Rectal prolapse

Rectal prolapse happens when the rectum — the last section of your large bowel — gradually loses its normal support and slides down through the back passage. It is closely tied to weakness of the pelvic floor, the group of muscles that hold the bowel, bladder and (in women) the uterus in place. Years of constipation, straining, or the cumulative effects of childbirth are common contributors.

Rectal prolapse is much more common in women than in men, and the typical patient is in her sixties, seventies or older — though it can happen at any age. This is not something you have caused; it is a recognised consequence of how the pelvic floor changes over time.

"Rectal prolapse" actually covers three different things, which look similar but are managed differently. It is worth knowing which one you have.

• Full-thickness rectal prolapse — the entire wall of the rectum comes out through the back passage. This is what most people mean by "rectal prolapse" and is the form that benefits most clearly from surgery.
• Internal rectal prolapse (intussusception) — the rectum folds in on itself internally but does not come right out. You may feel a strong sense of incomplete emptying or a "blockage" sensation without anything visible from the outside.
• Mucosal prolapse — only the innermost lining of the rectum slips down. It can look very similar to a true prolapse from the outside, but it is a different condition and is treated differently. It is also sometimes confused with prolapsing haemorrhoids.

Sorting out exactly which form you have is one of the first things done at assessment.

The most noticeable symptom is a lump or protrusion coming out of the back passage — often after a bowel motion, sometimes when you cough, sneeze, or stand up. It may slide back in on its own, or you may need to gently push it back in yourself.

Other things you might notice: a mucous or bloody discharge, a persistent sense of not having emptied fully, and constipation that is hard to relieve.

Over time, the repeated stretching from the prolapse can damage the sphincter muscles that control your bowel — leading to leakage or difficulty holding on (faecal incontinence). This is one of the important reasons not to simply put up with a prolapse: treating it earlier protects the sphincter while it can still recover.

Most rectal prolapse is diagnosed at the first examination — particularly when you are asked to strain down as if having a bowel motion, which makes the prolapse visible. For most people the diagnosis becomes clear straight away.

Some patients benefit from additional tests to build a fuller picture — especially when the prolapse is internal or bowel control is affected. These may include:

• Anorectal manometry — measures pressures inside the anal canal (a bit like a blood pressure test for your bowel)
• Endoanal ultrasound — a small probe gently placed inside the back passage to look at the sphincter muscles
• Defaecating proctography or MRI — imaging that watches how your bowel moves while you strain, performed in a radiology department with the scans reviewed in privacy

Treatment depends on the type of prolapse you have and how much it is affecting your life.

For mild internal prolapse or early symptoms, pelvic floor physiotherapy is helpful and worth trying first — particularly when pelvic floor weakness is part of the picture. See the Pelvic Floor Physiotherapy guide for what to expect.

For a full-thickness rectal prolapse that is causing symptoms, surgery is the most effective solution — pelvic floor exercises alone will not fix a prolapse that has been coming out. There are two broad surgical approaches:

• An abdominal approach — usually a laparoscopic or robotic ventral mesh rectopexy. The rectum is gently lifted back into its correct position from above and supported with a small mesh anchored to the sacrum (the bony base of the spine). This is the preferred operation for most patients — published series report good long-term anatomical and functional outcomes, with recovery from keyhole surgery generally quicker than from open surgery. In many patients, bowel control also improves once the sphincter is no longer being constantly stretched.
• A perineal approach — the Altemeier or Delorme procedure, performed through the back passage with no abdominal incision at all. This is offered to frail patients or those for whom abdominal surgery would carry too much risk.

Mr Nguyen's preferred operation for full-thickness prolapse is the robotic-assisted ventral mesh rectopexy, performed at Warringal Private Hospital or Epworth Eastern. The robotic platform allows precise dissection in the narrow space of the pelvis, and published series for this technique report good long-term outcomes. For frail patients or those for whom abdominal surgery is too risky, the perineal options (Altemeier or Delorme) are available instead.

Every recommendation is individual. Your age, fitness, symptoms, and what matters most to you all shape the decision — there is no one-size-fits-all answer for this condition, and the conversation about which operation suits you is unhurried.

If a prolapse has come out and you cannot push it back in — particularly if it is painful, turning a dark colour, or you feel unwell — this is an emergency. Go to your nearest hospital straight away.

For a prolapse that comes and goes, causes discomfort, is affecting your bowel control, or is having a real effect on your quality of life and confidence, please ask your GP for a referral. This is a very treatable condition — you do not need to simply live with it.

Your GP will send a referral and most patients are seen within one to two weeks. At the consultation a careful history is taken, you are examined, and any additional investigations that would be helpful are arranged — most often a defaecating proctogram or anorectal manometry where bowel control is affected.

Together these build a clear picture before any treatment decision is made. If surgery is recommended, a follow-up appointment is arranged afterwards to confirm recovery is going well and to discuss any improvement in bowel control.