Rectal prolapse: symptoms, causes, treatment and surgery

The Plymouth leaflet says the main symptom is a lump protruding from the anus. Initially the lump may come out during or after a poo or after straining and disappear on standing. With time it may protrude with other forceful activities such as coughing or sneezing, and eventually may be noticeable most of the time and interfere with daily life, such as walking. You may need to push it back inside with your hand.

Other symptoms include pain, constipation and bleeding from the back passage. The lump may rub against underwear and become ulcerated, and weakened anal muscles can lead to leakage of poo or sometimes mucus, which Plymouth describes as a jelly-like substance produced by the bowel wall. Guy's and St Thomas' lists bulging in the bowel or vagina, pain and discomfort, difficulty opening the bowels, difficulty controlling bowel movements or soiling without realising and discharge of mucus as symptoms for which surgery may be recommended.

The rectum is the lower end of the large bowel, held in place by supporting tissues and muscles. Guy's and St Thomas' describes rectal prolapse as when the last few inches of the bowel become stretched and stick out from the bottom. The Plymouth leaflet explains that the problem is insufficient support of the rectum, which then drops outside the anus, often alongside weakening of the anal sphincter.

A key distinction is between a full prolapse, in which the whole wall of the rectum comes out, and a partial prolapse in which only the lining of the bowel pops out. The Plymouth leaflet says a partial prolapse can usually be treated without surgery, although the extra tissue sometimes needs banding or suturing.

Guy's and St Thomas' says the treatment decision depends on the type of prolapse, any previous surgery and your medical health. Non-surgical help includes learning correct techniques for going to the toilet, pelvic floor exercises and ways of emptying the bowels from a specialist nurse or physiotherapist, which can prevent further prolapse or incontinence, and in some cases rectal irrigation taught in a bowel function clinic.

The Plymouth leaflet gives practical tips: a small prolapse may be gently pushed back using a gloved finger and lubricant, or gauze; address underlying constipation or diarrhoea, with a laxative or stool bulking agent if needed to avoid straining; supportive underwear can help; supporting the area around the anus with two fingers while opening the bowels can reduce further protrusion; avoid heavy lifting where possible; and tighten the pelvic floor before coughing, sneezing or laughing, a technique known as the Knack.

Surgery repairs the prolapse either through the tummy (an abdominal approach) or from below through the back passage. Guy's and St Thomas' describes the perineal repairs, Delorme's operation and the Altemeier procedure, in which the lining or the prolapsed section of bowel is removed and stitched back together; it takes about an hour and can be done under a spinal or general anaesthetic. Its listed risks include failure of the repair with the prolapse returning, bleeding, narrowing of the anal canal, problems controlling the bowels that may be temporary or permanent, and rarely a leak from the join in the rectum, which can be life threatening.

Plymouth lists constipation with prolonged straining, childbirth including multiple or traumatic vaginal deliveries causing pelvic floor injury and weakness, and neurological problems affecting the brain, spinal cord and nerves. Guy's and St Thomas' lists vaginal childbirth, long-term constipation, heavy lifting and weak pelvic floor muscles as factors that can weaken the supporting tissue so the bowel falls down.

The leaflet notes that the true number of cases is unknown and is thought to be under-reported. Because it is more common in older people and in women, it is often discovered when someone finally mentions a lump they had been embarrassed about. There is no reason to feel embarrassed about raising it with a GP or nurse.

Several other conditions can cause a lump at the back passage, and the Plymouth leaflet describes them. Telling them apart needs an examination, so do not assume a lump is piles.

After examination, the Plymouth leaflet says you may be offered a colonoscopy or flexible sigmoidoscopy, in which a thin flexible tube with a camera is passed through the anus into the lower bowel, anal physiology tests to evaluate the function and strength of the back passage muscles, a defaecating proctogram, an X-ray test of how well the bowel empties that can also identify other prolapses, and a colonic transit study, an X-ray examination showing how quickly food passes through the digestive system. You will not necessarily need every test.

The Plymouth leaflet says most people can cope with pushing the prolapse back, but if it cannot be pushed back, bleeds excessively or becomes dusky or purple in colour, you should seek a medical review urgently as you may need to be seen by the surgeon. That means contacting your GP, NHS 111 or an emergency department the same day rather than waiting for a routine appointment.

See a GP in any case if you notice a lump or new bleeding, a change in bowel habit, leakage, or pain. The NHS says that changes in your poo, blood in your poo and bleeding from the bottom should be checked, partly because several different conditions can cause them.

On the NHS the pathway usually runs from the GP to a colorectal or pelvic floor service, with pelvic floor physiotherapy, specialist nurse input and surgery planned by a colorectal surgeon. Private colorectal surgeons offer the same operations; the differences are mainly in waiting times and choice of surgeon. Whichever route you use, ask which operation is proposed, what the recurrence and incontinence risks are for you and who to contact if problems arise afterwards.