Synopsis
Distinguish external rectal prolapse from mucosal disease, recognise threatened bowel and select repair around anatomy, function and individual operative fitness.
- External full-thickness rectal prolapse typically has concentric mucosal rings; haemorrhoidal or mucosal prolapse usually has radial folds or discrete columns.
- Assess colour, tenderness and reducibility immediately: compromised or irreducible bowel needs urgent colorectal care and timely surgery if reduction fails or viability is threatened.
- Choose elective repair from prolapse length, constipation, continence, pelvic anatomy and fitness for anaesthesia; chronological age alone does not choose the operation.
Key red flags
New severe pain in previously painless prolapsing bowel suggests incarceration or threatened blood supply.
Persistent irreducibility, increasing oedema or dark mucosa warrants urgent review even before shock develops.
Abdominal distension, vomiting, peritonism or haemodynamic deterioration may indicate obstruction, necrosis or perforation.
A mass, anaemia or unexplained bleeding still requires investigation for a separate colorectal lesion.
Investigation priorities
Exclude a lead-point lesion or another explanation for bleeding before elective repair.
Management branches
A 79-year-old woman has recurrent reducible external prolapse and leakage despite stool regulation.
- Examination during straining demonstrates a viable 3 cm circumferential prolapse with concentric folds. Her baseline is liquid leakage twice weekly without troublesome constipation; appropriate colonic assessment finds no lead-point lesion. Cardiopulmonary assessment identifies substantial risk from prolonged general anaesthesia and pneumoperitoneum, so the team discusses a perineal repair.
- After explaining recurrence, bleeding, urgency and the possibility of persistent incontinence, she chooses a Delorme procedure. The surgeon removes the mucosal sleeve and plicates the underlying muscle; this short prolapse is suitable for that approach. The choice follows her anatomy, function and operative risk, rather than an age cutoff.