The phrase “rectal prolapse” may be easily confused with the term “rectocele” yet they may be very distinct clinical presentations. A rectocele refers to a prolapse of the posterior wall of the vagina that allows the rectum to bulge forward towards the posterior vaginal wall. This condition occurs most often in women rather than men. A rectal prolapse is a protruding of the rectum itself outside of the anal verge or opening. An overview article published in 2013 in the Journal of Gastrointestinal Surgery provides information about the condition that may assist the pelvic rehabilitation provider with valuable clinical concepts. Prior to becoming a full external prolapse, an internal intussusception may occur (and observed on defecography) and progress to include an external mucosal prolapse. Rectal prolapse may occur with or without other conditions of pelvic organ descent such as a cystocele or uterine prolapse. Although the prevalence of complete rectal prolapse is low, and occurs more often in women or in elderly patients, interference with quality of life may be significant.
Symptoms can include pain, difficulty emptying the bowels, bloody and or mucous discharge, urinary incontinence, and fecal incontinence or constipation. Patients may also complain of a lump or a bulge in the rectum that may or may not improve following a bowel movement. A complete rectal prolapse can be described as a full-thickness protrusion of the rectum through the anus. A more serious consequence of this condition is strangulation of the bowel. Features of a rectal prolapse often include a redundant sigmoid colon, levator ani muscle diastasis, and loss of the vertical position of the rectum, according to the article.
Treatment of a rectal prolapse may include surgery. Prior to surgery, a physical exam, colonoscopy, anoscopy, and possibly manometry and defecography may be completed. The surgical goals are to correct the prolapse, improve any complaints of discomfort, and to resolve bowel dysfunction. Surgical approaches may include abdominal or perineal approaches, minimally invasive versus open surgery, and techniques can include posterior versus ventral and rectopexy with or without sigmoidectomy. For more details about the specific approaches for rectal prolapse repair, see the linked article. The authors of this overview article point out that because “…there is a paucity of data evaluating the effectiveness and appropriateness of the various surgical techniques…”, there is not one single management strategy for each patient.
Nonsurgical recommendations for management of a rectal prolapse include appropriate daily fluid and fiber, suppositories or enemas if needed, biofeedback training, and pelvic floor muscle exercises. A patient may benefit from education in all of these concepts, before and/or following surgery. Pelvic rehabilitation providers are well poised to offer conservative management in these conditions prior to and following any needed surgery.
To learn more about rectal prolapse and related dysfunctions, join Dr. Lila Abbate, PT, DPT, MS, OCS at Bowel Pathology, Function, Dysfunction and the Pelvic Floor this November in New York, NY!