Rectal Prolapse (Anal Prolapse) Surgery in Ankara, Turkey

Rectal prolapse surgery is a surgical intervention performed when the rectum protrudes outside the anus. This operation aims to restore the rectum to its normal anatomical position and preserve functional integrity. Treatment is planned according to the severity of the disease and the patient’s overall condition.

Abdominal and perineal methods are commonly used techniques in rectal prolapse surgery. Abdominal approaches are generally preferred in younger patients with good general health, while perineal methods are applied in older patients and those with comorbid conditions.

In the postoperative period, special care is required to regulate bowel functions and reduce the risk of recurrence. Nutrition and physical activity are planned to prevent the development of constipation and incontinence after surgery.

Long-term follow-up after rectal prolapse surgery is important for the sustainability of surgical success and for improving quality of life. Patients should not miss regular doctor visits, as these are necessary for early detection of possible complications.

You can contact Prof. Dr. Ebru Soy, one of the doctors performing Rectal Prolapse (Anal Prolapse) Surgery in Ankara, to get information about Rectal Prolapse (Anal Prolapse) Surgery prices, the process, and the hospital where Rectal Prolapse (Anal Prolapse) Surgery is performed.

What Is Rectal Prolapse (Anal Prolapse)?

Rectal prolapse is the protrusion of the inner lining or the entire thickness of the rectum (the last part of the large intestine) out through the anus. It is generally associated with advanced age, chronic constipation, childbirth trauma, or pelvic floor weakness. In mild cases, only the inner lining protrudes, while in advanced cases the entire rectum may prolapse. Treatment varies from medical methods to surgical intervention depending on the degree of prolapse.

Why Does Rectal Prolapse (Anal Prolapse) Occur and Who Is Affected?

The mechanism of anal prolapse is not due to a single cause. It usually occurs when factors that accumulate over years weaken the muscle structure at the base of the pelvis, which we call the pelvic floor. When the supporting tissue in this area weakens, gravity and increased intra-abdominal pressure cause the rectum to slide downward. Our patients usually notice this condition after long periods of constipation.

Risk factors that predispose to the development of this condition are as follows:

• Advanced age
• Chronic constipation
• Chronic diarrhea
• Having multiple deliveries
• Difficult vaginal deliveries
• History of hysterectomy
• Pelvic floor weakness
• Spinal cord injuries
• Neurological diseases
• Genetic predisposition

Among these factors, the habit of straining is particularly decisive. Spending a long time on the toilet and excessive straining apply constant pressure to the pelvic floor muscles. Over time, these muscles become fatigued, stretch, and eventually can no longer support the rectum. Although it is more common in women due to anatomical structure and childbirth processes, it is not rare in men either.

What Are the Symptoms of Anal Prolapse and How Is It Distinguished from Hemorrhoids?

Our patients usually come to the clinic with complaints such as “I feel something in my hand” or “my anus is coming out.” However, a very critical distinction must be made here. Not every swelling in the anal region is a prolapse. Rectal prolapse is often confused with advanced-stage hemorrhoidal disease. This confusion may lead to delayed treatment or incorrect planning.

The physical features we consider to distinguish hemorrhoids from true anal prolapse are as follows:

Hemorrhoid Structure: Hemorrhoids are generally in the form of separate, grape-cluster-like swellings around the anus. The striations on them have a radial pattern extending outward from the center.

Prolapse Structure: In full-thickness anal prolapse, the protruding tissue is in a single piece. It has a red, shiny, and velvety appearance. The most distinctive feature is that the striations on it are in the form of concentric rings.

In addition, the daily complaints experienced by our patients also give us clues.

Common symptoms in patients with anal prolapse are as follows:

• A mass protruding from the anus
• Bloody, mucous discharge
• Soiling of underwear
• Wetness in the anal area
• Itching
• A sensation of incomplete evacuation
• Gas leakage
• Fecal incontinence
• Constipation

Especially complaints of gas and fecal incontinence occur because the prolapsed bowel continuously stretches the anal sphincter muscles and, over time, causes these muscles to weaken. This is the most serious problem that disconnects the patient from social life.

How Are Rectal Prolapse Staged and Anatomically Classified?

When deciding on the treatment of the disease, we must know the degree of prolapse. Not every prolapse is the same, and not every patient can have the same operation. Sometimes the prolapse occurs only internally and is not visible from the outside, and sometimes the bowel is outside even while the patient is walking. To classify this, we use methods such as the Oxford Radiological Grading System. This system dynamically shows how far the bowel has descended.

The generally accepted anatomical stages are as follows:

• Stage 1: The bowel folds into itself but does not enter the anal canal. At this stage, the patient usually only feels a sense of fullness.
• Stage 2: The prolapse descends into the anal canal. During straining, it comes down to the anal opening but does not protrude outward. Patients feel a constant urge to defecate but cannot.
• Stage 3: This is true external prolapse. The bowel protrudes completely outside the anus. At first, it may come out only during defecation and go back in on its own, but as the disease progresses, it may protrude even with coughing or standing up.

This staging is the cornerstone of surgical planning. For example, a prolapse that is only internal (occult prolapse) creates more difficulty in defecation and a sensation of obstruction, whereas in stages with full external prolapse, incontinence complaints are more prominent.

Which Rectal Prolapse Tests Must Be Performed Before Surgery?

Although seeing anal prolapse may seem sufficient to make a diagnosis, for a successful surgery we must also examine the “invisible part of the iceberg.” It is not enough to correct only the anatomical disorder; we must also understand bowel function. Therefore, before deciding on surgery, we perform detailed physiological mapping.

The main methods we use in the diagnostic process are as follows:

• Physical examination
• Straining test
• Colonoscopy
• Defecography
• Anal manometry
• Endoanal ultrasound

Each of these tests has a very specific purpose:

• Physical Examination and Straining Test: We ask the patient to strain during the examination. In fact, sometimes to obtain the most accurate image, the patient may need to strain in the toilet position (squatting). This is the simplest yet most effective method for seeing the true extent of the prolapse.
• Colonoscopy: Anal prolapse can sometimes coexist with more serious diseases, such as tumors, or mimic them. Therefore, it is essential for safety to check the inside of the large intestine with a camera before surgery and ensure there is no other pathology.
• Defecography (Defecation Imaging): This test is a dynamic imaging method that simulates the act of defecation. After a contrast liquid is administered, the patient defecates in an MRI or X-ray device. In this way, we can clearly see whether there is a hidden herniation inside (rectocele), small bowel descent (enterocele), or whether the pelvic floor muscles are working incoordiately.
• Anal Manometry and Endoanal Ultrasound: With these tests, we measure the strength and structure of the anal sphincter muscles. If there is significant damage or weakness in the muscles, we can provide our patient with realistic information about how much continence function may improve after surgery. If muscle damage is extensive, correcting only the prolapse may not completely resolve the incontinence problem.

In the Surgical Treatment of Rectal Prolapse, Should the Approach Be Abdominal or Perineal?

The definitive treatment of anal prolapse is surgery; it is not possible for the prolapsed bowel to be permanently repositioned with medication, creams, or exercise. However, the answer to the question “which surgery” varies from patient to patient. Here, the surgeon has two main paths: surgeries performed through the abdomen (abdominal) and surgeries performed through the anus (perineal).

The criteria we consider when making this decision are as follows:

• The patient’s age
• Overall health status
• Anesthesia risk
• Expectations regarding sexual function
• Constipation status
• Incontinence status
• Risk of recurrence

As a general principle, if the patient is medically suitable and can receive general anesthesia, abdominal surgeries are considered the “Gold Standard.” Because these methods have very low recurrence rates (between 0% and 8%) and better functional outcomes. However, if the patient is very elderly and cannot receive general anesthesia due to heart or lung problems, then we prefer the less risky perineal surgeries performed through the anus. The recovery process of perineal surgeries is milder, but the recurrence rate is significantly higher than abdominal surgeries.

What Is Laparoscopic Ventral Mesh Rectopexy (Minimally Invasive Anal Prolapse Surgery)?

Today, for patients who have no contraindication to surgery, the method we most frequently prefer and that yields the most successful results is Laparoscopic Ventral Mesh Rectopexy (LVMR). This operation is performed (minimally invasively) by entering through only a few small holes, without making large incisions in the abdominal area.

The main stages of this operation are as follows:

• Entry with the camera
• Preparation of the rectum
• Placement of the mesh
• Fixation of the mesh

The logic of the operation is to pull the prolapsed rectum upward and suspend it to strong tissue behind the pelvic bone (the sacral promontory). However, to prevent sutures from cutting into the bowel, we use a special mesh. One end of this mesh is fixed to the anterior surface of the rectum, and the other end is fixed to bone tissue.

The greatest advantage of this method is that it is “nerve-sparing.” Since work is performed only on the anterior surface of the bowel, the nerves that pass laterally and posteriorly and provide sexual function and urination are not damaged. In addition, when the prolapsed bowel is suspended upward and the anatomical structure is corrected, complaints of gas and fecal incontinence also improve dramatically in the vast majority of patients who had these complaints before surgery.

Which Rectal Prolapse Surgery Is Preferred in Severe Constipation?

In some patients, anal prolapse is accompanied by very severe, chronic, and treatment-resistant constipation. The intestines are so sluggish or so long that performing only a suspension surgery does not relieve the patient’s complaints; in fact, sometimes the prolapse improves but the patient still cannot have bowel movements.

In this special patient group, the method we call “Resection Rectopexy” comes into play. In this operation, the bowel is not only suspended; at the same time, the redundant and prolapsing segment of the large intestine (sigmoid colon) is surgically removed. The remaining ends are connected and the rectum is suspended upward.

The advantages and disadvantages of this method are as follows:

• Advantage: It is very effective in resolving constipation. Since the extra bowel is removed, defecation becomes easier.
• Disadvantage: Removing and reconnecting a portion of the bowel increases surgical risks somewhat (such as the risk of leakage). In addition, after this surgery, the patient’s ability to hold stool may be slightly weaker compared to suspension surgery with mesh alone.

Therefore, if the patient’s main complaint is incontinence, suspension with mesh (LVMR) is preferred; if the main complaint is “not being able to defecate at all,” a bowel-resection method (resection) is preferred. This is a tailor-made decision based entirely on the patient’s functional status.

What Are the Perineal Rectal Prolapse Surgery Options for Elderly and High-Risk Patients?

In very elderly or frail patients for whom anesthesia is very risky, entering the abdominal cavity can create a life-threatening risk. In this situation, we use perineal (through-the-anus) operations, which can be considered the “best of a bad situation,” performed without putting the patient under major stress. These operations can also be performed without general anesthesia, using only regional anesthesia (spinal anesthesia).

Two main techniques stand out here:

• Altemeier Procedure (Perineal Rectosigmoidectomy): The prolapsed segment of bowel is pulled out through the anus, the redundant part is cut off, and after the remaining ends are sutured together externally, it is pushed back inside. It is less painful than abdominal surgeries. This method is generally preferred when the prolapsed segment is very long.
• Delorme Procedure: In this method, the bowel is not resected. The mucosal layer of the prolapsed segment is stripped, and the remaining muscular layer is folded onto itself like an accordion (plicated) and sutured. In this way, a bulk is created inside the anus and prolapse is prevented. It is a shorter procedure with a lower risk of bleeding, but it has the highest recurrence rate among all methods (around 26%). It is generally used in very short prolapses or in very fragile patients.

The biggest disadvantage of perineal operations, as mentioned above, is the high risk of recurrence and the fact that they may not be as successful as abdominal operations in improving incontinence complaints.

What Is the Recovery Process and What Are the Possible Complications After Rectal Prolapse Surgery?

Thanks to modern surgical techniques, the recovery process after anal prolapse surgeries is quite comfortable. Patients who undergo surgery with a minimally invasive (laparoscopic) method usually stay in the hospital for a very short time and return to their daily lives quickly.

Expected general situations during recovery are as follows:

• Hospital stay of 1–3 days
• Mild pain
• Rapid mobilization
• Early feeding
• Return to work in a short time

As with any surgical procedure, these operations also carry some risks, but in experienced hands these occur at quite low rates.

Possible complications are as follows:

• Difficulty urinating
• Temporary constipation
• Mesh infection
• Mesh erosion
• Bleeding
• Leakage at the bowel anastomosis site
• Recurrence

Especially in surgeries using synthetic mesh, the risk of the mesh eroding into tissue may worry patients. However, the literature reports this rate to be around 1–2%, and by using biological meshes, this risk can be managed even further. Problems such as difficulty urinating or constipation are generally temporary and improve with medical treatment.

What Is Done in the Case of Recurrent Rectal Prolapse?

Unfortunately, no surgical method can provide a 100% guarantee. Rectal prolapse may recur, especially in patients with weak tissues or after perineal surgeries. Recurrence is discouraging for both the patient and the physician, but it is not without a solution.

In cases of recurrence, our strategy is generally to change the method. If the first surgery was performed through the anus (Delorme or Altemeier) and the disease recurs, we prefer to perform the second surgery through the abdomen (Laparoscopic Ventral Mesh Rectopexy) as long as the patient’s health allows. Abdominal repairs have quite high success rates even in recurrent cases.

However, it should be known that technical difficulty increases in revision surgeries and functional results (especially the ability to hold stool) may not be as perfect as after the first operation. Therefore, choosing the correct first operation and performing it in the most experienced hands is of vital importance.

Frequently Asked Questions

In which situations is rectal prolapse surgery necessary?

Rectal prolapse requires surgery in cases that impair quality of life, such as when the rectum protruding from the anus cannot return to its place spontaneously, causes fecal incontinence, and leads to recurrent infections.

How many different methods can rectal prolapse surgery be performed with?

Surgery is performed with two main approaches: abdominal and perineal. Laparoscopic rectopexy, Altemeier, and Delorme techniques are preferred depending on the patient’s age and general condition.

Does bowel control improve after rectal prolapse surgery?

Yes, in most patients complaints of fecal incontinence decrease significantly. However, full control may not be achieved in people with very weak sphincter muscles. Pelvic floor exercises contribute positively.

What is the recovery process like after rectal prolapse surgery?

While recovery may take 4–6 weeks after open surgeries, this period is shorter in laparoscopic procedures. In the first weeks, it is important to avoid constipation, avoid straining, and attend regular follow-up visits.

Is there a risk of recurrence after rectal prolapse surgery?

Yes, the risk of recurrence is higher in patients with advanced age, chronic constipation, and weak connective tissue. Appropriate surgical technique and lifestyle changes can reduce this risk.

Is sexual function affected after rectal prolapse surgery?

In abdominal surgeries, sexual function may rarely be affected due to the risk of nerve injury. If vaginal prolapse accompanies the condition in women, combined pelvic surgeries may be needed.

How should nutrition be after rectal prolapse surgery?

To prevent constipation, a fiber-rich diet, plenty of water intake, and, if necessary, the use of stool softeners are recommended. Excessive straining should be avoided.

For which patients is the perineal approach more suitable?

In elderly patients with comorbidities and those whose general condition cannot tolerate major surgery, the perineal approach provides safer and faster recovery.

Is rectal prolapse in children also treated surgically?

In children, prolapse is mostly temporary. Surgery may be required in cases that are prolonged, do not resolve spontaneously, or cause fecal incontinence.

Is exercise recommended after rectal prolapse surgery?

Yes. Pelvic floor strengthening exercises and biofeedback therapies support recovery and reduce the risk of recurrence.

How Long Does Rectal Prolapse (Anal Prolapse) Surgery Take?

Rectal prolapse surgery generally takes between 1.5 and 3 hours, depending on the chosen surgical method. Abdominal and perineal approaches may require different durations.

Which Doctor or Department Should Be Consulted for Rectal Prolapse (Anal Prolapse)?

For diagnosis and treatment of this condition, patients should consult a general surgeon, especially surgeons specialized in colorectal surgery.