Disease Description (Causes and Symptoms)
- Definition: A condition in which the anal and rectal mucosa or the entire rectal wall protrudes outside the anus and does not return spontaneously or remains exposed externally (anal prolapse). Prolapsed hemorrhoids (prolapse of internal hemorrhoids) and full-thickness rectal prolapse are distinguished.
- Causes/Pathophysiology:
- Weakening of the supporting structures of the anus and rectum (anal muscles, pelvic floor muscles, and ligaments), either congenital or due to aging or changes after childbirth.
- Chronic straining during bowel movements (constipation, prolonged time on the toilet), chronic diarrhea, obesity, repeated increases in intra-abdominal pressure (lifting heavy objects), pregnancy, and childbirth.
- If internal hemorrhoids enlarge and prolapse or the rectal mucosa stretches and descends, partial (mucosal) or full-thickness (mucosa plus wall layers) anal prolapse can occur.
- Main symptoms:
- A sensation that something is protruding from the anus (during bowel movements or continuously), mucous discharge from the anus (wetness and foul odor), itching (pruritus), bleeding, a sensation of incomplete evacuation (residual stool sensation), pain (mainly in cases with complications), skin irritation and eczema, and, in severe cases, anemia.
- Classification (clinical stages):
- Stage 1: Temporary protrusion during bowel movements that returns spontaneously.
- Stage 2: Prolapse during bowel movements that returns when pushed back manually.
- Stage 3: Frequent prolapse requiring manual reduction.
- Stage 4: Constant external exposure with impaired anal contraction function.
Treatment Methods and Precautions
- Conservative (non-surgical) treatment — first-line for mild cases (Stages 1–2):
- Increase dietary fiber (adequate intake of fiber and fluids) and correct constipation or diarrhea.
- Correct bowel habits (avoid excessive straining and prolonged time on the toilet), control weight, and limit lifting heavy objects.
- Sitz baths (warm-water baths) to improve blood flow and relieve discomfort.
- Antacid-based relievers/topical ointments (to relieve pain and inflammation), suppositories or laxatives (if necessary), and stool softeners (osmotic laxatives when constipation is the main cause).
- Non-surgical procedures (mainly used for prolapsed hemorrhoids):
- Sclerotherapy: Used for small internal hemorrhoids.
- Rubber band ligation: Commonly used for Grade 1–2 internal hemorrhoids.
- Laser treatment: Mainly used for external hemorrhoids and superficial lesions.
- Surgical treatment — for moderate to severe cases (Stages 3–4), failure of conservative treatment, or complications:
- Surgery focused on hemorrhoidal prolapse: Hemorrhoidectomy or haemorrhoidopexy, among others.
- Surgery for full-thickness rectal prolapse (typical rectal prolapse):
- Abdominal approach: Rectopexy (open, laparoscopic, or robotic), often combined with bowel resection (the intraperitoneal approach has a low recurrence rate and an excellent reconstructive effect).
- Perineal approach (for older patients or patients at high surgical risk): Delorme procedure (mucosal excision and muscular plication), Altemeier procedure (repair and resection), and others.
- The choice of surgery is determined according to the patient’s condition, age, comorbidities, presence of fecal incontinence, and surgical risk.
- Complications and precautions:
- Postoperative bleeding, infection, pain, fecal incontinence, or defecation problems may occur.
- Immediate treatment is necessary in cases of necrosis or infection of the prolapsed tissue (an early emergency situation).
- For patients taking anticoagulants, the risk of bleeding must be considered (adjustment is required before surgery).
- Prognosis:
- Symptoms may improve with appropriate treatment. In cases of full-thickness rectal prolapse, recurrence is possible (influenced by the surgical method and patient-related factors).
Checklist Before an Outpatient Visit (Items to Bring and Example Questions)
- Items to bring and medical records:
- A list of current medications (including anticoagulants and antiplatelet agents).
- A history of previous surgeries and childbirth, and records of long-term constipation or diarrhea.
- Whether there has recently been bloody stool, dizziness, or symptoms of anemia (recent blood test results if anemia is suspected).
- A bowel movement diary (when symptoms began, frequency, amount of bleeding, duration of prolapse and whether it returns), and photographs of the symptoms (if possible).
- Previous endoscopy (colonoscopy) or anal imaging results (if available).
- Examples of key items the doctor may ask about during the outpatient visit:
- When did the symptoms begin? Do they occur only during bowel movements?
- When prolapse occurs, does it return spontaneously, does it need to be pushed back manually, or does it remain continuously exposed?
- Are there accompanying symptoms such as bleeding, pain, discharge, odor, or defecation problems (incomplete evacuation or incontinence)?
- Lifestyle habits (diet, fiber intake, exercise, handling of heavy objects), pregnancy and childbirth history, existing diseases, and medications.
Examples of General Questions to Ask the Doctor
- How can it be determined whether this is anal prolapse caused by hemorrhoids or full-thickness rectal prolapse?
- What treatment options are recommended for my current symptoms (conservative treatment vs. a procedure vs. surgery), and what are the advantages, disadvantages, and expected recovery times of each?
- How will my current medications, especially anticoagulants, affect the surgical plan?
- What is the risk of recurrence after surgery, and how likely are functional complications such as fecal incontinence (or constipation)?
- What must I observe in daily life (diet, bowel habits, and exercise)?
Examples of Condition-Specific Questions
- Which stage (1–4) is my anal prolapse classified as, and is conservative treatment currently sufficient?
- If surgery is necessary, which surgical method is most appropriate for my age and health status (abdominal rectopexy vs. perineal approach), and what are the expected recurrence rate and recovery time?