Rectal prolapse happens when the rectum slides out of its normal position and pushes through the anus. The causes range from chronic straining and weakened pelvic floor muscles to connective tissue disorders, nerve damage, and prior surgeries. Women over 50 are affected far more often than men, largely because of the cumulative effects of childbirth, hormonal changes, and pelvic floor weakening over time.
How Rectal Prolapse Develops
The rectum is held in place by muscles, ligaments, and connective tissue that anchor it to the pelvis. When these support structures weaken or stretch, the rectal wall can begin to fold inward on itself, a process called intussusception. At first, this folding stays inside the anal canal (internal prolapse). Over time, it can progress until the full thickness of the rectal wall protrudes outside the body.
There are two main types. Mucosal prolapse involves only the inner lining of the rectum slipping through the anus. Full-thickness prolapse means all layers of the rectal wall push through. The difference matters because full-thickness prolapse involves deeper structural failure and typically requires surgical repair. In either case, the underlying problem is the same: the tissues that should keep the rectum anchored have lost their ability to do so.
Chronic Straining and Constipation
Repeated, forceful straining during bowel movements is one of the most common contributors. Each episode of straining creates shearing forces inside the rectum, where the passage of stool pushes and pulls against mucosal folds. Over months and years, these forces gradually involve deeper layers of the rectal wall, stretching the connective tissue that holds the rectum in place. The damage also reduces blood flow to the rectal wall, creating a cycle: the weakened tissue obstructs normal bowel function, which leads to more straining, which causes further damage.
Long-standing constipation is the usual driver, but chronic diarrhea can contribute too. Any condition that forces you to bear down repeatedly, including chronic coughing from lung disease or heavy lifting over many years, places similar mechanical stress on the pelvic floor and rectal supports.
Childbirth and Pelvic Floor Damage
Vaginal delivery is the single most significant modifiable risk factor for pelvic floor disorders, including pelvic organ prolapse. During birth, the levator ani muscle (the main muscle forming the “hammock” of the pelvic floor) and surrounding tissues must stretch to over three times their original length. This overstretching, rather than compression or nerve damage, is what tears the muscle. Imaging studies show these injuries occur in up to 19% of first-time mothers.
The consequences often don’t appear right away. The injury is present in 55% of women who develop prolapse later in life, and women with levator damage have roughly seven times the risk of prolapse compared to women with intact pelvic floor muscles. Nerve stretching also plays a role: abnormal nerve function in the pelvic floor has been documented in 29% of women six months after delivery. The pudendal nerve, which controls the voluntary anal sphincter, and the sacral nerves supplying the pelvic floor can both be affected, gradually reducing the muscular support that keeps the rectum in position.
Multiple vaginal deliveries compound the risk. Each delivery adds strain to tissues that may not have fully recovered from the last one.
Prior Pelvic Surgery
Hysterectomy is a recognized risk factor. Removing the uterus changes the structural geometry of the pelvis, and the rectum loses a neighboring organ that helped keep it supported. Combined rectal and vaginal vault prolapse after hysterectomy is more common than clinical literature has historically acknowledged. Women who have had a hysterectomy followed by one or more vaginal repair surgeries appear to be at particularly elevated risk, as each procedure can further disrupt the connective tissue network that stabilizes pelvic organs.
Connective Tissue Disorders
Conditions that affect collagen and connective tissue throughout the body can predispose someone to rectal prolapse at an unusually young age. Ehlers-Danlos syndrome (EDS), a group of hereditary disorders affecting collagen synthesis with a prevalence of about 1 in 5,000 people, is a notable example. Women with EDS frequently develop pelvic organ prolapse without the typical risk factors like pregnancy, delivery, or menopause. It can appear in patients who have never given birth.
Other connective tissue conditions, including Marfan syndrome, can similarly weaken the structural scaffolding of the pelvis. If rectal prolapse occurs in a younger person with no obvious cause, an underlying connective tissue disorder is worth investigating.
Nerve and Spinal Cord Conditions
The muscles that hold the rectum in place and control the anal sphincters depend on intact nerve signals from the lower spinal cord. Spinal cord injuries at or below the lower segments can disrupt this signaling, leading to a pattern called neurogenic bowel. Stool collects and becomes impacted, and paradoxical liquid incontinence around the impaction can contribute to rectal prolapse over time.
Conditions affecting the cauda equina (the bundle of nerves at the base of the spine), sacral nerves, or pudendal nerves can all impair the reflexes that coordinate defecation and maintain rectal tone. Multiple sclerosis, spina bifida, and other neurological conditions that affect lower spinal cord function carry similar risks, because they reduce the muscle tone and coordination needed to keep the rectum in its anatomical position.
Rectal Prolapse in Children
In children, rectal prolapse occurs equally in boys and girls, with the highest incidence between ages 1 and 3. The anatomy of a toddler’s pelvis is less supportive than an adult’s, and the rectum sits more vertically, making it more vulnerable to prolapse during straining.
Cystic fibrosis deserves special mention. About 3% of children with cystic fibrosis develop rectal prolapse, driven by a combination of bulky bowel movements, coughing episodes, and undernutrition. In some cases, rectal prolapse is the first sign that leads to a cystic fibrosis diagnosis. Clinical clues include oily or foul-smelling stools that float, poor growth, wheezing, and digital clubbing (widening of the fingertips). Even without respiratory symptoms, a sweat chloride test to rule out cystic fibrosis is standard when a child presents with rectal prolapse.
Aging and Hormonal Changes
Age is one of the strongest risk factors. The pelvic floor muscles and connective tissues naturally lose strength and elasticity over decades. In women, the drop in estrogen after menopause accelerates this process, because estrogen helps maintain the collagen content and tone of pelvic tissues. This is a major reason rectal prolapse disproportionately affects older women. The combination of age-related tissue weakening with accumulated damage from earlier childbirth injuries explains why many cases appear in the sixth, seventh, or eighth decade of life, even when the original pelvic floor injury happened decades earlier.
How to Tell It Apart From Hemorrhoids
Rectal prolapse is sometimes confused with severe hemorrhoids that protrude from the anus, but there’s a reliable visual distinction. Rectal prolapse produces circular folds of tissue, because the entire circumference of the rectal wall is sliding through the anal canal. Prolapsed hemorrhoids, by contrast, have radial folds radiating outward like spokes, because hemorrhoids are localized clusters of swollen blood vessels rather than a circumferential problem. If you notice tissue protruding from the anus and aren’t sure which you’re dealing with, the pattern of the folds is the key difference a clinician will look for.