Rectal prolapse
Protrusion of the rectal wall through the anus (pelvic floor weakness)
Overview
Protrusion of the rectal wall through the anus — full-thickness (true) prolapse or mucosal prolapse. Associated with chronic straining/constipation, pelvic-floor weakness and multiparity (and in children, cystic fibrosis/malnutrition). Presents with a protruding mass, mucus discharge, bleeding and faecal incontinence. Managed by treating constipation and surgical repair; reduce an incarcerated prolapse promptly.
Recognise
- A protruding rectal mass on straining/defecation (concentric mucosal folds in full-thickness prolapse), mucus discharge, bleeding
- Faecal incontinence (stretched sphincter), tenesmus; chronic straining/constipation, multiparity, pelvic-floor weakness
- Children: associated with cystic fibrosis, malnutrition, chronic constipation
Red flags
- Incarcerated/irreducible prolapse with ischaemia → urgent reduction/surgery
- A child with rectal prolapse → screen for cystic fibrosis
Differentials & how to tell them apart
Investigations
Clinical (ask the patient to strain); defecating proctography/colonoscopy to assess and exclude other pathology. Sweat test in children (CF).
Management
Treat constipation + pelvic-floor measures; surgery (rectopexy) for full-thickness
- 1Treat constipation and straining; pelvic-floor measures. Reduce an acutely prolapsed rectum.Gate: Distinguish full-thickness rectal prolapse (CONCENTRIC mucosal rings) from prolapsing haemorrhoids (radial grooves); a CHILD with rectal prolapse should be screened for cystic fibrosis
- 2Full-thickness prolapse → surgery (abdominal rectopexy ± resection, or perineal procedure); manage incontinence; treat underlying causes.
Key points
Protruding mass with concentric mucosal rings + straining history = full-thickness rectal prolapse (vs radial grooves of haemorrhoids). In a child, think cystic fibrosis.
Monitor & prognosis
Recurrence; continence.
Good with surgery; continence may be slow to recover.
Source: ACPGBI; NICE