Rectal prolapse is treated based on its severity, ranging from dietary changes and pelvic floor therapy for mild cases to surgery for full-thickness prolapse. Most adults with a complete prolapse will eventually need a surgical procedure, but the type of surgery depends on age, overall health, and how severe the prolapse has become.
Conservative Treatment for Mild Cases
When the prolapse is partial, meaning only the inner lining of the rectum slides out rather than the full wall, non-surgical measures can sometimes keep things manageable. The core strategy is eliminating straining during bowel movements, since straining is one of the main forces that worsens prolapse over time. That means increasing fiber intake, drinking more water, and using stool softeners to keep stools easy to pass.
Pelvic floor physical therapy can also help. A therapist uses biofeedback to retrain the muscles around the rectum and pelvis, teaching you to coordinate them properly during bowel movements. Sessions typically run once a week for four to eight weeks and include breathing exercises, muscle strengthening, relaxation techniques, and practical tips like positioning (using a footstool to raise your knees while sitting on the toilet) and abdominal massage to stimulate the gut.
These measures won’t reverse a full-thickness prolapse, where the entire rectal wall telescopes out through the anus. But they play an important supporting role before and after surgery by addressing the straining and pelvic floor weakness that contributed to the problem in the first place.
Choosing Between Surgical Approaches
Surgery for rectal prolapse falls into two broad categories: abdominal and perineal. The choice between them is one of the most important decisions in treatment, and guidelines from the American Society of Colon and Rectal Surgeons recommend tailoring it to each patient’s health, history, and preferences.
Abdominal surgery accesses the rectum through the abdomen, either with a traditional open incision or laparoscopically through small incisions. The surgeon reattaches the rectum to the sacrum (the bone at the base of the spine), sometimes using mesh to hold it in place. This approach generally produces lower recurrence rates, making it the preferred option for younger, healthier patients who can tolerate a longer operation and recovery.
Perineal surgery works through the anus itself, avoiding abdominal incisions entirely. Because it’s less invasive, it’s often chosen for older patients or those with significant health problems that make abdominal surgery risky. The tradeoff is a somewhat higher chance the prolapse will return. Data from a large national surgical quality database found that abdominal surgeries had longer operating times, longer hospital stays, and higher overall complication rates compared to perineal procedures. Open abdominal surgery in particular carried more wound infections, wound breakdowns, and a greater likelihood of being discharged to a rehabilitation facility rather than home.
Laparoscopic abdominal surgery narrows this gap considerably. It produces complication rates and hospital stays closer to those of perineal procedures while maintaining the lower recurrence rates associated with the abdominal approach. For patients healthy enough for either option, laparoscopic surgery often represents the best balance.
Types of Perineal Surgery
The two main perineal procedures are the Altemeier and Delorme operations. In the Altemeier procedure, the surgeon removes the prolapsing segment of rectum through the anus and reconnects the remaining bowel. In the Delorme procedure, only the inner lining of the prolapsed section is stripped away, and the exposed muscle layer is folded and stitched to shorten the rectum and pull it back into position.
A systematic review found median recurrence rates of 11.4% for the Altemeier procedure and 14.4% for the Delorme. Both procedures also improved fecal incontinence, a common symptom of prolapse, in a majority of patients: 61.4% after the Altemeier and 69% after the Delorme. These operations can typically be performed under regional anesthesia rather than general anesthesia, which is another advantage for patients with heart or lung conditions.
Abdominal Rectopexy and Mesh Options
Rectopexy, the abdominal approach, involves mobilizing the rectum and fixing it to the sacrum so it can no longer slide downward. Surgeons may use sutures alone or place a piece of synthetic or biological mesh to reinforce the attachment. Ventral mesh rectopexy, where the mesh is placed along the front of the rectum, has become a popular variation because it avoids disturbing the nerves running along the back of the rectum. This reduces the risk of new-onset constipation after surgery, a problem that can occur when posterior nerve pathways are disrupted.
The ASCRS guidelines note that ventral mesh rectopexy carries acceptable complication rates and may be particularly useful for patients who already struggle with constipation. Conversely, simply mobilizing the rectum without actually fixing it in place is associated with higher recurrence and is generally not recommended.
What to Expect Before Surgery
Before any surgical repair, your doctor will evaluate sphincter function and rule out other conditions. A colonoscopy is typically performed to check for polyps or tumors that could be acting as a “lead point,” essentially dragging the rectum downward. Anorectal manometry, a pressure test that measures how well the muscles around the anus contract and coordinate, helps the surgical team understand how much sphincter damage has already occurred. This information influences both the choice of procedure and realistic expectations for continence after surgery.
Recovery After Surgery
Hospital stays vary by approach. Perineal surgery usually requires two to three days in the hospital, while abdominal surgery may mean staying up to a week. After discharge, returning to normal activity takes anywhere from a few weeks to several weeks depending on the procedure and your baseline health.
The post-operative period focuses heavily on preventing the conditions that caused the prolapse. You’ll be advised to increase fiber and water intake, use stool softeners, and avoid straining during bowel movements. Heavy lifting is restricted during the healing period. These habits aren’t just short-term recovery measures; maintaining them long-term reduces the chance of recurrence.
Treatment in Children
Rectal prolapse in children is a different situation from adult prolapse. Most mild cases are treated by a doctor manually pushing the prolapse back into place, combined with addressing the underlying cause. That usually means stool softeners and more dietary fiber to prevent the constipation and straining that triggered the prolapse.
Children with frequent or severe prolapse may need a procedure. Options include sclerotherapy, where an injected solution causes scarring that anchors the rectal lining in place, with success rates ranging from 80% to 100% in some studies. It’s less invasive and less expensive than surgery, making it a practical first step before considering operative repair. If sclerotherapy doesn’t resolve the problem, surgical options include transanal resection (removing the prolapsed tissue through the anus) or laparoscopic rectopexy, similar to what’s done in adults. One study of 67 children found that prolapse resolved in 79% of those who had surgery compared to 54% who received sclerotherapy as initial treatment, though many families and surgeons still prefer to start with the less invasive approach.