Rectal prolapse is a condition in which the rectum—the final portion of the large intestine—protrudes outward through the anus. It appears in two main forms:
• Rectal Mucosal Prolapse
Only the inner mucosal layer of the rectum prolapses through the anus. It is commonly seen in children, young adults, and individuals with chronic straining. It is a frequent but milder form of prolapse, although it may progress if left untreated.
• Total Rectal Prolapse (Full-Thickness Prolapse)
The entire wall thickness of the rectum protrudes through the anus. This is a more advanced and severe form, often accompanied by more prominent symptoms.
This article focuses primarily on rectal mucosal prolapse, with a brief comparison to total prolapse for completeness.
Causes of Rectal Mucosal Prolapse
Rectal mucosal prolapse typically develops due to pelvic floor weakness, reduced anal sphincter tone, or conditions that exert excessive pressure on the rectal mucosa.
Main causes include:
1. Chronic Constipation and Straining
Persistent straining pushes the rectal mucosa outward and weakens its attachments.
2. Prolonged or Recurrent Diarrhea
Frequent bowel movements and continuous irritation of the anal region can lead to mucosal laxity.
3. Pelvic Floor Weakness
Often associated with childbirth in women, aging, or connective tissue disorders.
4. Hemorrhoids and Inflammatory Anorectal Diseases
Chronic inflammation in the region promotes loosening of mucosal support.
5. Anal Sphincter Development Disorders in Children
In infants and young children, the most common contributors are chronic constipation and improper toilet habits.
6. Surgical History
Prior anorectal surgeries may weaken the supporting tissues of the mucosa.
Symptoms of Rectal Mucosal Prolapse
Symptoms vary depending on the severity of the prolapse. The most common complaints include:
- Straining during bowel movements, a sensation of blockage, or difficulty passing stool
- A small, pink-red mucosal tissue protruding from the anus (in advanced stages)
- A feeling of fullness or pressure in the anal region
- Mucous discharge
- A sensation of incomplete evacuation
- Mild bleeding or streaks of fresh blood
- Anal itching and irritation
- Mild gas or stool leakage in some patients
The prolapsed mucosal tissue usually retracts spontaneously, which helps distinguish it from total rectal prolapse.
Clinical Findings and Diagnosis
Diagnosis is primarily made through physical examination. Because the prolapse often does not appear at rest, the examination must be performed while the patient is in a toilet position and while to strain.
Typical findings during examination include:
- Mucosal folds appearing during straining on digital rectal exam
- Visible mucosal protrusion from the anus (in progressive cases)
- Reduced anal sphincter tone on digital exam
- Mucosal prolapse showing radial folds
- Total rectal prolapse presenting with circular (concentric) folds
Additional diagnostic tests may include:
- Anoscopy / rectoscopy
- Defecography
- Anal manometry (to assess sphincter strength)
- Colonoscopy (especially if bleeding or additional bowel symptoms are present)
Treatment of Rectal Mucosal Prolapse
Treatment is determined based on the degree of prolapse, patient age, underlying causes, and associated anorectal disorders.
1. Conservative (Lifestyle and Medical) Treatment
First-line therapy, especially in children and early-stage disease.
- Effective constipation management: fiber supplements, increased water intake
- Avoiding prolonged sitting on the toilet
- Correct toilet habits
- Pelvic floor exercises (Kegel exercises)
- Avoiding foods that irritate the mucosa
These measures can significantly reduce symptoms in mild cases.
2. Injection Therapy (Sclerotherapy)
Used to support the mucosa and prevent prolapse.
More common in children; selectively used in adults.
3. Surgical Treatment
Indicated in persistent, recurrent, or symptomatic prolapse that does not respond to conservative measures.
Surgical options for mucosal prolapse include:
• Mucosal Resection (Delorme Procedure)
- Only the prolapsing mucosa is removed.
- The sphincter is preserved and recovery is typically rapid.
• Mucopexy / Suspension Techniques
- The mucosa is fixed in place to prevent recurrent prolapse.
• Combined Procedures
- If associated hemorrhoids or anal fissure are present, they may be treated in the same session.
Treatment of Total Rectal Prolapse
- Usually requires surgery.
- Abdominal or perineal approaches may be used.
- Pelvic floor repair is often performed simultaneously.
Prevention of Rectal Mucosal Prolapse
The most important preventive measure is maintaining healthy bowel habits.
Recommended strategies include:
- Preventing constipation: regular fiber intake and adequate hydration
- Avoiding excessive straining
- Limiting time spent sitting on the toilet
- Strengthening pelvic floor muscles
- Early treatment of severe diarrhea episodes
- Timely management of hemorrhoids, fissures, and other anorectal disorders
Rectal mucosal prolapse can often be successfully treated with lifestyle adjustments and minimally invasive methods when diagnosed early. If left untreated, it may progress and evolve into a more serious condition such as total rectal prolapse.
Therefore, the following are essential:
- Accurate diagnosis
- Patient-specific treatment planning
- Assessment of pelvic floor function
- Regular follow-up
Total rectal prolapse and its comparison with mucosal prolapse will be addressed in separate, detailed articles.
