risk for rectal prolapse:

• Chronic constipation
• Always have to strain to poop
• Lower back injury or disc disease
• Muscle weakness in your anus or pelvic floor
• Someone in your family also had rectal prolapse
• Parasitic infections like schistosomiasis
• Chronic obstructive pulmonary disorder (COPD)
• Benign prostatic hypertrophy
• Any injury or problems with ligaments that keep your rectum attached to the intestinal wall
• Congenital bowel disorders like Hirschsprung’s disease or neuronal intestinal dysplasia

Rectal Prolapse Diagnosis

Your doctor can do a rectal exam. While you may hesitate to do this, your doctor may ask you to sit on a toilet and poop or at least try to go. This is helpful because it allows your doctor to see the prolapse.

You may need some other, more advanced tests to diagnose rectal prolapse, especially if you have other related conditions:

• Anal electromyography (EMG): This test checks to see if nerve damage is causing your anal sphincter problems.
• Anal manometry: A thin tube is inserted into your rectum to test muscle strength.
• Anal ultrasound: A probe inserted into your anus and rectum is used to examine muscles and tissues.
• Pudendal nerve terminal motor latency test: It checks your pudendal nerves, which you use to control bowel movements.
• Proctography: X-ray videos of your rectum during a poop show how well it holds and releases feces.
• Colonoscopy: A long tube inserted into your rectum with a tiny camera at the end can show the inside of your intestines and look for any problems that may be causing your prolapse.
• Proctosigmoidoscopy: This test also uses a long tube with a camera on the end. It’s inserted deep into your intestines to look for inflammation, scarring, or a tumor.
• MRI: Imaging scan examines all of the organs in your pelvic area.

Rectal Prolapse Treatment

The most common treatment for rectal prolapse is surgery to put the rectum back in place, and there are several types. The kind of surgery your doctor recommends will depend on factors such as your overall health, age, and how serious your condition is. The two most common types of surgery:

• Abdominal: This type of surgery can be done either with a large incision or using laparoscopy, which uses small cuts and a camera attached to an instrument so the surgeon can see what needs to be done and if there are any additional issues that need to be fixed.
• Perineal: Also called rectal repair, this approach may be used if you are older or have other medical problems. This type of surgery can involve the inner lining of the rectum or the portion of the rectum extending out of the anus.

If your rectal prolapse is very minor and it is caught early, your doctor might have you treat it by taking stool softeners to make it easier to go to the bathroom and by pushing the rectum’s tissue back up the anus by hand. But, typically, you will eventually need to have surgery to fix rectal prolapse.

Rectal Prolapse Prevention

To prevent rectal prolapse, try not to strain when you poop. Try these tips to ease or prevent constipation that leads to straining:

• Get more fiber in your diet. Aim for at least five servings of fruits and veggies each day.
• Drink 6 to 8 glasses of water a day.
• Get regular exercise.
• Keep your weight at a healthy level or lose weight if you need to.
• If you have constipation often, talk to your doctor. They may direct you to take a stool softener or laxative.

Avoid heavy lifting, as this could put pressure on your bowel muscles.

Rectal Prolapse Complications

Rectal prolapse, if it’s not treated, could lead to these complications:

• Rectal damage like ulceration or bleeding
• Your rectum can’t be manually pushed back up inside you
• Strangulation, or the blood supply in your rectum is reduced
• Gangrene, or the strangulated rectal tissue decays and dies

Show Sources

Foundation of the American Society of Colon and Rectal Surgeons: Rectal Prolapse Expanded Version.

Cleveland Clinic: “Rectal Prolapse.”

Mayo Clinic: “Rectal Prolapse Surgery.”

American Congress of Obstetricians and Gynecologists: “Laparoscopy.”

American Society of Colon and Rectal Surgeons: “Rectal Prolapse.”

Victoria State Government Better Health: “Rectal Prolapse.”

University of Massachusetts Memorial Medical Center: “What Is Rectal Prolapse?”

Cedars-Sinai Hospital: “Rectal Prolapse: What is rectal prolapse?”

Rectal Prolapse

Rectal prolapse occurs when your rectum, part of your large intestine, slips down inside your anus. It’s caused by a weakening of the muscles that hold it in place. Rectal prolapse may look or feel like hemorrhoids, but unlike hemorrhoids, it doesn’t go away on its own. You’ll eventually need surgery to fix it.

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Overview

Your rectum is the end portion of your intestine as it reaches your anus. When your rectum prolapses, it falls down into your anus.

What is rectal prolapse?

Your rectum is the last segment of your large intestine before your anus. This is where poop prepares to exit your body. When poop arrives in your rectum, it triggers the urge to defecate (poop), and a network of muscles pushes the poop out through your anus. But when rectal prolapse occurs, the rectum itself travels with it, slipping down telescope-style into the anal canal — and sometimes out the other side.

“Prolapse” is the term healthcare providers use to describe any body part that has fallen from its normal position in your body. It usually means that the muscles supporting the part have weakened or deteriorated. Some weakening or deterioration is normal with aging, but extra wear and tear on the muscles can accelerate the process. Childbirth, chronic constipation or diarrhea can affect your rectum.

Who does rectal prolapse affect?

It most commonly affects people who were assigned female at birth, especially those over the age of 50. Less commonly, it may occur in young children as a result of chronic diarrhea or cystic fibrosis.

How common is this condition?

It’s estimated to occur in about 2.5 in every 1000 people.

Is rectal prolapse serious?

It’s not urgently serious, but it can cause discomfort for some people, and it can lead to possible complications down the road. The most common complications are pooping difficulties, such as fecal incontinence.

Symptoms and Causes

What causes rectal prolapse?

Failure of the muscles that hold the rectum in place leads to rectal prolapse. Many things may contribute to this. Some possibilities include:

• Aging.
• Pregnancy and childbirth.
• Previous injury or surgery to your pelvis.
• Chronic constipation or diarrhea.
• Intestinal parasite infections.
• Chronic coughing or sneezing.
• Spinal cord or nerve damage.
• Cystic fibrosis.

What does rectal prolapse look like?

Rectal prolapse can look different in different people. If you have an internal prolapse, your rectum has begun to drop partway into your anus, but it hasn’t yet come out the other end. If you have a mucosal prolapse, the inside mucous lining of your rectum has turned inside-out and begun to poke out of your anus. External prolapse is when your entire rectum falls out. At first, prolapse may only occur when you poop, but eventually, it’s constant.

What are the signs or symptoms of rectal prolapse?

You might notice:

• A feeling of pressure or a bulge in your anus.
• A feeling like there’s something left inside your anus after you poop.
• A red, fleshy mass hanging out of your anus.
• Leakage of mucus, poop or blood from your anus.
• Anal pain or itching.

How do I know if I have rectal prolapse vs. hemorrhoids?

Rectal prolapse and hemorrhoids can have similar symptoms, and it’s not uncommon to mistake one for the other. Hemorrhoids — swollen blood vessels in the anus or rectum — can also cause itching, pain or bleeding. Hemorrhoids can even prolapse — slip out of your anus — and they may look similar to mucosal rectal prolapse if they do. After all, they occur within the same red, fleshy mucous lining.

Both hemorrhoids and rectal prolapse can occur during and after pregnancy, or in conjunction with chronic constipation or diarrhea. While rectal prolapse has many possible causes, hemorrhoids are mainly caused by excessive straining. They are also temporary and will go away on their own after a week or so. Rectal prolapse is chronic and progressive. The symptoms may change, but it won’t go away.

Diagnosis and Tests

How is rectal prolapse diagnosed?

Your healthcare provider will review your medical history, then examine your rectum. They might ask you to activate your muscles as if you were pooping. To confirm the diagnosis or rule out other possible problems, they might use one or several of the following tests:

• Digital Rectal Exam. This is a physical exam using lubricated gloved fingers.
• Defecography. This is an imaging study of your muscles when you poop, using an X-ray or MRI.
• Anorectal Manometry. This test measures the strength and tightness of your anal sphincters.
• Lower GI Series(barium enema). A series of video X-rays of your lower gastrointestinal tract.
• Colonoscopy. This test examines the inside of your large intestine with a flexible scope.
• Electromyography (EMG): This test determines if nerve damage is the reason why the anal sphincters are not working properly. It also examines muscle coordination.

If you have weak pelvic floor muscles, you may have one or several other conditions in addition to rectal prolapse. Your healthcare provider may want to check for these other conditions so that they can address them all together. Possible secondary conditions include:

• Pelvic floor dysfunction.
• Rectocele.
• Urinary incontinence.
• Small bowel prolapse.
• Vaginal prolapse.
• Bladder prolapse.

Management and Treatment

Will rectal prolapse go away on its own?

Not in adults. If rectal prolapse occurs in your child, it might go away after you treat the cause. For example, if your child has hard stools, diarrhea or a parasite infection, treating these conditions will relieve the stress on their pelvic floor muscles. The muscles will repair themselves as your child continues to grow. If you’re an adult, however, rectal prolapse won’t improve without surgery.

What happens if rectal prolapse is left untreated?

If it’s not causing bothersome symptoms, you may be able to live for some time with rectal prolapse, taking care of it at home. Taking care of it means pushing your rectum back inside manually. Healthcare providers recommend that you lie on your side with your knees to your chest and use a wet, warm cloth to gently push your rectum back into place. However, prolapse will continue to worsen over time.

Untreated rectal prolapse can lead to several possible complications, including:

• Fecal incontinence. As your anal muscles continue to stretch, you may have increased difficulty holding in gas and poop. Of those with rectal prolapse, 50% to 75% of people report this complication.
• Constipation. Bunching of the rectum and muscle coordination problems may cause you difficulty evacuating your stool. Some people have alternating constipation with incontinence.
• Rectal ulcers. Friction and exposure of the mucous lining of your rectum may cause rectal ulcers and painful sores which can bleed. Uncontrolled bleeding could lead to anemia.
• Incarceration. An “incarcerated” rectum gets stuck hanging out of your anus and can’t be pushed back in. The danger of this is that it could become cut off from blood supply (“strangulation”). This could lead to tissue death and decay of the rectum (gangrene).

How do you fix rectal prolapse?

There are several surgical approaches to fixing rectal prolapse. Which procedure you have will depend on the specifics of your condition. For generally healthy adults, the first choice is usually a rectopexy, which is a procedure to repair your rectum through your abdomen. However, some people might not be good candidates for abdominal surgery. In these cases, rectal surgery is another option.

Abdominal approach (rectopexy)

This procedure restores your rectum to its original position in your pelvis. Your surgeon will attach your rectum to the back wall of your pelvis (your sacrum) with permanent stitches. They may also reinforce it with mesh. These will hold your rectum in place long enough for scar tissue to develop, which will hold it in place after that. Rectopexy has a 97% long-term success rate in fixing rectal prolapse.

Depending on the judgment and experience of your surgeon, you may have your rectopexy by either open abdominal surgery or minimally invasive (laparoscopic) surgery. Open surgery means opening up your abdominal cavity to access your organs. Laparoscopic surgery is done through small “keyhole” incisions, using a small camera, and is sometimes done with the use of a surgical robot. Both procedures are done under general anesthesia.

If you’ve had a history of chronic constipation, and if this was a contributing factor to your rectal prolapse, your surgeon may suggest a partial bowel resection at the time of your rectopexy. That means removing a section of your colon. Your surgeon can identify the part of your colon where difficulties with constipation tend to occur. Removing the problem section often improves bowel function afterward.

Rectal approach (perineal)

If abdominal surgery isn’t an ideal option for you, your surgeon may approach your rectal prolapse through your anus. Rectal surgery doesn’t always require general anesthesia as abdominal surgery does. Some people can have it with epidural anesthesia. The rectal or “perineal” approach may also be a better choice if you have a very minor prolapse, or if your rectum is stuck on the outside (incarcerated). There are two common procedures:

Altemeier procedure. In this procedure, your surgeon pulls the prolapsed rectum out through your anus and removes it. They may also remove the lower part of the colon (sigmoid colon) if it is involved in the prolapse (proctosigmoidectomy). Then they sew the two ends of your large intestine (your remaining colon and your anus) back together. The new end of your colon now becomes your new rectum.

This procedure is less invasive than open abdominal surgery and easier to recover from, but its disadvantage is that prolapse may recur afterward. One reason is that the new rectum made from your colon is not as strong as your original rectum was. Because of this, some surgeons combine the altemeier procedure with a “levatoroplasty” — tightening the pelvic floor muscles by sewing them closer together.

Delorme procedure. If you only have a mucosal prolapse, or a small external prolapse, your surgeon may choose a more minor procedure. The Delorme procedure only removes the prolapsed mucosal lining of your rectum. Your surgeon then folds back the muscle wall of the rectum onto itself and stitches it together inside your anal canal. The double muscle wall helps to reinforce the rectum.

What are the possible risks or complications of rectal prolapse surgery?

All surgeries come with a low risk of certain general complications, including:

• Bleeding.
• Infection.
• Blood clots.
• Injury to nearby organs.
• Anesthesia complications.

Additional risks associated with rectal prolapse surgery include:

• Anastomotic leak. If the two ends of your bowel that were severed and reconnected don’t heal correctly, it may cause your bowel to leak, requiring another surgery to repair.
• Constipation. For some people, constipation gets worse after surgery, and sometimes it occurs even if you didn’t have it before. Scar tissue in your bowels might be one reason.
• Sexual dysfunction. Rectopexy has a small (1% to 2%) chance of damaging a nerve connected with male sexual function.

Prevention

How can I prevent rectal prolapse from occurring or from recurring after surgery?

• Treat chronic bowel disorders. Don’t let chronic constipation or diarrhea persist. Ask your healthcare provider about treatment options, including lifestyle changes and medications.
• Strengthen your pelvic floor. Kegel exercises can help keep your pelvic muscles fit and strong. They have been shown to prevent incontinence as well as possible pelvic organ prolapse.

Outlook / Prognosis

What is the outlook if I have rectal prolapse?

It may not be a major problem at first, but it will continue to get worse over time. If you already have bowel problems, you should probably see your healthcare provider sooner than later. Most of the time, surgery will fix rectal prolapse, but it may return in a small number of people. Surgery also has mixed results for bowel complications. These problems may need additional treatment to be solved.

A note from Cleveland Clinic

Rectal prolapse is usually the result of a long, gradual process of muscle deterioration. It’s not a medical emergency, but it can be dismaying when it occurs. Some deterioration is inevitable, but self-care can make a difference. By paying attention to your bowel health and exercising your pelvic floor muscles, you can help keep your pelvic organs in the best condition possible. If prolapse does occur, surgery can fix it.