Overview

Rectal prolapse refers to a condition in which the rectum, a part of the large intestine, slips out of the anus. Your organs are held in place by a number of ligaments and musculature. `When any of these weaken, it results in a prolapse. 

A prolapse is not reversible. It requires surgery to deal with, however, it is a relatively uncommon condition. In the UK, a reported 2.5 per 100,000 individuals are affected by rectal prolapse each year.

Another common GI symptom is tenesmus. It’s the constant feeling of wanting to go poop even though your bowels are empty. The urge from tenesmus persists regardless of evacuating, and it is always a sign of an underlying condition. 

Oftentimes, rectal prolapse and tenesmus go hand in hand. For this reason, it is important to recognise these signs of the two as it can lead to their proper diagnosis and early detection.

Knowing about these conditions can also help raise awareness, which allows others to take preventative measures before the situation gets worse. 

Understanding rectal prolapse

The large intestine is divided into several parts depending on its location in the body. The lower end of the tract is referred to as the rectum. It is the final site where poop is stored before being expelled from the body. Due to a number of reasons, the rectum can bulge out of the anal opening. When that happens, it is referred to as a rectal prolapse. 

Why does rectal prolapse happen? 

Prolapse occurs as a result of weakened muscles that support the rectum. Our body has specialised groups of muscles called the levator ani which lift and keep the rectum in place. Due to certain conditions, the muscle function can be compromised. Such conditions exert pressure and cause excessive strain on the muscle. These include:

• Childbirth 
• Constipation 
• Genetic defects in the GI tract
• Spinal cord defects
• Cystic Fibrosis

Having said that, rectal prolapses are common in older people.¹ It is commonly seen in people aged 50 or above. Most of them are women. If a prolapse does occur in younger people, it is likely due to an underlying health condition or some kind of drug therapy. 

Symptoms of rectal prolapse

The typical indication of a rectal prolapse is a feeling of pressure or bulge in the anus. If you take a look, the bulge will resemble a reddish lump that sticks out of the anal opening. 

Other symptoms you’ll observe are:

• Tenesmus 
• Pressure feeling
• Constipation 
• Leakage of stools or mucus
• Pain or itching in the anus
• Bleeding

Diagnosing rectal prolapse

To diagnose a prolapse, your doctor will start by asking you about your symptoms. 

This includes questions like when you felt the bulge and if you have any of the risk factors or diseases that contribute to it.

Based on the history, the doctor will then proceed to examine your rectum. This can be either by manually inserting a finger with lubricated gloves or using other imaging studies. 

Some of the common methods of assessment include:²

• Barium enema – a chalky liquid is inserted up your rectum, and a series of X-rays are taken to determine its structure and shape
• Anorectal Manometry –  a probe is placed in your rectum, and data about the tightness of the muscles is sent to a machine
• Electromyography – a needle is inserted to determine the electrical activity of your nerves
• Colonoscopy – this involves directly looking in the colon by using a tool to expand the walls

Understanding tenesmus  

Tenesmus refers to the constant feeling of wanting to empty your bowels. The feeling can be limited to the bowels, but sometimes can also impact the bladder. Most people describe tenesmus as being painful and uncomfortable. 

The underlying cause of tenesmus is inflammation. This is a process by which the body fights off infection. In moderate amounts, inflammation is good as the body is trying to protect itself. However, too much inflammation can be harmful and can lead to health problems.

Excess inflammation in the lower bowels irritates the area and makes the nerves overreact. Hyper stimulated nerves fire false signals to the brain which makes it think you have to go poop when you do not. 

The most common cause of tenesmus is inflammatory bowel disease.³ However, it can also be a symptom indicating:

• Infections
• Cancer
• Haemorrhoids 
• Side effects of radiation therapy 

Diagnosing tenesmus requires evaluation of symptoms and recommending appropriate tests. A doctor may recommend:

• Colonoscopy 
• Blood tests
• Stool samples 
• X-Ray, MRI, or CT scan

Treating tenesmus 

It's important to diagnose tenesmus and treat it accordingly. Not only can it be a sign of cancer, but tenesmus can significantly interfere with daily life. It disrupts daily schedules, puts patients in discomfort and pain, and can lead to feelings of embarrassment and anxiety. 

What role does tenesmus play in rectal prolapse? 

Tenesmus is commonly seen in inflammatory conditions of the bowel, however, it is also a symptom of rectal prolapse. A rectal prolapse begins internally and initially presents with symptoms like fullness and tenesmus. 

Think of it as an obstruction. When the rectum is dislodged from its normal anatomical position, it can fold on itself to create a blockage. This leads to the constant sensation of feeling like you have to evacuate.

Apart from acting as a physical blockage, a prolapse rectum may also become inflamed as it is outside the body, somewhere it is not supposed to be. An inflamed rectum leads to irritation in the nerves, which drives a constant cycle of feeling like you have to go even when the rectum is empty.

What are the treatment options?

Rectal prolapse

Treating rectal prolapse requires surgery.⁴ It is a serious condition that cannot be fixed by medication or physical therapy. The surgery can be done in a number of different ways. Depending on your condition and health, your doctor will suggest the best option. 

The surgery can either be done through the abdomen or via the anus. The approach depends on factors like:

• Size of prolapse
• Age of the patient
• Other existing health conditions
• Surgeon’s preference

Approach to prolapse repair 

The abdominal approach requires a cut in the abdomen to access the rectum.⁵ Using surgical sutures, the surgeon fixes the rectum back to the pelvic bone. Sometimes, a little camera can be used to visualise the abdomen too.

The other more commonly used approach is the perineal approach, where the surgeon pulls the rectum and removes the prolapsed part. The rest of the rectum is joined to the colon, and stitches are placed to repair the cut.⁶

Recovery

After the surgery, you’ll spend some time recovering until full bowel function is restored. A high fibre diet and stool softening agents may be recommended to prevent straining and the risk of another prolapse. Once 4 to 6 weeks are over, you will be discharged.

Tenesmus

The treatment of tenesmus requires an understanding of the cause. Antibiotics may be prescribed for treating an infection, and corticosteroids may be advocated to lower the intensity of gut inflammation. 

As for pain, anal suppositories or antispasmodics can be prescribed to keep the muscle in a relaxed state. For conditions like cancer, a whole therapy plan may be required to correct tenesmus.

Long-term prevention tips for tenesmus and rectal prolapse

Preventing rectal prolapse and tenesmus requires a series of dietary modifications as well as lifestyle changes. To maintain good gut movement, ensure taking a high fibre diet and maintaining ample hydration.⁷ 

According to Better Health, the recommended daily fiber intake for men under 50 is 30g, and for women under 50, it is 25g. Incorporate more fiber into your diet by choosing high fiber cereals, eating fruits and vegetables with their skins, and choosing whole wheat grains over processed grains. As for movement, aiming for a daily 30 – 35 minute brisk walk is sufficient. You should aim to get at least 150 minutes of moderate activity per day. 

Lastly, incorporate good bowel habits. Avoid habits like straining on the toilet, as this can increase the pressure in the rectum. Consider buying a stool to elevate your legs on the toilet so you can keep your knees higher than your hips. Do not ignore the urge to go to the toilet and aim for a bowel movement at least three times a week. 

Other things you can do are practice regular kegel exercises to strengthen the pelvic floor muscles. Moreover, if you have a persistent health condition that exerts pressure on the rectum, i.e, constipation or cough, consult a healthcare professional.

FAQs

How do I differentiate between rectal prolapse and haemorrhoids? 

A haemorrhoid and prolapse can be confused with each other, however, they are fundamentally different. A haemorrhoid is smaller and can be best described as small bumps in the lower anal region. On the other hand, a prolapse tends to be larger and lumpy in shape. A haemorrhoid is acute and can even resolve with simple diet and lifestyle modifications. Contrary to that, a prolapse requires surgical intervention.

How can I manage a prolapse non-surgically?

A small prolapse can easily be pushed back using your fingers. However, it is only a matter of time before this gets worse, and that's when urgent medical care is needed. You can use supportive underwear to support abdominal tone. Avoid exercises that include heavy lifting. Consider using skin protection ointment to protect the prolapse from sustaining injuries.

When should I see a doctor?

You require urgent medical care if you suffer from:

• A prolapse that cannot be pushed back
• Excessive bleeding from the anus
• The lump becomes discoloured 
• Changing bowel movements

Summary

Rectal prolapse and tenesmus are two medical conditions that can drastically affect a patient’s quality of life. A prolapse is defined as the slipping out of the rectum from the anal canal. It is associated with several risk factors and requires surgery to repair. One of the signs of a prolapse can be tenesmus, which is defined as the sensation of incomplete evacuation. It is important to pick out this symptom as it can also be the cause of something greater, like cancer. Early detection is key for successful treatment. Should you experience any medical symptoms as mentioned, refer to a healthcare professional immediately.