Dr Margaret answers e-mailers' embarrassing problems in this biweekly problem page.

Rectal prolapse

Dear Dr Margaret
I have a friend who has something called prolapsing rectum, I believe it is called. She has trouble feeling when she needs to use the toilet, plus part of the rectum comes out through her back passage, thus she is afraid to go out much at all. I am the only person she even told about this problem. She’s too embarrassed to talk about it to people, thus avoids most public functions, keeping her sort of isolated and depressed. What causes this? Can anything be done to help her?

‘Rectal prolapse’ is fairly common in the elderly. Many people who have it are in their 80s and 90s, and most are women.

To understand rectal prolapse, you have to know a bit about the anatomy of the area. The large bowel (colon) leads into the last part of the gut, which is called the rectum. The rectum is about 12–15 cm long. The final 3 cm of the gut is called the anal canal. In rectal prolapse, when the person strains to have their bowels open, the inside of the lower part of the rectum is pushed out through the anus. Sometimes it protrudes a few centimetres, but in severe cases it could be 10 cm or more. Usually, the person notices a large lump, which appears at the anus after they have had their bowels open, or sometimes when they stand, walk or cough. It can usually be pushed back in, or goes back on its own when the person lies down.

The cause of rectal prolapse is not really known. Some experts blame weakness of the ‘pelvic floor’, which is the ligaments and muscle that hold the rectum and anal canal in their correct position. The pelvic floor can be weakened by childbirth, which might explain why rectal prolapse is much more common in women than men. Like all the other ligaments and muscles of the body, the pelvic floor become weaker as we age, which might explain why rectal prolapse usually affects very elderly people. Other experts say there is no scientific evidence that weakness of the pelvic floor is the cause.

It is not a very nice thing to have, because it is uncomfortable. It usually gives the problem your friend describes, of not knowing whether you need to pass faeces. There may be a permanent feeling of needing to defaecate, and some leakage of faeces can occur. Also, the lining of the rectum naturally secretes slime, which is messy, and it can become sore by rubbing on undergarments.

People try to cope by wearing a pad or sanitary towel, but there is no need to put up with it. Various surgical operations are possible, depending on the exact situation. The US Government website www.nlm.nih.gov/medlineplus/ency/presentations/100037_2.htm has diagrams explaining the most common operation. Your friend needs to see her doctor, so she can be referred to a specialist surgeon.

Any more questions?
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