WHAT IS RECTAL PROLAPSE?
It is a condition in which the rectum tends to slide downward and protrude outside the anus. The anal sphincters may not fully perform their function, leading to the involuntary loss of mucus or feces in cases of rectal prolapse. This condition is more common in women than in men. Rectal prolapse can be complete when the rectum completely protrudes from the anus, often extending several centimeters, resembling an inverted sock. It can also be internal when the rectum folds in on itself (recto-rectal intussusception) or invaginates into the anal canal (recto-anal intussusception), or it can be only mucosal, where only the rectal mucosa tends to descend into the anal canal or outside the anus (see hemorrhoids).
WHY DOES RECTAL PROLAPSE DEVELOP?
Several factors can contribute to the development of rectal prolapse. The most common causes are constipation and excessive straining during evacuation, especially in elderly individuals. Childbirth can also play a significant role in the formation of rectal prolapse. The stretching and weakening of specific ligaments supporting the rectum in the pelvis can lead to its descent, affecting the anal sphincters. Sometimes, rectal prolapse is part of a larger defect involving the entire pelvic floor and is associated with urinary incontinence and prolapse of other pelvic organs, such as the uterus and bladder. Less frequently, it can be caused by neurological injuries like spinal cord lesions.
IS RECTAL PROLAPSE THE SAME AS HEMORRHOIDS?
Rectal prolapse is caused by the prolapse of the rectal mucosa. Some symptoms are common, such as bleeding and/or protrusion outside the anus. External hemorrhoids are a consequence of rectal prolapse and are its first manifestation.
HOW IS THE DIAGNOSIS OF RECTAL PROLAPSE MADE?
In the case of complete rectal prolapse, it is sufficient to have the patient push as if during defecation to provoke the complete protrusion of the rectum from the anus. In cases of internal or mucosal prolapse, anoscopy performed during a colon-proctological examination allows for diagnosis. Defecography, in addition to demonstrating internal prolapse (recto-rectal or recto-anal intussusception), can determine its degree and detect concomitant pathologies such as rectocele, cystocele, enterocele, or others. Anorectal manometry can be used to evaluate the function of the anal sphincters, especially in anticipation of reparative surgical intervention.
HOW IS RECTAL PROLAPSE TREATED?
The progression of rectal prolapse can be slowed by correcting constipation and excessive straining during defecation. There are numerous surgical techniques that vary depending on the type of prolapse. Surgeries can be performed transanally or abdominally. In selected cases, laparoscopic treatment may be an option. Techniques for correcting complete rectal prolapse include transanal approaches such as the Delorme proctopexy (performed when the rectum protrudes from the anus only a few centimeters, primarily in elderly individuals) and the Altemeier rectosigmoidectomy (involves the removal of the entire rectosigmoid tract transanally). Recently, a transanal technique using both semicircular and linear staplers has been proposed, but it still requires scientific validation.
Among abdominal techniques, the Wells technique (posterior rectopexy) aims to fix the rectum to the sacrum bone using a prosthetic mesh, while the Ripstein technique aims to fix the rectum by encircling its entire circumference with a prosthesis. The Orr-Loygue procedure also employs a specific prosthesis, and the Frykman-Goldberg operation involves the resection of the prolapsed rectosigmoid tract. In cases of internal rectal prolapse, such as recto-anal intussusception, often associated with rectocele and contributing to obstructed defecation syndrome, transanal surgical procedures are preferable. These include the STARR (Stapled Trans Anal Rectal Resection), developed by Prof. Antonio Longo, which entails the "en block" removal of the prolapsed rectum and rectocele using two circular staplers. More recently, Prof. Longo has proposed the Transtar procedure, involving the removal of a larger amount of prolapsed rectum using a stapling device called CCS30 Contour Transtar. These two procedures have yielded excellent results but are sometimes associated with complications such as urgency in defecation and chronic pelvic pain. Another technique used successfully is the "internal Delorme," which requires good technical skills for its execution but has shown very encouraging results. In cases where rectal prolapse is only mucosal (associated with hemorrhoidal disease), treatments are discussed in the "hemorrhoids" section (see).
DOES SURGICAL TREATMENT FOR RECTAL PROLAPSE GUARANTEE CURE?
The majority of patients, thanks to surgical intervention, experience complete healing or report a significant improvement in symptoms. The success of treatment depends on many factors, such as the functionality of the anal sphincters before surgical intervention, the type of prolapse (complete, internal, or mucosal), and the presence or absence of other pathologies.
It is a condition in which the rectum tends to slide downward and protrude outside the anus. The anal sphincters may not fully perform their function, leading to the involuntary loss of mucus or feces in cases of rectal prolapse. This condition is more common in women than in men. Rectal prolapse can be complete when the rectum completely protrudes from the anus, often extending several centimeters, resembling an inverted sock. It can also be internal when the rectum folds in on itself (recto-rectal intussusception) or invaginates into the anal canal (recto-anal intussusception), or it can be only mucosal, where only the rectal mucosa tends to descend into the anal canal or outside the anus (see hemorrhoids).
WHY DOES RECTAL PROLAPSE DEVELOP?
Several factors can contribute to the development of rectal prolapse. The most common causes are constipation and excessive straining during evacuation, especially in elderly individuals. Childbirth can also play a significant role in the formation of rectal prolapse. The stretching and weakening of specific ligaments supporting the rectum in the pelvis can lead to its descent, affecting the anal sphincters. Sometimes, rectal prolapse is part of a larger defect involving the entire pelvic floor and is associated with urinary incontinence and prolapse of other pelvic organs, such as the uterus and bladder. Less frequently, it can be caused by neurological injuries like spinal cord lesions.
IS RECTAL PROLAPSE THE SAME AS HEMORRHOIDS?
Rectal prolapse is caused by the prolapse of the rectal mucosa. Some symptoms are common, such as bleeding and/or protrusion outside the anus. External hemorrhoids are a consequence of rectal prolapse and are its first manifestation.
HOW IS THE DIAGNOSIS OF RECTAL PROLAPSE MADE?
In the case of complete rectal prolapse, it is sufficient to have the patient push as if during defecation to provoke the complete protrusion of the rectum from the anus. In cases of internal or mucosal prolapse, anoscopy performed during a colon-proctological examination allows for diagnosis. Defecography, in addition to demonstrating internal prolapse (recto-rectal or recto-anal intussusception), can determine its degree and detect concomitant pathologies such as rectocele, cystocele, enterocele, or others. Anorectal manometry can be used to evaluate the function of the anal sphincters, especially in anticipation of reparative surgical intervention.
HOW IS RECTAL PROLAPSE TREATED?
The progression of rectal prolapse can be slowed by correcting constipation and excessive straining during defecation. There are numerous surgical techniques that vary depending on the type of prolapse. Surgeries can be performed transanally or abdominally. In selected cases, laparoscopic treatment may be an option. Techniques for correcting complete rectal prolapse include transanal approaches such as the Delorme proctopexy (performed when the rectum protrudes from the anus only a few centimeters, primarily in elderly individuals) and the Altemeier rectosigmoidectomy (involves the removal of the entire rectosigmoid tract transanally). Recently, a transanal technique using both semicircular and linear staplers has been proposed, but it still requires scientific validation.
Among abdominal techniques, the Wells technique (posterior rectopexy) aims to fix the rectum to the sacrum bone using a prosthetic mesh, while the Ripstein technique aims to fix the rectum by encircling its entire circumference with a prosthesis. The Orr-Loygue procedure also employs a specific prosthesis, and the Frykman-Goldberg operation involves the resection of the prolapsed rectosigmoid tract. In cases of internal rectal prolapse, such as recto-anal intussusception, often associated with rectocele and contributing to obstructed defecation syndrome, transanal surgical procedures are preferable. These include the STARR (Stapled Trans Anal Rectal Resection), developed by Prof. Antonio Longo, which entails the "en block" removal of the prolapsed rectum and rectocele using two circular staplers. More recently, Prof. Longo has proposed the Transtar procedure, involving the removal of a larger amount of prolapsed rectum using a stapling device called CCS30 Contour Transtar. These two procedures have yielded excellent results but are sometimes associated with complications such as urgency in defecation and chronic pelvic pain. Another technique used successfully is the "internal Delorme," which requires good technical skills for its execution but has shown very encouraging results. In cases where rectal prolapse is only mucosal (associated with hemorrhoidal disease), treatments are discussed in the "hemorrhoids" section (see).
DOES SURGICAL TREATMENT FOR RECTAL PROLAPSE GUARANTEE CURE?
The majority of patients, thanks to surgical intervention, experience complete healing or report a significant improvement in symptoms. The success of treatment depends on many factors, such as the functionality of the anal sphincters before surgical intervention, the type of prolapse (complete, internal, or mucosal), and the presence or absence of other pathologies.