Rectal Prolapse (Bowel Prolapse)

Rectal prolapse is the downward slipping of the rectum, the last part of the large bowel, from its normal position. In advanced cases the rectum can come out through the anus. In everyday language it is also known as “bowel prolapse”.

Rectal prolapse can occur in three different forms:

• Full-thickness external rectal prolapse: All layers of the rectal wall come out through the anus.
• Mucosal prolapse: Only the tissue lining the inside of the rectum or anal canal slips out.
• Internal rectal prolapse: The rectum folds in on itself but does not come out through the anus. This condition is also called “rectal intussusception”.

Rectal prolapse can occur in both women and men. In adults it is more common in women, especially at older ages. However, it is not a condition limited to women who have given birth.

Full-thickness rectal prolapse is not a directly life-threatening condition; however, it can grow over time, impair bowel control and lead to bleeding and skin irritation. In adults, the lasting treatment for marked full-thickness prolapse is usually surgery [1].

What symptoms does rectal prolapse cause?

The most obvious sign is red or pink tissue coming out of the anus during a bowel movement. This tissue usually looks like rings inside one another.

Other symptoms include:

• Tissue coming out of the anus during or after a bowel movement
• Needing to push the prolapsed tissue back in by hand
• A feeling of fullness or pressure in the anus
• Mucus discharge and constant wetness
• Itching and skin irritation around the anus
• Bleeding from the back passage
• Constipation and excessive straining
• A feeling of incomplete emptying
• Difficulty controlling wind or stool
• Not reaching the toilet in time, or faecal incontinence

At first, the prolapse may appear only during a bowel movement and go back in on its own. Over time it may also come out when coughing, walking or standing, and may need to be pushed back in by hand.

Why can faecal incontinence develop?

The prolapsing rectum can constantly stretch the anal muscles and stop them working effectively. In addition, existing damage to the nerves and muscles of the pelvic floor can contribute to the development of both prolapse and faecal incontinence.

Correcting the prolapse can improve bowel control in many patients. However, if the damage to the anal muscles or nerves is advanced, the incontinence may not improve completely [1].

Why does rectal prolapse develop?

In most patients there is no single cause. The pelvic floor muscles, connective tissues, nerves and bowel movements all play a part together.

Factors that can increase the risk include:

• Long-standing constipation and excessive straining
• Chronic diarrhoea
• Weakness of the pelvic floor muscles
• Older age
• Difficult or multiple vaginal births
• Previous pelvic operations
• Chronic cough
• Certain diseases affecting connective tissue
• Diseases of the spinal cord and nervous system
• Prolapse of the womb, bladder or vagina
• Uncoordinated working of the pelvic floor muscles during bowel movements

Constipation can contribute to rectal prolapse; the prolapse itself can also make it harder for stool to pass and so make constipation worse.

The diagnosis is often made from the patient’s history and an examination.

Your doctor will ask:

• When the prolapse first appeared,
• Whether it goes back in on its own,
• Whether it needs to be pushed back by hand,
• Whether there is constipation or diarrhoea,
• Whether there is leakage of wind or stool,
• About urinary and other pelvic floor complaints.

An examination of the anus and rectum is carried out. If the prolapse cannot be seen during the examination, the patient may be asked to strain in a sitting position. A photograph taken by the patient of a prolapse that appears at home can also help with the diagnosis.

What tests may be needed?

Not every test is needed for every patient. Depending on the complaints, the following investigations may be used:

• Colonoscopy: May be carried out if there is bleeding, anaemia, a change in bowel movements or a need for bowel cancer screening.
• Defecography: Shows the movements of the rectum and pelvic floor while the patient passes stool.
• MR defecography: Can show internal rectal prolapse together with problems such as a rectocele or prolapse of the bladder or vaginal organs.
• Anorectal manometry: Assesses the pressure of the anal muscles, rectal sensation and how the pelvic floor works during a bowel movement.
• Balloon expulsion test: Investigates whether the pelvic floor relaxes enough during a bowel movement.
• Colonic transit study: May be carried out in patients in whom slow bowel movement is suspected.
• Endoanal ultrasound: Can show damage to the anal muscles, especially if there is faecal incontinence.

Dynamic pelvic floor imaging helps to assess internal prolapse and other pelvic organs affected at the same time [2].

When the treatment plan is being prepared, not only the appearance of the prolapse but also constipation, diarrhoea, faecal incontinence, pelvic floor function, age, general state of health and previous operations are assessed together.

Is treatment without surgery possible?

In adults, full-thickness rectal prolapse does not disappear anatomically with medicines, exercises or pelvic floor physiotherapy.

Nevertheless, non-surgical treatments:

• Can reduce constipation and straining.
• Can bring diarrhoea under control.
• Can ease faecal incontinence.
• Can reduce skin irritation around the anus.
• Can regulate bowel function before surgery.

Depending on your doctor’s advice, adjustment of fibre intake, drinking enough fluid, suitable stool softeners, treatment of diarrhoea and pelvic floor physiotherapy may be used.

In patients whose pelvic floor muscles do not relax during bowel movements, biofeedback therapy can be helpful. However, this treatment does not permanently correct a full-thickness rectal prolapse that comes out through the anus [1,3].

When is rectal prolapse surgery needed?

In marked full-thickness external rectal prolapse, surgical treatment is considered if the patient’s general condition is suitable for an operation.

The aims of the operation are:

• To return the rectum to its normal anatomical position,
• To prevent it from coming out again,
• To improve bowel movements and bowel control as far as possible,
• To reduce bleeding, discharge and skin irritation.

The operations can be performed through the abdomen or from around the anus. There is no single “best” method for every patient. The choice is made individually [1].

Operations through the abdomen

In operations through the abdomen, the rectum is returned to its normal position and fixed to the back part of the pelvis. This procedure is called rectopexy.

In suitable patients the operation can be performed laparoscopically, that is, through small incisions.

The main methods are:

• Suture rectopexy: The rectum is fixed with stitches to the firm tissues in front of the bone.
• Resection rectopexy: While the rectum is being fixed, part of a long or poorly functioning sigmoid colon is removed.
• Ventral mesh rectopexy: The front of the rectum is suspended in its normal position with the help of a mesh.

Operations through the abdomen usually provide a more durable anatomical repair. However, the patient’s surgical and anaesthetic risk should be assessed when the method is being chosen.

What is ventral mesh rectopexy?

In ventral mesh rectopexy, the front of the rectum is freed to a limited extent. A mesh placed in front of the rectum is fixed to the firm tissue at the front of the pelvic bone so as to hold the rectum in its normal position.

This method may be considered in:

• Full-thickness external rectal prolapse,
• Selected internal rectal prolapse,
• Some multicompartment pelvic floor prolapses.

Because the back and sides of the rectum are not extensively freed, it may reduce the risk of newly developing constipation after the operation in some patients. Nevertheless, it is not suitable for every patient.

A 2025 international expert consensus recommends detailed assessment of patient selection, accompanying pelvic floor problems, the surgeon’s experience and the risks specific to the use of mesh [3].

Although rare, the use of mesh can cause:

• Infection,
• Erosion of the mesh into the bowel or vagina,
• Chronic pain,
• Fistula,
• Complications requiring removal of the mesh. These risks should be discussed openly with the patient before the operation.

The mesh placed through the abdomen in ventral rectopexy and prolapse meshes placed through the vagina are not the same procedure.

Operations from around the anus

Perineal operations are carried out without opening the abdomen, on the bowel that has come out through the anus. They may be preferred particularly in older patients, in those with serious accompanying illnesses or in those for whom abdominal surgery carries a high risk.

The main methods are:

• Delorme’s operation: The lining of a shorter prolapsed section of the rectum is removed, and the muscle layer is folded to strengthen it.
• Altemeier’s operation: The prolapsed rectum and, when necessary, part of the sigmoid colon are removed through the anus; the ends of the bowel are then joined again.

In some patients, perineal operations can be performed with a lower surgical burden. On the other hand, the chance of the prolapse coming back may be higher than with some abdominal operations.

How is the surgical method decided?

The following characteristics are taken into account in the decision:

• The patient’s age and general state of health
• The length and type of the prolapse
• Whether constipation or faecal incontinence is the main problem
• Whether bowel movements are slow
• An accompanying rectocele or other pelvic organ prolapse
• Previous abdominal and pelvic operations
• The patient’s expectations
• The surgeon’s experience with the methods concerned

The aim is not only to correct the prolapse but to improve bowel function and quality of life as far as possible.

The length of the hospital stay varies according to the surgical method and the patient’s state of health. After laparoscopic (keyhole) abdominal operations or perineal operations, a stay of a few days in hospital may be needed.

After the operation:

• Pain is controlled.
• You start walking early.
• Eating and drinking are reintroduced gradually.
• Treatment may be given to keep the stool soft.
• The aim is to prevent excessive straining.

Returning to desk work is possible for most patients within about 2–4 weeks. Returning to heavy lifting and strenuous exercise may require waiting longer.

You should contact your healthcare team in the following situations:

• High fever
• Abdominal or anal pain that keeps getting worse
• Persistent vomiting
• Inability to pass wind or stool
• Heavy bleeding from the back passage
• Foul-smelling discharge
• A marked prolapse developing again

Rectal prolapse can come back after surgery. The risk of recurrence varies according to the method used, the condition of the connective tissue and whether constipation and excessive straining continue.

1. Bordeianou L, Paquette I, Johnson E, et al. Clinical Practice Guidelines for the Treatment of Rectal Prolapse. Diseases of the Colon & Rectum. 2017;60(11):1121–1131. doi:10.1097/DCR.0000000000000889. ASCRS guideline
2. Gurland BH, Khatri G, Ram R, et al. Consensus Definitions and Interpretation Templates for Magnetic Resonance Imaging of Defecatory Pelvic Floor Disorders. American Journal of Roentgenology. 2021;217(4):800–812. doi:10.2214/AJR.21.26488. PubMed record
3. Perry WRG, Christensen P, Collinson RJ, et al. Ventral Rectopexy: An International Expert Panel Consensus and Review of Contemporary Literature. Diseases of the Colon & Rectum. 2025;68(5):593–607. doi:10.1097/DCR.0000000000003656. PubMed record
4. Van de Bruaene C, De Schepper H, Surmont M, et al. Guideline on Pelvic Floor Disorders: Consensus on Obstructed Defecation Syndrome. Acta Gastro-Enterologica Belgica. 2026;89(2):385–405. doi:10.51821/89.2.15231. PubMed record