Synopsis
Differentiate rectal prolapse from haemorrhoidal or pelvic-organ prolapse, assess faecal incontinence systematically, and progress from reversible causes to specialist functional treatment.
- Full-thickness rectal prolapse produces concentric circumferential folds; prolapsing haemorrhoids form discrete radial columns, while mucosal prolapse is a more limited lining descent.
- Symptoms include a protruding mass, mucus, bleeding, incomplete evacuation, obstructed defaecation, urgency and passive leakage; patients may need to photograph an intermittent prolapse.
- Faecal incontinence means involuntary loss of stool that is a social or hygienic problem and should be asked about directly and without stigma.
- Urgency incontinence suggests inability to defer despite sensation; passive leakage suggests impaired sensation or resting sphincter function; post-defaecation seepage suggests incomplete evacuation.
- First identify treatable drivers such as diarrhoea, faecal impaction with overflow, medicines, infection, rectal loading, cognitive or mobility barriers and inadequate toilet access.
- A focused examination includes abdomen, perineum, prolapse during strain, anal sensation, digital rectal examination, sphincter squeeze and relevant neurological findings.
- Initial continence care aims for predictable formed stool, planned toileting, skin protection and pelvic-floor or bowel-retraining support rather than reflex antidiarrhoeal prescribing.
- Persistent symptoms may need anorectal physiology, endoanal ultrasound, defaecography and multidisciplinary treatments such as biofeedback, irrigation, sphincter repair, rectopexy or sacral neuromodulation.
Key red flags
A swollen irreducible segment with escalating pain, bleeding, ulceration or dusky colour suggests venous obstruction and threatened ischaemia, requiring urgent specialist reduction or surgery.
Abrupt incontinence with urinary retention, saddle numbness, bilateral sciatica or leg weakness may represent cauda equina syndrome and requires immediate spinal pathway assessment rather than routine pelvic-floor referral.
Weight loss, anaemia, persistent bleeding, a hard rectal mass, nocturnal diarrhoea or new bowel change requires colorectal investigation even when prolapse or incontinence is visible.
Investigation priorities
Define stool form, timing, triggers, urgency, leakage and toileting context.
Management branches
Any involuntary stool loss that causes a social or hygienic problem.
- Ask sensitively about solid, liquid and flatus leakage, awareness, urgency, frequency, obstetric and surgical history, stool form, diet, medicines, cognition, mobility and toilet access.
- Treat immediate reversible causes including faecal loading, acute diarrhoea, infection and medication effects; investigate red flags and provide skin protection and practical containment meanwhile.
- Aim for a predictable Bristol type 3 to 4 stool using individualised diet, fibre or antidiarrhoeal strategies, avoiding a generic high-fibre instruction that could worsen loose stool or bloating.
- Refer persistent symptoms to a specialist continence service for bowel retraining, pelvic-floor exercises, biofeedback and targeted physiology or imaging.