Rectal prolapse is the protrusion of the full thickness of the rectal wall through the anus. Its annual incidence is about 2.5 per 100,000, and most patients are older women. Definitive treatment is surgical: abdominal rectopexy (laparoscopic or robotic) or a perineal operation, depending on the patient.
What is rectal prolapse?
Full-thickness rectal prolapse is the protrusion of all layers of the rectal wall through the anal ring. At first it appears only during bowel movements or straining and goes back by itself; over time it may need to be pushed back by hand or remain outside permanently.
It is different from mucosal prolapse (often seen with advanced haemorrhoids) and from internal rectal intussusception, where the wall folds downwards without coming out of the anus.
How common is it?
Rectal prolapse is relatively uncommon. In a population study the annual incidence was about 2.5 per 100,000, with around 9 in 10 patients being women and a median age of 69.
It can also occur in younger patients, often with a history of chronic constipation.
How does it present?
The main symptom is the feeling or sight of a mass coming out of the anus, at first after a bowel movement.
- Protrusion of the rectum during bowel movements, coughing or standing
- Mucus discharge and skin irritation
- Bleeding from the exposed lining
- Faecal or flatus incontinence (in a large proportion of patients)
- Constipation or a feeling of incomplete emptying
Rarely, the prolapsed rectum cannot be pushed back, swells and becomes painful (incarceration). This is an emergency and needs immediate medical assessment.
How is it diagnosed?
Diagnosis is mainly clinical. The prolapse is often only visible when the patient strains, so examination in a sitting position or a photograph taken by the patient may help.
A colonoscopy is usually recommended before surgery to rule out other bowel disease. Depending on symptoms, dynamic imaging of evacuation (defecography) and anorectal manometry may be needed, especially with incontinence or constipation.
What increases the risk?
- Female sex and older age
- Chronic constipation and prolonged straining
- Pelvic floor weakness (for example after multiple births)
- Previous pelvic surgery
- Connective tissue disorders
Modern treatment options
Full-thickness prolapse does not resolve with medication; definitive treatment is surgical. The choice of technique is individualised according to age, general health, the size of the prolapse and associated symptoms (incontinence, constipation). In general, abdominal techniques have lower recurrence, while perineal techniques are less demanding for the patient.
Laparoscopic or robotic abdominal rectopexy
The rectum is mobilised and fixed to the sacrum, often with a mesh on its front surface (ventral mesh rectopexy). Low recurrence and good functional results, especially when constipation coexists.
Delorme procedure
The prolapsed rectal lining is removed and the muscle wall is plicated, without an abdominal incision. Suitable for smaller prolapses and high-risk patients.
Perineal rectosigmoidectomy (Altemeier)
The prolapsed bowel is removed through the anus and an anastomosis is made. An option for large prolapses, elderly patients or incarceration.
| Option | Approach | Duration | Hospital stay | Return |
|---|---|---|---|---|
| Laparoscopic or robotic abdominal rectopexy | Minimally invasive | 1.5–3 hours | 1–3 days | 2–4 weeks |
| Delorme procedure | Perineal | ~1 hour | 2–4 days | Recurrence: Higher |
| Perineal rectosigmoidectomy (Altemeier) | Perineal | 1.5–2 hours | 3–5 days | Recurrence: Higher |
Frequently asked questions
Can rectal prolapse resolve without surgery?
Full-thickness prolapse is not cured by medication or exercises. Fibre, good hydration and pelvic floor physiotherapy improve symptoms, but definitive treatment is surgical.
Is it the same as haemorrhoids?
No. In haemorrhoids, enlarged vascular cushions of the anus prolapse, whereas in rectal prolapse the whole rectal wall comes out, with characteristic circular folds. Clinical examination tells them apart.
Is mesh safe in rectopexy?
In large series of minimally invasive ventral mesh rectopexy, mesh-related complications are uncommon (about 1–2%). The choice of material and technique is discussed individually.
When is it an emergency?
When the rectum comes out and will not go back, swells, changes colour or is very painful. This needs immediate hospital assessment.
Does incontinence improve after surgery?
In many patients continence improves after the prolapse is corrected, but not in all. The likelihood of improvement is discussed before surgery.