Why does this happen: the reasons are different for young and old
Rectal prolapse is the result of a combination of two factors: weakening of the holding apparatus of the rectum and a constant increase in intra-abdominal pressure. But the set of causes varies markedly in different age groups, and the approach to treatment depends on this.
- In older women - the most common group: multiple and traumatic births, weakening of the pelvic floor muscles, estrogen deficiency after menopause, chronic constipation
- In the elderly of both sexes - general weakness of connective tissue, decreased muscle tone, inactivity, prolonged straining with constipation
- In young men, more often there are anatomical features: a deep pouch of Douglas, an elongated sigmoid colon, weakness of the ligamentous apparatus, as well as heavy physical activity and lifting heavy weights.
- In children under 3–4 years of age - immaturity of the fixation apparatus due to diarrhea, constipation, prolonged sitting on the potty, cough; at this age the condition usually goes away when the cause is eliminated
- Common to all: chronic cough, prostate adenoma with straining when urinating, previous operations and injuries of the perineum, neurological diseases
Separately, there are circumstances that do not cause prolapse in themselves, but greatly accelerate its development in a predisposed person: chronic cough of a smoker, daily heavy lifting at work, the habit of sitting for a long time in the toilet with a smartphone and straining. The latter is most often underestimated. Prolonged sitting with straining creates exactly the same repetitive pressure mechanism that stretches the ligamentous apparatus of the rectum year after year. A good rule of thumb is to avoid staying on the toilet for more than a few minutes and not to substitute straining for the normal consistency of your stool.
Stages and types
The stage is determined by two criteria: under what load the intestine prolapses and whether it is reduced on its own. This is not an abstract classification - both the volume of the operation and the likelihood that retention will be fully restored depend on the stage.
- Первая: кишка выпадает только при дефекации с сильным натуживанием и самостоятельно вправляется обратно.
- Вторая: выпадает при дефекации, самостоятельно не вправляется — приходится вправлять рукой; начинается недостаточность удержания газов.
- Третья: выпадение происходит при кашле, смехе, ходьбе и минимальной нагрузке; выражено недержание.
- Четвёртая: кишка находится снаружи практически постоянно, вправляется с трудом и снова выпадает; слизистая изъязвляется, удержание утрачено.
Separately, internal prolapse is distinguished - intussusception, when the intestinal wall moves inward, but does not come out. Nothing is visible from the outside, but there are complaints: a feeling of incomplete emptying, the need to strain for a long time, a feeling of obstacles, sometimes the need to help yourself with your hand. Such patients are often treated for years for “chronic constipation”, and the correct diagnosis is made only after defecography.
The speed of transition between stages varies from person to person and is often measured in years rather than months. It is this slowness that creates the false feeling that nothing serious is happening: changes accumulate so gradually that a person gets used to them, adjusts clothes, daily routine and routes to them, and notices the problem only when he loses control over gases. By this point, we are no longer talking about the early stage, and the scope of the operation is different.
How is it different from hemorrhoids?
This is the most common diagnostic confusion and costs patients years of inappropriate treatment. Both conditions are manifested by a formation emerging from the anus when straining, but their nature is different: with hemorrhoids, enlarged vascular nodes fall out, with prolapse - the entire intestinal wall.
- With intestinal prolapse, the folds of the mucosa are located concentrically, in rings around the lumen; with hemorrhoids, the nodes are separated by grooves and run radially
- The prolapsed intestine looks like a cylinder or cone several centimeters long, hemorrhoids look like separate formations
- With prolapse, gas and mucus incontinence appears early; this is not typical for hemorrhoids
- Bleeding is typical for hemorrhoids; with prolapse, blood often appears later, due to injury and ulceration of the mucous membrane
- Suppositories and ointments relieve hemorrhoids, but in case of prolapse they do not affect the course at all
Confusion is also possible in the other direction: a large pedunculated polyp or prolapsed hypertrophied anal papillary tissue is sometimes mistaken for intestinal prolapse. The practical conclusion is the same - the formation coming out of the anus should be seen by a doctor at least once. An examination with straining takes just a few minutes, does not require preparation and immediately answers the question of what we are talking about. Years of self-medication usually begin precisely with the fact that a person did not allow himself these few minutes.
Survey
- Осмотр в покое и обязательно с натуживанием — иногда врач просит натужиться в положении на корточках, чтобы увидеть картину, которая не воспроизводится на кушетке.
- Пальцевое исследование прямой кишки с оценкой тонуса сфинктера и силы волевого сокращения.
- Аноскопия и ректороманоскопия — состояние слизистой, наличие язв и воспаления.
- Колоноскопия — обязательна для взрослых, чтобы исключить опухоль как причину натуживания и кровотечения.
- Дефекография — исследование, показывающее, что происходит с кишкой в момент опорожнения; ключевой метод при внутреннем выпадении.
- Аноректальная манометрия и оценка функции удержания — важны для прогноза восстановления после операции.
- Оценка состояния других органов малого таза у женщин: пролапс редко бывает изолированным.
Some of the studies may seem redundant, but each answers its own question. Colonoscopy excludes a tumor, which itself can cause straining and bleeding and completely changes tactics. Defecography shows what exactly happens at the moment of emptying, and often reveals combined pelvic floor disorders that the patient was not aware of. Manometry helps to understand what recovery of continence can be expected after surgery - and this influences both the choice of method and an honest conversation about expectations before the intervention, and not after it.
Treatment: what surgery solves and what it doesn’t
In adults, rectal prolapse is a surgical problem. Conservative measures do not eliminate the anatomical cause, but they are required both before and after surgery: without normalizing stool and reducing straining, relapse is likely with any technique.
- Normalization of stool: fiber, sufficient fluid volume, mild laxatives if necessary - the goal is to completely stop severe straining
- Pelvic floor muscle training and biofeedback - especially useful for concomitant incontinence and in preparation for surgery
- Treatment of underlying conditions: chronic cough, prostate adenoma, hypothyroidism, neurological pathology
- Operations through the abdomen, often laparoscopic: the intestine is brought into the correct position and fixed, if necessary, using a mesh implant; such interventions have the lowest relapse rate and are preferable in patients able to tolerate anesthesia and abdominal surgery
- Perineal surgeries: performed without entering the abdominal cavity, are easier to tolerate and are usually chosen in older patients with severe comorbidities
- When combined with prolapse of other pelvic organs, the scope of intervention is planned together with a gynecologist or urologist
In children, the tactics are fundamentally different: in most cases, it is enough to eliminate the cause - cure diarrhea or constipation, change diet, stop prolonged sitting on the potty, and the loss goes away as the fixation apparatus matures. Surgery is rarely used in children and only when conservative measures are ineffective.
In adults, the choice of access - through the abdomen or through the perineum - is not a matter of surgeon preference, but a decision based on age, comorbidities and tolerance to anesthesia. Abdominal interventions have a lower relapse rate and are therefore preferable in more intact patients; Perineal ones are easier to tolerate and are reasonable where the risk of anesthesia and abdominal surgery is high. It is worth discussing this choice in advance, together with the doctor, understanding how one option differs from the other - then the decision is made consciously, and not perceived as imposed.
What will happen to retention after treatment?
- Недержание, связанное с механическим растяжением сфинктера выпавшей кишкой, обычно начинает восстанавливаться в первые месяцы после операции.
- Восстановление идёт постепенно и может занять от нескольких месяцев до года, особенно если выпадение существовало долго.
- Если сфинктер повреждён давно и мышца атрофирована, полное восстановление функции может не наступить — это ещё один довод не откладывать обращение.
- После операции продолжают работать со стулом и тазовым дном: это влияет и на удержание, и на риск рецидива.
- Плановые осмотры колопроктолога в первый год позволяют вовремя заметить возврат симптомов.
There is also a practical side that is rarely talked about out loud. While continence is being restored, the patient needs a clear plan and realistic guidelines: what foods thicken stool, how to plan long trips, and when to return to work and physical activity. It is worth discussing this with your doctor before discharge, rather than finding out experimentally at home. The feeling of control over the situation here also has a completely medical meaning: anxiety and attempts to limit drinking and eating “just in case” themselves worsen intestinal function.
