14 Causes of Rectal Prolapse and 9 Treatments for the Condition

Rectal prolapse accounts for only 0.5% of all proctological diseases in adults, so this problem is considered rare. In medicine, it is called rectal prolapse and is considered a serious pathology that requires complex therapy. This disease is expressed by partial or complete prolapse of the rectum from the anus.

The likelihood of rectal prolapse varies. In the USA, for example, it affects mainly women over 50 years of age, while in post-Soviet countries, prolapse is diagnosed in women 5 times less often than in men.

What is rectal prolapse and why is it dangerous?

Rectal prolapse is not a life-threatening condition, but it brings a lot of inconvenience to the patient’s life: constant physical and psychological discomfort, the inability to do usual activities, etc. The condition is characterized by weakening and stretching of the terminal intestine (sigmoid and rectum) and increased mobility.

Sometimes, with rectal prolapse, there is a sharp tension in the mesentery connecting the anterior and posterior abdominal walls. At this moment, the patient experiences severe pain, which can cause pain shock or collapse. Such conditions are life-threatening and require urgent medical intervention.

In adult patients, rectal prolapse is directly associated with intussusception, when one part of the intestine descends and penetrates the lumen of the underlying intestine.

In this case, discomfort is accompanied by the appearance of round formations in the anus, which can easily be mistaken for hemorrhoids if you do not know the features characteristic of prolapse. As the disease progresses, the rectal mucosa falls out of the anus, and as the disease progresses, the submucosal and muscular layers fall out.

If treatment for rectal prolapse is not started in time, there is a risk of complications:

• acute intestinal obstruction;
• peritonitis;
• intestinal necrosis;
• psychological and mental disorders (they develop against the background of constant stress).

In order not to bring the condition to a critical level, if you suspect rectal prolapse, you should not expect the disease to go away on its own. It is even more dangerous to use unconventional treatment at home. The only way to get rid of rectal prolapse is to consult a proctologist and undergo complex therapy for the disease.

Degrees

With first-degree prolapse, bowel prolapse occurs only during bowel movements.
Later it falls into place on its own. This may be accompanied by discomfort, a sensation of a foreign body in the anus. As the pathology progresses to the second degree, prolapse occurs not only during bowel movements, but also when walking, sneezing, and severe coughing. A prolapsed bowel causes significant discomfort and pain. It can still be adjusted manually, after which the unpleasant sensations dull or disappear.

With third-degree pathology, the intestine can prolapse even at rest. It is already difficult to set it back, and the sphincter cannot hold it for long. A person's quality of life deteriorates significantly. Depression and apathy may develop.

Symptoms of prolapse and its stages

The main symptoms of rectal prolapse vary depending on the stage of the disease. Common to all stages of disease progression are:

• difficulty with bowel movements or spontaneous bowel movements;
• sensation of a foreign object in the rectum or anus;
• dull pain in the lower abdomen, anus, lower back and groin;
• anal bleeding of varying intensity.

The intensity of these symptoms varies depending on the stage of the disease. The deeper the changes, the stronger they manifest themselves.

There are other signs by which a doctor can determine how far rectal prolapse has progressed:

1. At the first stage, the rectal mucosa prolapses by 1-2 cm, and the anus remains in normal condition. Prolapse occurs during bowel movements, the rectal mucosa returns to its normal position on its own, but the discomfort described above persists for several hours.

In the second stage, the prolapse is more pronounced; in addition to the mucous membrane, the submucosal layer of the rectum also descends. Reduction occurs independently, but more slowly than in the first stage. The anus remains in a normal state and retains the ability to contract. Discomfort in the rectum is complemented by periodic scanty bleeding.

1. At the third stage, the pathological process includes weakening of the sphincter, due to which it cannot hold the rectum. She turns out quite 10-15 cm, including when coughing, and cannot independently return to the physiological position. Foci of necrosis and superficial damage (erosion) are visible on the everted mucosa. In addition to increased bleeding, patients are concerned about incontinence of gases and feces.
2. At the fourth stage, the symptoms of the disease become even more severe. In addition to the rectum, the anus and parts of the sigmoid colon are everted. The prolapsed part reaches 20-25 cm. This happens even at rest. Large areas of necrosis are visible on the mucous membrane, and the patient suffers from constant itching and pain. It is very difficult to straighten the rectum.

The symptoms of this disease are similar to those of hemorrhoids, so they are often confused. The only way to distinguish between rectal prolapse and hemorrhoids is to carefully examine the formation that has prolapsed from the anus. The photo below will help you take a closer look at what rectal prolapse and hemorrhoids look like and how they differ.

If the folds on it are located longitudinally, and the color is flesh-colored or pale pink, it is a hemorrhoid, while transverse folds and the bright red color of the formation indicate rectal prolapse.

Clinical picture

Rectal prolapse symptoms and treatment in women and men are almost similar.

The most common complaints are:

• for aching or nagging pain in the anus, intensifying after physical work or defecation;
• feeling of a foreign body in the anus;
• false urge to evacuate - tenesmus;
• incontinence of gas or feces;
• when the mucous membrane is injured, the presence of mucus and blood in the stool.

Symptoms develop gradually, the first prolapse often occurs with sudden straining during bowel movements or lifting something heavy. The pain syndrome can be so severe that the patient loses consciousness. It is associated with the tension of the mesentery (a specific structure formed by the peritoneum) of the rectum, located in its upper part. Intestinal prolapse symptoms in women are the same, with the exception of one distinctive feature - possible joint prolapse of the uterus.

In severe cases of pathology, complications such as intestinal obstruction, strangulation of the prolapsed area with its subsequent necrosis, peritonitis, and a pronounced disturbance of the psycho-emotional background may develop.

Causes of pathology

The main cause of rectal prolapse is intussusception. however, it is not the only one that plays a role in the development of the disease. It was found that the main provocateurs of the disease are the anatomical or genetic characteristics of the body:

• weak muscles located in the pelvic floor, which cannot cope with the load during bowel movements and gradually stretch;
• abnormal location of the uterus relative to the rectum, in which the depth of the parietal peritoneum becomes increased;
• elongated mesentery (ligament connecting the posterior and anterior walls of the peritoneum);
• elongated sigmoid colon;
• anomalies in the structure of the sacrum and coccyx when they are located vertically;
• weak anal sphincter.

The listed causes relate to congenital pathologies, but they can also be of a traumatic nature. Thus, weakening of the pelvic floor muscles and anal sphincter can occur after childbirth (natural birth only) in women. Surgical interventions, injuries to the anterior abdominal wall, perineum, rectum or anus can affect the holding abilities of muscles and ligaments.

Weakening of the sphincter and the ligaments that hold the rectum can also occur with regular anal sex.

According to statistics, in men, hair loss more often occurs due to the anatomical features of the body and due to excessive physical exertion. Among the female population, the causes of rectal prolapse are associated with increased load on the pelvic floor muscles during pregnancy and their stretching during childbirth. Moreover, pathological changes do not become noticeable immediately, but after several years or even decades, since most patients with this diagnosis are aged 50 years or older.

Diagnosis of the disease

Diagnosis of rectal prolapse includes an initial examination, during which a doctor (usually a proctologist) visually assesses the condition of the anus and rectum. In addition, a simple test is performed: the patient is asked to squat down and strain a little, as during a bowel movement. If the sphincter opens and the rectum comes out, proceed to a comprehensive instrumental examination, which includes:

• defectography is an X-ray examination that can be used to evaluate the anatomical structures in the pelvic area and the tone of the pelvic floor muscles during stimulation of bowel movements;

• sigmoidoscopy and colonoscopy - a visual examination of the rectum and intestines using an instrument equipped with a camera and a light source, during which you can take tissue for analysis or take photos of individual sections of the digestive tract;

• manometry - measuring the tone of the anal sphincter.

Based on the results of the examination and medical history, the proctologist will be able to find out the causes of rectal prolapse and select treatment.

Treatment

Elimination of the disease is performed only surgically.
Conservative methods may bring short-term relief at an early stage, but the disease will still return in the future. The Yusupov Hospital uses the most effective and gentle methods of surgical intervention. The surgeon’s tactics will depend on the patient’s condition and the presence of concomitant diseases. The most commonly used method is laparoscopic intervention, which allows complex manipulations on internal organs without incision in the abdominal cavity.

The purpose of the operation is to excise the prolapsed area and fix the rectum in an anatomically correct position. Additionally, plastic surgery of the anal sphincter is performed, which should hold the rectum and its contents.

How to treat rectal prolapse in adults

To eliminate rectal prolapse, conservative and surgical treatment is used. Patients are recommended to follow a diet to normalize stool, and perform a set of exercises to strengthen the muscles of the pelvic floor, anal sphincter and perineum. To avoid progression of the disease, exercise should be completely avoided.

Drug therapy

Conservative treatment is effective in the first stages of rectal prolapse, when the rectum retracts on its own, and the disease arose no more than 3 years before contacting a proctologist. Goals of therapy:

• reduction of unpleasant symptoms;
• elimination of constipation and diarrhea;
• restoration of the tone of the anal sphincter and rectum.

The list of medications for this disease is small. In most cases, stool-regulating medications are prescribed, such as laxative suppositories or oral medications (tablets, powdered drinks). For severe pain, painkillers can be used. It is advisable to discuss this issue with a proctologist.

Important! Laxatives should be used with extreme caution and only with the permission of the attending physician. Attempts to soften stool with them without chronic constipation can lead to increased stress on the rectum and rectal sphincter.

If a woman experiences rectal prolapse during pregnancy, the choice of medications should be approached with extreme caution. Most medications are contraindicated for this category of patients. To restore stool, expectant mothers are recommended to use oil enemas or Microlax microenemas and drugs to normalize colon function (Duphalac, Fitomucil). To select therapy, consultation with a specialist is recommended.

Also, for rectal prolapse, rectal sclerosis is used. The method is conservative and is used mainly to treat young people and children. During the procedure, the doctor injects a sclerosing drug based on 70% ethyl alcohol into the peri-rectal tissue, as a result of which it is partially scarred and better retains this part of the intestine.

Additionally, patients are prescribed a complex of vitamins with iron. This helps restore overall well-being and strengthen the immune system.

Surgical intervention

Surgical treatment is used at stages 3 and 4 of rectal prolapse, as well as when conservative therapy is ineffective. There are several methods for securing the rectum in a physiologically correct position, and not a single doctor can tell which operation is the most effective. All of them are divided into several groups and differ in the principle of their effect on organs.

Methods of surgical treatment of total rectal prolapse:

1. Methods of narrowing the anus or artificially strengthening the external sphincter
2. Operations of rectopexy or attachment of the distal rectum to fixed parts of the pelvis
3. Methods of colopexy, i.e. transperitoneal fixation of the distal sigmoid colon to fixed formations of the pelvis or abdominal wall
4. Operations aimed at strengthening the pelvic floor and perineum
5. Methods for partial or complete resection of prolapsed bowel

Of the variety of surgical treatment methods proposed by various authors, only a few have stood the test of time, due to the high percentage of relapses in some cases, high morbidity and many complications in others. Today, the most common procedures for rectal prolapse are:

Kümmel-Zerenin operation

A laparotomy is performed (i.e. an incision in the anterior abdominal wall). The rectum stretched upward is sutured with interrupted seromuscular sutures to the longitudinal ligament of the sacral promontory.

Posterior loop rectopexy according to Walles

Posterior loop rectopexy with mesh was proposed by EHWells in 1959. The operation can be performed as usual, i.e. with laparotomy and laparoscopically. After mobilization of the rectum and its tightening, the posterior wall of the intestine is fixed to the sacrum using a polypropylene mesh. According to various authors, the number of relapses after surgery ranges from 2% to 8%.

Operation Mikulic

It is a perineal excision of the prolapsed part of the rectum. Mikulich's operation is relatively simple in technical execution, low-traumatic, the operational risk during its implementation is minimal, but it produces a large number of relapses, according to various authors, up to 60%. Taking into account the advantages and disadvantages, it is performed mainly by elderly patients.

Operation Delorme (Sklifosovsky-Juvarra-Ren-Delorme-Bier)

It is based on the principle of removing the mucous membrane of the prolapsed rectum and subsequent plication of the exposed intestinal wall to form a kind of muscle coupling that prevents subsequent prolapse. This operation is also low-traumatic, the operational risk during its implementation is minimal, and it can be performed under local anesthesia. Its disadvantage is the same as that of the previous operation - it produces a large number of relapses (according to various authors, up to 40%), although significantly less than the Mikulicz operation. It is also performed mainly on elderly patients.

After surgery, local anesthetics and oral analgesics are used to reduce pain, anti-inflammatory and healing drugs (suppositories, ointments or gels).

During the postoperative period, it is important for the patient to follow a strict diet to prevent constipation or diarrhea.

Within a year after surgery, the patient should regularly come to see a proctologist.

Diet

The patient's diet includes foods with coarse plant fibers: fruits and vegetables, cereals, whole grain bread (preferably dried), dairy products. They should become the basis of the diet. Meals should be regular, without overeating. There should be at least 5 meals a day.

It is undesirable to include in your diet foods and dishes that irritate the intestines and cause constipation:

• marinades and pickles;
• smoked meats;
• fatty meats;
• legumes;
• mushrooms;
• fresh milk;
• foods fried in large amounts of fat or oil;
• citrus;
• spices, especially hot ones.

You should also give up alcohol, coffee, and carbonated drinks. They irritate the intestines no less than the products listed above. It is better to drink natural berry fruit drinks and compotes, jelly, herbal tea and water. The minimum volume of liquid that should be consumed per day is 2 liters.

Folk remedies

Traditional medicine is not particularly effective for rectal prolapse. They help eliminate unpleasant symptoms and avoid irreversible changes in the rectum. Sitz baths with herbal decoctions will help improve your condition:

• meadowsweet mixed with sage and knotweed;
• chestnut and oak bark;
• chamomile with calamus root.

Lotions made from evaporated quince juice, tincture of mantle or shepherd's purse will be useful. Also, treatment at home involves taking herbal preparations orally. As a rule, these products have stool-regulating properties. Decoctions of calamus roots and mantle shoots have a good effect.

Important! Traditional medicine is not an alternative to standard therapeutic methods. The mentioned products can only be used with the approval of the attending physician!

Exercise therapy and other methods

If the cause of rectal prolapse is weakness of the anal sphincter or pelvic floor muscles, proctologists recommend performing a set of special exercises daily:

• quickly or slowly squeeze and relax the anus;
• raise the pelvis from a supine position, while simultaneously drawing in the stomach;
• “walk” on the buttocks.

Additionally, finger massage of the rectum can be used. It is carried out only by a specialist, and helps to increase the tone of the muscles of the rectum and the muscles and ligaments that hold it.

During therapy, the patient must maintain careful perineal hygiene. After defecation, it is advisable to use soft, slightly moistened paper. The ideal option is to wash with slightly cool water.

Consequences and prevention of rectal prolapse

In the absence of timely treatment, rectal prolapse can be complicated by tissue necrosis, ischemic colitis, trophic ulcers, proctitis and even gangrene. Such diseases are observed with a long course of the disease with frequent rectal prolapse. In some cases, against the background of complicated prolapse, polyps form, which can then degenerate into a cancerous tumor.

The only way to avoid such problems is to prevent the occurrence of prolapse. It includes the elimination of factors leading to overstrain of the anterior abdominal wall and increased intra-abdominal pressure:

• prolonged cough;
• constipation;
• carrying heavy loads;
• prolonged standing or sitting.

If it was not possible to avoid the disease, it is necessary to treat it under the supervision of a proctologist and follow all his recommendations.

For basic information about rectal prolapse, the risk of its occurrence and treatment methods, watch the video.

List of sources

• Vorobyov G.I., Shelygin Yu.A., Orlova L.P. and others. Clinic, diagnosis and treatment of patients with rectal prolapse // Ros. magazine gastroenterol., hepatol., coloproctol. - 1996. - T. 6. - P. 78–82.
• Shelygin, Yu. A. Clinical recommendations. Coloproctology / ed. Yu. A. Shelygina - Moscow: GEOTAR-Media, 2015. - 528 p.
• Vorobyov, G. I. Fundamentals of coloproctology / G. I. Vorobyov - M.: MIA, 2006. - 332 p.
• Gaivoronskaya S.S., Vasiliev S.V., Chania Z.D., Popov D.E., Nedozimovanyy A.I. Possibilities of complex treatment of rectal prolapse / Bulletin of surgery. 2007.S. 99-101.
• Imanova S.S., Zeynalov B.M. Choice of surgical tactics for rectal prolapse/Biomedicine.2017.-No. 2. P.56-58.