Rectal prolapse is a condition in which the rectum (the final section of the large intestine) turns inside out and protrudes through the anus. While often mistaken for hemorrhoids, rectal prolapse is a more significant condition that can cause considerable discomfort, pain, and impact on quality of life. It is primarily a surgical condition, as non-surgical management is rarely curative for complete prolapse.

Define Rectal prolapse

Rectal prolapse occurs when the rectal wall, or sometimes just the rectal mucosa, loses its normal attachments and slides out through the anal opening. It is distinct from hemorrhoids, which are swollen blood vessels, although both can present as a mass protruding from the anus.

Types of Rectal Prolapse

Rectal prolapse is classified based on the extent of the protrusion:

1. Complete (Full-Thickness) Rectal Prolapse (Procidentia): This is the most common and clinically significant type. The entire thickness of the rectal wall protrudes through the anus. It often appears as a reddish, cylindrical mass with concentric rings (folds of mucosa). It can be partial (protrudes only with straining) or complete (protrudes spontaneously and may remain prolapsed).

2. Mucosal Prolapse: Only the inner lining (mucosa) of the rectum protrudes through the anus. It typically appears as a smaller, radial (star-shaped) mass. This is often associated with hemorrhoids and may be less severe.

3. Internal (Occult) Rectal Prolapse (Intussusception): The rectum telescopes into itself but does not protrude through the anus. It remains inside the anal canal or rectum. This type can be difficult to diagnose and may cause symptoms similar to obstructed defecation.

Causes and Risk Factors

Rectal prolapse is thought to be a multifactorial condition, often resulting from a combination of weakened pelvic floor muscles, laxity of the rectal support structures, and chronic straining. It is more common in older adults, particularly women.

• Weakened Pelvic Floor Muscles: Age-related weakening, multiple vaginal deliveries, episiotomies, and obstetric trauma can damage the pelvic floor.

• Chronic Straining: Persistent constipation, chronic diarrhea, excessive coughing (e.g., in COPD), or prolonged straining during urination (e.g., in BPH).

• Laxity of Rectal Support Structures: Weakness in the ligaments and fascia that hold the rectum in place.

• Neurological Conditions: Conditions that affect nerve supply to the pelvic floor and anal sphincter, such as stroke, spinal cord injury, multiple sclerosis, or pudendal neuropathy.

• Anatomical Factors: A deep rectovaginal pouch (in women), a redundant sigmoid colon, or a loose rectal mesentery.

• Prior Pelvic Surgery: Hysterectomy can sometimes contribute to pelvic floor weakness.

• Aging: Connective tissue and muscle strength naturally decline with age.

• Sex: More common in women than men (ratio approximately 6:1), especially multiparous women.

• Malnutrition/Emaciation: Loss of perirectal fat can reduce support.

Pathophysiology

The exact pathophysiology is debated, but it involves a combination of factors leading to the loss of normal rectal support and fixation:

1. Loss of Rectal Fixation: The rectum is normally held in place by various ligaments and attachments (e.g., sacral attachments). Weakening or stretching of these supports allows the rectum to become more mobile.

2. Weakened Pelvic Floor: The muscles of the pelvic floor (levator ani muscles) and the anal sphincter provide support and help maintain continence. Damage or weakening of these muscles reduces their ability to hold the rectum in place.

3. Chronic Increased Intra-abdominal Pressure: Repeated or prolonged straining (e.g., chronic constipation, coughing) increases pressure within the abdomen, pushing the rectum downwards and outwards.

4. Intussusception: In many cases, rectal prolapse begins as an internal intussusception, where the upper rectum telescopes into the lower rectum. With continued straining, this intussusception can progress and eventually protrude through the anus.

5. Loss of Rectal Curvature: The normal anterior curve of the rectum (sacral curvature) may be lost, making it more prone to prolapse.

6. Diastasis of Levator Ani Muscles: Separation of the levator ani muscles, often due to childbirth trauma, can create a wider opening in the pelvic floor, allowing the rectum to descend.

The protruding mass can lead to further irritation, edema, and mucosal changes. Chronic prolapse can stretch and weaken the anal sphincter muscles, leading to fecal incontinence.

Clinical Manifestations (Signs and Symptoms)

The symptoms of rectal prolapse can vary but often include:

• Protrusion of a Mass from the Anus: This is the hallmark symptom. Initially, it may only occur with straining during defecation and reduce spontaneously. As it progresses, it may protrude with coughing, sneezing, walking, or even standing, and require manual reduction (pushing it back in). In severe cases, it may be permanently prolapsed.

  • Appearance: A complete prolapse appears as a reddish, cylindrical mass with concentric (circular) folds. Mucosal prolapse is smaller with radial (star-shaped) folds.

• Fecal Incontinence: Very common, ranging from minor leakage of mucus or liquid stool to complete loss of bowel control. This is due to stretching and weakening of the anal sphincter muscles and chronic irritation/mucus production.

• Constipation: Paradoxically, many patients experience chronic constipation and straining, which contributes to the prolapse. Some may also experience a sensation of incomplete evacuation or obstructed defecation.

• Rectal Bleeding: Often bright red, from irritation or ulceration of the prolapsed mucosa.

• Mucus Discharge: Excessive mucus production from the prolapsed rectal lining, leading to perianal irritation and hygiene issues.

• Pain and Discomfort: A dull ache, pressure, or feeling of fullness in the rectum or perineum. If the prolapse becomes incarcerated (trapped and unable to be reduced) or strangulated (blood supply cut off), severe pain and necrosis can occur (a medical emergency).

• Sensation of a Mass: A feeling of something “coming out” or a lump in the anal area.

• Difficulty with Defecation: Despite the prolapse, patients may still struggle to empty their bowels.

Diagnosis

Diagnosis of rectal prolapse is primarily clinical, based on patient history and physical examination.

• Medical History: Detailed history of symptoms, bowel habits, straining, previous pregnancies/deliveries, and neurological conditions.

• Physical Examination:

  • Inspection: The prolapse may be visible upon inspection, especially if it is permanent.

  • Patient Straining: The patient is asked to strain as if having a bowel movement while sitting on a commode or lying on their side. This helps to elicit the prolapse if it is not spontaneously protruding.

  • Digital Rectal Examination (DRE): To assess anal sphincter tone, identify any masses, and differentiate between mucosal and full-thickness prolapse. In complete prolapse, the examiner may be able to feel the full thickness of the rectal wall.

• Differentiation from Hemorrhoids:

  • Rectal Prolapse: Has concentric rings (full thickness) or radial folds (mucosal). Often larger and involves more tissue.

  • Hemorrhoids: Appear as individual swollen vascular cushions.

• Defecography: A specialized imaging study (X-ray or MRI) performed while the patient defecates. This helps visualize the internal dynamics of defecation, identify occult prolapse (intussusception), and assess other pelvic floor dysfunctions.

• Anorectal Manometry: Measures the pressures of the anal sphincter muscles and rectal sensation. Can help assess sphincter weakness and identify contributing factors to incontinence.

• Colonoscopy/Sigmoidoscopy: May be performed to rule out other colorectal pathologies (e.g., polyps, tumors) that might be contributing to symptoms or to assess the health of the rectal mucosa.

Management

Management of rectal prolapse depends on the type, severity, patient’s age, overall health, and symptoms. For complete rectal prolapse, surgery is almost always required.

Non-Surgical Management (Limited Role)

Non-surgical approaches are generally only effective for very mild mucosal prolapse or as temporary measures for complete prolapse in patients who are not surgical candidates.

• Managing Constipation: High-fiber diet, adequate fluid intake, stool softeners, and laxatives to prevent straining.

• Pelvic Floor Exercises (Kegel exercises): To strengthen pelvic floor muscles, but rarely curative for complete prolapse.

• Manual Reduction: Patients are taught to gently push the prolapsed rectum back into place using gentle pressure with a gloved, lubricated hand.

• Addressing Underlying Causes: Treating chronic cough, managing BPH, etc.

Surgical Management (Primary Treatment for Complete Prolapse)

Numerous surgical procedures exist, broadly categorized by the approach:

• Abdominal Approach (Rectopexy): Considered the gold standard for many cases, especially in younger, healthier patients. Involves fixing the rectum to the sacrum (rectopexy) to prevent it from prolapsing. This can be done open, laparoscopically, or robotically.

  • Examples: Suture rectopexy, mesh rectopexy.

  • Advantages: Lower recurrence rates, better improvement in continence.

  • Disadvantages: More invasive, longer recovery time, higher risk of complications (e.g., ileus, constipation).

• Perineal Approach: Less invasive, performed through the anus. Often preferred for older, frail patients or those with significant comorbidities.

  • Examples: Altemeier procedure (perineal rectosigmoidectomy – resection of the prolapsed segment), Delorme procedure (mucosal plication).

  • Advantages: Less invasive, shorter hospital stay, quicker recovery.

  • Disadvantages: Higher recurrence rates compared to abdominal approaches, may not improve continence as effectively.

The choice of surgical procedure depends on the patient’s age, health status, extent of prolapse, and surgeon’s preference.

Nursing Management

Nursing care for patients with rectal prolapse involves pre-operative preparation, post-operative care, and comprehensive patient education.

Pre-operative Nursing Care:

• Assessment:

  • Detailed history of bowel habits, symptoms, and impact on quality of life.

  • Assess the type and reducibility of the prolapse.

  • Assess for fecal incontinence and its severity.

  • Assess for constipation and straining behaviors.

  • Assess nutritional status and hydration.

  • Assess patient’s understanding of the planned surgery and expectations.

• Bowel Preparation: Administer prescribed bowel preparation (laxatives, enemas) as ordered to cleanse the bowel before surgery. Explain the process to the patient.

• Hydration: Ensure adequate hydration during bowel preparation.

• Education:

  • Explain the surgical procedure in understandable terms.

  • Discuss expected post-operative pain management.

  • Educate on post-operative activity restrictions (e.g., avoiding heavy lifting, straining).

  • Explain expected bowel function changes after surgery.

• Manual Reduction (if prolapsed): If the prolapse is out, teach the patient or assist with gentle manual reduction using lubrication.

Post-operative Nursing Care:

• Pain Management:

  • Administer prescribed analgesics regularly to control pain.

  • Assess pain level frequently using a pain scale.

  • Utilize multimodal pain management strategies.

• Fluid and Electrolyte Balance:

  • Monitor IV fluid administration.

  • Monitor I&O, assess for signs of dehydration or fluid overload.

  • Monitor serum electrolytes.

• Bowel Function Management:

  • Crucial: Prevent constipation and straining.

  • Administer stool softeners and mild laxatives as ordered, typically starting early post-op.

  • Encourage adequate fluid intake and a high-fiber diet as tolerated.

  • Assess for return of bowel sounds and passage of flatus.

  • Monitor first bowel movement post-op for ease of passage and characteristics.

  • For perineal approaches, monitor for rectal bleeding or discharge.

• Wound Care:

  • Monitor surgical incision (abdominal approach) or perineal wound for signs of infection (redness, swelling, warmth, discharge), dehiscence, or hematoma.

  • Perform dressing changes as ordered using aseptic technique.

• Mobility and Activity:

  • Encourage early ambulation to promote circulation, prevent DVT, and stimulate bowel function.

  • Educate on activity restrictions (e.g., no heavy lifting, no straining for several weeks/months).

• Urinary Function:

  • Monitor for urinary retention, especially after abdominal surgery. May have a Foley catheter initially.

• Preventing Complications:

  • Deep Vein Thrombosis (DVT): Encourage ambulation, use sequential compression devices (SCDs) or anti-embolism stockings, administer prophylactic anticoagulants as ordered.

  • Infection: Monitor for fever, chills, wound infection signs. Administer prophylactic antibiotics as ordered.

  • Ileus: Monitor for absent bowel sounds, abdominal distension, nausea, vomiting.

  • Recurrence: Educate on long-term prevention strategies.

• Patient Education (Discharge Planning):

  • Reinforce instructions on proper bowel habits: high-fiber diet, adequate fluids, stool softeners, avoid straining.

  • Discuss activity restrictions and gradual return to normal activities.

  • Teach wound care if applicable.

  • Educate on signs of complications to report (e.g., fever, worsening pain, excessive bleeding, inability to have a bowel movement, new prolapse).

  • Emphasize the importance of follow-up appointments.

  • Discuss potential for continued fecal incontinence and management strategies if applicable.

• Emotional Support: Provide emotional support to patients who may feel embarrassed or distressed by the condition and its impact on their daily life.