INTRODUCTION — Rectal procidentia, also called rectal prolapse, is a pelvic floor disorder that typically occurs in older adult women but can occur in patients of all ages [1,2]. Rectal prolapse results in local symptoms (eg, pain, bleeding, and seepage), bowel dysfunction (eg, constipation, incontinence), and a diminished and disabled quality of life [3,4].
PELVIC FLOOR ANATOMY — The pelvic floor, also called the pelvic diaphragm, is made up of a combination of muscles (eg, levator ani, coccygeus) and fascia that support the pelvic organs of the lower abdominal cavity (eg, rectum, bladder, uterus) (figure 1 and figure 2). The pelvic floor separates the true pelvis from the perineum. The linked figures illustrate the pelvic anatomy for men (figure 3 and figure 4 and figure 5) and women (figure 6 and figure 7). The female pelvic anatomy is reviewed elsewhere. (See "Surgical female pelvic anatomy: Uterus and related structures".)
DEFINITION — No standard method of classification has been widely accepted [3]. Clinically, rectal procidentia is commonly referred to as complete, partial, or occult:
●Complete rectal procidentia, or full-thickness rectal prolapse, is the protrusion of all layers of the rectum through the anus, manifesting as concentric rings of rectal mucosa (picture 1) [5].
●Partial procidentia, or rectal mucosal prolapse, involves prolapse of the mucosa only.
●An occult rectal prolapse is also termed rectal intussusception, a "telescoping" of the bowel on itself internally, without protruding through the anal verge, and is not a true rectal prolapse [1]. An occult prolapse (ie, intussusception) does not always lead to full-thickness rectal prolapse, although patients may experience similar symptoms (eg, obstructed defecation, seepage) [6-8]. (See 'Clinical features' below.)
EPIDEMIOLOGY AND RISK FACTORS — Rectal procidentia is uncommon, with a prevalence of between 0.25 to 0.42 percent in the adult population [2,9], and the prevalence is estimated at 1 percent in adults over age 65 years [3,9].
Factors that increase the risk of rectal procidentia include [10-12]:
●Age over 40 years
●Female sex
●Multiparity
●Vaginal delivery
●Prior pelvic surgery
●Chronic straining
●Chronic diarrhea
●Chronic constipation
●Cystic fibrosis
●Dementia
●Stroke
●Pelvic floor dysfunction (eg, paradoxical puborectalis contraction, nonrelaxing puborectalis muscle, abnormal perineal descent)
●Pelvic floor anatomic defects (eg, rectocele, cystocele, enterocele, deep cul-de-sac)
CLINICAL FEATURES
Patient presentation — Patients with rectal procidentia present with symptoms that include abdominal discomfort, incomplete bowel evacuation, mucus and/or stool discharge associated with altered bowel habits, and a "mass" that prolapses through the anus that may reduce spontaneously or require manual reduction [13,14]. Straining to initiate or complete defecation, incomplete evacuation, and a history of digital maneuvers to aid with defecation can occur as the prolapse progresses. Pain is not a typical presenting feature and suggests another diagnosis. (See 'Differential diagnosis' below and "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Defecatory symptoms'.)
Physical examination — The diagnosis of rectal procidentia is typically made by the clinical evaluation. The most common sign is a full-thickness protrusion of the rectum, which may be intermittent [13,14]. The concentric rings of the rectum protruding through the anus are the hallmark of rectal prolapse.
This is often best produced by asking the patient to Valsalva or "bear down" in a simulation of defecation. The prolapse may be best identified with the patient in the squatting position or even sitting on the commode. If that is difficult, it can also be done in standing position with one leg elevated on a stool. A mirror can be used to assist in visualization of the perineum, or an enema may be required to facilitate prolapse occurrence.
In addition, the vaginal introitus should be examined to look for signs of pelvic organ prolapse that may prompt evaluation of the anterior compartment. If there is visible bulging tissue at the vaginal introitus or beyond, further urogynecologic evaluation should be obtained.
The digital rectal examination may detect a patulous anus, attenuated sphincter tone, palpable fullness, folds or mass, and/or concomitant pelvic floor pathology (eg, rectocele, cystocele or uterine prolapse). The patient should be asked to tighten the anal sphincter and again Valsalva in order to assess proper contraction and relaxation of the puborectalis and other pelvic floor muscles.
The perineum must be examined clinically. This is usually done in the left lateral decubitus position as a prone jackknife position may cause a small prolapse or lax perineum to not be visible. If a good examination can be done with the patient sitting on the commode, that is also helpful. There may be evidence of a flattened or ballooning perineum. Strong consideration should be given to a radiographic evaluation, particularly if the prolapse cannot be produced during the examination, and as patients with procidentia have an approximately 15 to 30 percent risk of concomitant pelvic floor disorder (eg, abnormal rectal evacuation, dyssynergia) [1,15-20]. (See 'Radiographic studies' below.)
Pelvic floor abnormalities are discussed separately. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management" and "Pelvic organ prolapse in women: Diagnostic evaluation".)
DIAGNOSIS — The diagnosis of rectal procidentia is based on the observation of rectal protrusion on physical examination or defecography.
A thorough review of bowel habits is essential since as many as 75 percent of patients experience fecal incontinence, while constipation is reported in 15 to 65 percent of patients with rectal procidentia [13,14,21,22]. Additionally, a detailed review of diet, fiber intake, fluid intake, and use of both prescription and over-the-counter medications can often identify common causes of constipation. The patient should also be queried about any pelvic or anorectal surgery. Finally, the patient should be asked questions regarding the presence of concomitant uterine or vaginal prolapse as well as associated urinary incontinence, which may need to be addressed [23,24].
DIFFERENTIAL DIAGNOSIS — A true rectal prolapse must be differentiated from several other common rectal and anal lesions, including [1]:
●Prolapsed internal hemorrhoids (picture 2). Internal hemorrhoids are swollen and/or inflamed veins present in the left lateral, right posterior, and right anterior walls of the anal canal. Grade IV hemorrhoids are prolapsed and cannot be reduced. The clinical features that distinguish rectal procidentia from prolapsed internal hemorrhoids include the presence of circumferential rings of mucosa (stacked coins) and a full-thickness protrusion with rectal prolapse (picture 1). Prolapsing hemorrhoids result in linear folds. (See "Hemorrhoids: Clinical manifestations and diagnosis".)
●Occult rectal prolapse (intussusception). An occult rectal prolapse involves intussusception, a "telescoping" of the bowel on itself internally, without protruding through the anal verge, and is not a true rectal prolapse. This is best seen on defecography.
●Rectal mucosal prolapse. A small amount of rectal mucosa can protrude with straining that does not progress to full-thickness prolapse.
●Solitary rectal ulcer. This is an uncommon rectal disorder characterized by one or more mucosal ulcers or a polyp-like mass in the rectum. Patients present with bleeding, passage of mucus, straining during defecation, and a sense of incomplete evacuation. (See "Solitary rectal ulcer syndrome".)
POSTDIAGNOSTIC EVALUATIONS — Complex pelvic floor abnormalities, such as cystocele, vaginal vault prolapse, and enterocele, are frequently associated with rectal procidentia in women and should be looked for and further evaluated by urogynecology prior to treatment. Identification of additional abnormalities alters the surgical approach from procedures that address only the rectal procidentia to complex pelvic floor repairs. (See "Surgical approach to rectal procidentia (rectal prolapse)".)
Pelvic organ prolapse and repair procedures in women are reviewed separately. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management".)
The following studies and their indications for assessing complex pelvic floor abnormalities associated with rectal procidentia include:
Radiographic studies — In patients for whom the prolapse cannot be reproduced on physical examination, or when symptoms are present suggestive of additional pelvic floor disorders, functional imaging is useful [19,20,25]. Defecography, either via traditional fluoroscopy or dynamic magnetic resonance imaging (MRI), can reveal defects associated with rectal prolapse in up to 80 percent of patients with obstructive defecation symptoms [12].
Pelvic physiology studies — Anorectal physiology studies including manometry, electromyography (EMG), and pudendal nerve terminal motor latency (PNTML) testing have been commonly used in patients with fecal incontinence secondary to obstetrical injuries, although their use in patients with procidentia with incontinence has been less extensively studied. Evaluation of fecal incontinence and pelvic organ prolapse is discussed separately. (See "Fecal incontinence in adults: Etiology and evaluation", section on 'Additional studies' and "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Neuromuscular examination'.)
Anal manometry serves as a useful baseline assessment of sphincter function as the internal anal sphincter muscle weakens from chronic dilation and can demonstrate low resting pressures. These findings may objectively document sphincter pressures to help predict continence following repair and the potential need for postoperative biofeedback, though the studies rarely change the operative approach [26-28].
While sphincter function can recover after treatment of prolapse with restoration of manometric pressures, these results do not correlate well with actual functional changes [29]. Regardless of manometry or ultrasound findings that demonstrate sphincter defects, most patients are treated for the prolapse and followed postoperatively to evaluate functional outcome and the need for any further treatment if fecal incontinence persists. Treatment of fecal incontinence is discussed elsewhere. (See "Fecal incontinence in adults: Management".)
PNTML involves stimulation of the pudendal nerves, generally using a specialized Saint Mark's glove, at the level of the ischial spines. This stimulation evokes contraction of the external sphincter muscle and allows individual nerve measurement (normal latency 2.0 + 0.2 msec). While there are some data to suggest that prolonged PNTML preoperatively is associated with worse postoperative continence, most authors have failed to demonstrate an association of PNTML or manometry with postoperative functional outcome via either perineal or abdominal approaches [25,30]. These studies are routinely done at baseline so that preoperative counseling can be provided to patients regarding potential persistent bowel dysfunction.
Colonoscopy — Colonoscopy should be performed on all average-risk patients per screening guidelines and can be performed selectively for younger patients, high-risk patients, and those with new symptoms since their last colonoscopy. Very rarely does colonoscopy provide information that may lead to a change in management directly related to a rectal prolapse. However, other pathology (eg, malignancy) may be detected and warrant specific treatment. (See "Screening for colorectal cancer: Strategies in patients at average risk".)
Colonic transit study — A colonic transit study is performed for operative candidates that have a severe or lifelong history of constipation to determine if a sigmoid colectomy or even total abdominal colectomy is indicated to treat the constipation associated with the prolapse. (See 'Indications for surgical management' below and "Etiology and evaluation of chronic constipation in adults", section on 'Colon transit studies'.)
MEDICAL MANAGEMENT — Medical management is offered to minimize symptoms prior to a surgical repair, for those with comorbid illnesses that preclude a surgical repair, and for those who refuse a surgical repair. Medical management strategies are determined by the patient's symptoms, degree of prolapse, and the magnitude of the adverse effect on the patient's quality of life.
Initial medical management for all patients includes ensuring adequate fluid and fiber intake. High-fiber foods, fiber supplements (total 25 to 30 grams per day), and 1 to 2 liters per day of water and other fluids are used to regulate bowel movements and attempt to control seepage and/or constipation [31]. Enemas and suppositories may be required for patients with severe constipation and difficulty evacuating the colon. (See "Management of chronic constipation in adults".)
Pelvic floor muscle exercises (eg, Kegel) may result in symptom improvement for women with pelvic organ prolapse in women. However, there are no data to suggest that exercises can effectively treat rectal procidentia. (See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management", section on 'Pelvic floor muscle exercises'.)
Although limited data are available on biofeedback for rectal prolapse specifically, based on retrospective studies, success rates of biofeedback for patients with fecal incontinence or obstructed defecation range between 30 and 90 percent when a full course of therapy is completed [32,33]. The least invasive option includes taping the buttocks or placing a bulky pad against the perineum to reduce or prevent protrusion. This is reserved for very old and frail, bedbound, or debilitated patients who cannot tolerate any operative procedure. This is only a palliative measure to minimize symptoms without treating the prolapse.
INDICATIONS FOR SURGICAL MANAGEMENT — Rectal procidentia is most commonly treated surgically, either by an abdominal or perineal approach. There are no randomized trials comparing a surgical repair with medical management. Morbidity and mortality rates and surgical outcomes vary, depending upon the surgical approach, which is also dependent upon the patient's clinical status. (See "Surgical approach to rectal procidentia (rectal prolapse)", section on 'Surgical outcomes'.)
The primary indications for a surgical repair include the presence of a mass from the prolapsed bowel and fecal incontinence and/or constipation associated with rectal procidentia. Delay of surgical repair is not recommended, because of the eventual progression of symptoms, weakening of the sphincter complex, and risk of incarceration, although the optimal surgical approach has not been elucidated [4]. In general, patients with procidentia should undergo a surgical consultation to determine operative eligibility.
Surgical management of rectal procidentia and the outcomes are discussed separately. (See "Surgical approach to rectal procidentia (rectal prolapse)".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Rectal prolapse".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Rectal prolapse in adults (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Epidemiology – Rectal procidentia (rectal prolapse) and intussusception (occult rectal prolapse) are pelvic floor disorders that typically occur in older adult women. (See 'Introduction' above.)
●Clinical features – The symptoms of rectal procidentia include a history of abdominal discomfort, incomplete bowel evacuation, rectal wall protrusion, and mucus and/or stool discharge associated with altered bowel habits. The most common sign is a full-thickness protrusion of the rectum though the anus, which may be intermittent. (See 'Clinical features' above.)
●Diagnosis – Rectal procidentia is diagnosed by the observation of rectal protrusion on physical examination or defecography. A true rectal prolapse must be differentiated from prolapsing internal hemorrhoids, partial (mucosal) rectal prolapse, occult rectal prolapse (intussusception), and solitary rectal ulcer syndrome. (See 'Diagnosis' above and 'Differential diagnosis' above.)
●Diagnostic evaluation – Complex pelvic floor abnormalities, such as cystocele, vaginal vault prolapse, and enterocele, are frequently associated with rectal procidentia in women and should be looked for at initial evaluation. Identification of additional abnormalities alters the surgical approach from procedures that address only the rectal procidentia to complex pelvic floor repairs. Diagnostic evaluations to detect associated pelvic floor disorders include physical examination, colonoscopy as per screening guidelines, defecography, and anorectal physiology studies. (See 'Postdiagnostic evaluations' above and "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management" and "Screening for colorectal cancer: Strategies in patients at average risk".)
●Surgical repair – Surgical repair is the mainstay of therapy for patients with rectal prolapse. The indications for a surgical repair include the sensation of a rectal prolapse and fecal incontinence and/or constipation associated with the prolapse. The simple presence of rectal prolapse is an indication for surgical repair because of the eventual progression of symptoms, weakening of the sphincter complex, and risk of incarceration. (See 'Indications for surgical management' above and "Surgical approach to rectal procidentia (rectal prolapse)".)
●Medical management – For patients with comorbid illness that precludes an operative procedure, or for patients who refuse a surgical repair, medical management, such as biofeedback or pelvic floor muscle exercises, can be tried to alleviate symptoms. (See 'Medical management' above.)
