Can rectal prolapse cause fecal incontinence?

Rectal Prolapse and Fecal Incontinence

Yes, rectal prolapse can cause fecal incontinence, with approximately 46-96% of patients with rectal prolapse experiencing some degree of fecal incontinence. 1, 2

Pathophysiology of Fecal Incontinence in Rectal Prolapse

• Rectal prolapse causes fecal incontinence through multiple mechanisms:
  • Internal anal sphincter defects (present in 60% of incontinent patients with prolapse vs. 6.2% in continent patients) 1
  • Decreased anal sphincter tone due to chronic stretching of the anal canal 2
  • Levator muscle diastasis (separation) 2
  • Pudendal nerve damage from chronic straining 1
  • Excessive perineal descent visible on imaging studies 3

Risk Factors for Incontinence in Rectal Prolapse

• Age over 45 years significantly increases risk (odds ratio 4.51) 1
• Previous hemorrhoidectomy (odds ratio 9.05) 1
• Chronic prolapse duration 4
• Severity of prolapse (higher Oxford score correlates with worse symptoms) 5

Diagnostic Considerations

• MR defecography or conventional cystocolpoproctography (CCP) can help assess:

  • Severity of prolapse 3
  • Anorectal angle changes (correlates with severity of fecal incontinence) 3
  • Presence of additional pelvic floor defects 3
  • Internal anal sphincter integrity 1

• Anorectal manometry may reveal:

  • Decreased resting and squeeze pressures 1
  • Abnormal rectal sensation 2

Management Options

• Surgical correction of rectal prolapse is the primary treatment for associated fecal incontinence 3

• Surgical approaches:

  • Abdominal approaches (rectopexy with or without resection):

    • Ventral rectopexy shows superior outcomes for fecal incontinence (73-97% improvement) 5, 4
    • Lower recurrence rates (0-8%) but higher morbidity 3
    • Laparoscopic approach has fewer complications and shorter hospital stay 3

  • Perineal approaches:

    • Better suited for elderly patients or those with significant comorbidities 3
    • Higher recurrence rates (5-21%) 3
    • Perineal proctosigmoidectomy (Altemeier procedure) may be combined with levatoroplasty to reduce recurrence 3

• Important considerations:

  • Bowel resection during rectopexy should be avoided in patients with pre-existing diarrhea or incontinence as these symptoms may worsen 3
  • Preoperative duration of incontinence >2 years is associated with better improvement after surgery (HR 1.99) 4
  • Chronic pelvic pain is associated with poorer outcomes for incontinence (HR 0.32) 4

Recovery and Outcomes

• Recovery time typically ranges from 4-6 weeks depending on surgical approach 6
• Fecal incontinence improvement occurs in approximately 46-64% of patients after surgical correction 1, 4
• Ventral rectopexy provides better continence outcomes compared to other surgical or medical therapies 4
• Bowel management with stool softeners is recommended during recovery to prevent straining 6

Clinical Pitfalls and Caveats

• Internal rectal prolapse may be missed on clinical examination alone and requires dynamic imaging for diagnosis 5
• Patients with rectal prolapse may present with both constipation (85%) and fecal incontinence (56%) 5
• Stapled transanal rectal resection (STARR) has shown inconsistent results with fecal incontinence occurring in up to 25% of patients at one year 5
• Conservative therapy alone rarely resolves fecal incontinence when structural rectal prolapse is present 4