Rectal prolapse can affect far more than bowel function. When the rectum protrudes through the anus, patients may experience a visible bulge, mucus discharge, bleeding, difficulty controlling bowel movements, or a persistent feeling that the bowel has not completely emptied. Over time, these symptoms can interfere with work, travel, sleep and confidence.
I understand that discussing these symptoms can sometimes feel uncomfortable or embarrassing. However, rectal prolapse is a medical condition that can be treated, and an appropriate assessment is the first step towards deciding whether surgery is necessary.
In this guide, I explain when I would consider rectal prolapse surgery, how I approach the choice between different surgical procedures, and what patients can generally expect during recovery.
What is rectal prolapse?
Rectal prolapse occurs when part or all of the rectum loses its normal support, moves downward and protrudes through the anus.
In adults, a full-thickness rectal prolapse is generally a structural problem. Medication, dietary changes and treatment for constipation may improve associated symptoms, but they do not usually correct the underlying loss of support.
One of the first things I want to establish is whether the problem is actually rectal prolapse. Hemorrhoids, prolapsing polyps and other anorectal conditions can sometimes produce similar symptoms, but their treatment can be very different.
This is why I recommend a proper specialist assessment rather than relying only on the appearance or symptoms.
When do I recommend rectal prolapse surgery?
For full-thickness rectal prolapse, surgery is generally the definitive treatment.
I do not base the decision on the appearance of the prolapse alone. I also consider how frequently it occurs, whether it can be pushed back inside, whether there is bleeding or ulceration, and how much it is affecting the patient’s daily life.
Surgery may be appropriate when the prolapse is recurrent, painful, difficult to reduce, bleeding or associated with fecal incontinence. Significant constipation or difficulty emptying the bowel can also be important considerations.
If the symptoms are substantially affecting quality of life, surgery may be appropriate even when the prolapse can still be manually reduced.
When is rectal prolapse an emergency?
I advise patients to seek urgent medical attention if a prolapse cannot be pushed back inside, becomes dark red, purple or black, develops severe pain, or is associated with significant bleeding.
These symptoms can indicate that the blood supply to the prolapsed tissue has become compromised. This should not be treated at home.
How I assess a patient before surgery
Before recommending an operation, I want to understand the patient’s symptoms and overall bowel function.
I will ask about constipation, bowel frequency, urgency and continence. I also want to know about previous abdominal or pelvic operations, childbirth history, medications and medical conditions that may influence the prolapse or the patient’s ability to undergo surgery.
The examination may include inspection of the anus and rectum while the patient strains, a digital rectal examination and assessment of pelvic floor function.
Not every patient needs extensive testing. Depending on the patient’s age, symptoms and previous screening, I may recommend a colonoscopy to look for a polyp, tumour, inflammation or another condition that could be contributing to altered bowel habits.
For patients with significant constipation, difficulty emptying the bowel or fecal incontinence, additional tests such as defecography, anal manometry or pelvic floor assessment may sometimes be useful.
My aim is not simply to confirm that a prolapse exists. I want to understand the patient’s bowel function as well, because this can influence which operation is most appropriate.
How I choose the type of rectal prolapse surgery
There is no single operation that is right for every patient.
Broadly, I consider two approaches: an abdominal repair and a perineal procedure.
Age and general fitness are important, but they are not the only factors I consider. Constipation, bowel control, previous abdominal surgery, pelvic floor function and the patient’s overall medical condition can all influence the recommendation.
My goal is to balance the durability of the repair with the risks of surgery for that particular patient.
Abdominal rectopexy
For patients who are fit enough to undergo abdominal surgery, I may recommend an abdominal rectopexy. In appropriately selected patients, abdominal repairs generally have a lower risk of recurrence than perineal procedures.
During a rectopexy, the rectum is mobilized, returned to its normal position and secured to the tissues around the sacrum.
The precise technique depends on the patient’s anatomy, bowel function and other clinical factors.
Laparoscopic and robotic rectopexy
In suitable patients, rectopexy can be performed using minimally invasive techniques, including laparoscopic or robotic surgery.
These approaches use small incisions rather than a large abdominal incision. For appropriately selected patients, this may result in less wound discomfort, a shorter hospital stay and an earlier return to normal activity.
However, I do not consider robotic or laparoscopic surgery to be automatically appropriate for everyone. Previous abdominal operations, anatomy, medical fitness and the specific circumstances of the prolapse all need to be considered.
Does rectopexy always require mesh?
No. Not every rectopexy uses mesh.
In selected patients, I may consider a ventral mesh rectopexy, in which mesh is used to reinforce the repair. Other rectopexy techniques can be performed using sutures without mesh.
If mesh is being considered, I believe it is important to discuss both the potential benefits and the possible mesh-related complications before making a decision.
The choice should be based on the patient’s anatomy, type of prolapse and associated bowel symptoms rather than applying the same technique to every patient.
What if I have constipation or fecal incontinence?
This is an important part of my assessment.
Some surgical techniques can affect bowel function, and extensive mobilization behind the rectum may worsen constipation in some patients. In selected patients, a ventral approach may be considered when constipation or an associated pelvic floor disorder is an important part of the clinical picture.
Fecal incontinence may improve after the prolapse is corrected because the prolapse itself can interfere with bowel control. However, I explain to patients that improvement cannot always be guaranteed, particularly when there is underlying weakness of the pelvic floor or anal sphincter.
For this reason, I consider bowel function before deciding which surgical approach is most suitable.
Perineal procedures
Perineal operations repair the prolapse through the anus and perineum rather than through the abdomen.
Two commonly used procedures are the Delorme procedure and perineal rectosigmoidectomy, also known as the Altemeier procedure.
I may consider a perineal approach for older or medically frail patients, particularly when an abdominal operation would carry a greater anaesthetic or surgical risk.
These procedures can be less physiologically demanding. However, the trade-off is that recurrence can be higher than with some abdominal repairs, particularly over longer follow-up.
The most extensive operation is therefore not necessarily the safest or most appropriate operation. A perineal procedure can be a very reasonable choice when it fits the patient’s age, health and clinical circumstances.
Preparing for rectal prolapse surgery
Before surgery, I will review the patient’s medical history, medications and general fitness for the planned procedure.
Depending on the patient’s health and the operation being considered, preparation may include blood tests and an anaesthetic assessment.
Blood thinners, diabetes medications and certain supplements may need to be adjusted around the time of surgery. I always advise patients not to stop prescribed medication unless their medical or anaesthesia team has instructed them to do so.
Depending on the procedure, bowel preparation and antibiotics may be required.
I also encourage patients to think about the recovery period before coming into hospital. Arranging help with driving, shopping, childcare and heavy household activities can make the first few weeks much easier.
If a patient smokes, has a persistent cough or has significant constipation, addressing these issues before surgery can also be helpful.
What can I expect during recovery?
Recovery depends on the operation performed and the patient’s general health.
Patients undergoing minimally invasive abdominal surgery often stay in hospital for several days, although the exact duration varies. Recovery after a perineal procedure can be shorter in some patients, but this also depends on medical needs and how quickly normal bowel function returns.
I encourage early movement after surgery. Walking helps reduce the risk of blood clots and supports normal lung function.
Pain relief is provided to allow patients to move comfortably while avoiding unnecessary sedation. Food and fluids are generally introduced gradually as bowel function returns.
When can I return to normal activities?
For several weeks after surgery, I generally advise patients to avoid heavy lifting and strenuous abdominal exercise while the repair heals.
Patients with desk-based jobs may be able to return to work sooner than those whose work involves significant physical activity.
Driving should only resume when the patient is comfortable performing an emergency stop and is no longer taking medication that could impair their ability to drive.
I give specific advice based on the type of operation and the individual’s recovery.
How should I look after my bowel after surgery?
One of my main priorities after rectal prolapse surgery is to help patients avoid straining.
Ideally, bowel movements should be soft and regular. I may recommend a stool softener or laxative for a period after surgery, together with adequate fluid intake and an appropriate amount of dietary fibre.
Fibre can be helpful, but I do not advise increasing it rapidly in every patient. Some people with obstructed defecation can experience more bloating and discomfort if fibre is increased too aggressively.
Patients should contact their medical team promptly if they develop persistent constipation or diarrhoea, worsening bowel leakage, fever, increasing abdominal pain, or difficulty passing urine or stool.
Risks and realistic expectations
As with any operation, rectal prolapse surgery carries potential risks. These include bleeding, infection, blood clots, anaesthetic complications, injury to nearby organs, urinary problems and, in some cases, bowel obstruction.
There are also risks specific to rectal prolapse surgery. These may include recurrence of the prolapse, constipation, persistent or new bowel-control problems, sexual dysfunction and, when mesh is used, mesh-related complications.
When I discuss surgery with a patient, I believe it is important to be realistic about what the operation can and cannot achieve.
Repairing the prolapse can significantly improve symptoms and quality of life, but it does not necessarily correct every aspect of pelvic floor dysfunction.
For example, constipation, urinary symptoms, vaginal prolapse or fecal incontinence may have additional causes. When these problems coexist, pelvic floor physiotherapy or assessment by another appropriate specialist may be beneficial.
My approach to rectal prolapse surgery
When I assess a patient with rectal prolapse, I look beyond the prolapse itself.
I consider bowel function, continence, constipation, previous operations, pelvic floor function and the patient’s general medical condition before recommending a particular procedure.
Where appropriate, minimally invasive or robotic techniques may be considered. However, I do not believe that the newest or most technologically advanced procedure is automatically the right choice for every patient.
The operation needs to be appropriate for the individual.
My aim is to achieve a durable repair while keeping the treatment as safe as possible and taking into account how the patient wants to return to normal life after surgery.
Questions I encourage patients to ask
A consultation should give you a clear understanding of your diagnosis and why a particular operation has been recommended.
I encourage patients to ask:
Do I definitely have a rectal prolapse?
Do I need surgery now?
Would an abdominal or perineal procedure be more appropriate for me?
Would laparoscopic or robotic surgery be suitable?
Will mesh be used?
Could the operation affect my constipation?
Is my bowel leakage likely to improve?
What is my risk of recurrence?
How long am I likely to stay in hospital?
When can I return to work, exercise and driving?
What happens if my bowel symptoms continue after surgery?
It is also useful to bring a list of your medications and a short record of your symptoms. In particular, note how often the prolapse occurs, whether it reduces by itself, and whether constipation, urgency or leakage is present.
Final thoughts
Rectal prolapse is a structural problem, but its effect on a person’s life can extend well beyond the prolapse itself.
Surgery can provide effective treatment, but choosing the right procedure requires more than simply looking at the prolapsed rectum. I consider the patient’s bowel function, continence, general health, previous surgery and individual circumstances before recommending an approach.
For me, the goal is not simply to repair the anatomical problem. It is to choose a treatment that provides an appropriate balance between safety, durability, bowel function and recovery.
If you are experiencing symptoms of rectal prolapse, a detailed assessment with an experienced colorectal surgeon can help establish the diagnosis and explain which treatment options are appropriate for you.