Clinical Review

The assessment and management of rectal prolapse, rectal intussusception, rectocoele, and enterocoele in adults

BMJ 2011; 342 doi: (Published 01 February 2011) Cite this as: BMJ 2011;342:c7099
  1. Oliver M Jones, consultant colorectal surgeon,
  2. Christopher Cunningham, consultant colorectal surgeon,
  3. Ian Lindsey, consultant colorectal surgeon
  1. 1Oxford Pelvic Floor Centre, Surgery and Diagnostics, Churchill Hospital, Headington, Oxford OX3 7LJ, UK
  1. Correspondence to: O M Jones oliver.jones{at}

Summary points

  • Pelvic floor disorders are common and debilitating and often have secondary symptoms such as anal fissure or haemorrhoids

  • Disorders of the posterior compartment often co-exist and dysfunction of the middle and anterior compartments may also be present

  • Detailed assessment with history, examination, and specialist tests is key

  • Patients with substantial symptoms resistant to conservative measures should be referred for consideration of surgery

Rectal prolapse is an extrusion of the full thickness of the wall of the rectum beyond the anal verge. Internal rectal prolapse, or intussusception, is defined as a full thickness prolapse of the rectum that does not protrude through the anus. Rectal prolapse and intussusception often coexist with a rectocoele (herniation of the rectovaginal septum anteriorly into the vagina) and an enterocoele (deep herniation of the rectovaginal peritoneum). Globally, these problems are often referred to as “pelvic floor dysfunction,” and this review focuses on the posterior compartment, the rectum, around which these pathologies occur.

Patients with these conditions are often unable to empty the rectum effectively (obstructed defecation syndrome) and make up about half of the estimated 2-27% of the population with constipation; the remainder have a problem of colonic inertia.1 They may also get additional symptoms including faecal incontinence and pain.

Interest in rectal prolapse has recently increased, with a multicentre randomised trial (PROSPER) now completed comparing surgical techniques. The advent of laparoscopic surgery also offers a potentially less invasive, better tolerated, and more durable surgical solution. Initial surgical attempts at treating intussusception were disappointing and led to its virtual abandonment for many years in favour of conservative measures. However, in recent years, good results with acceptable morbidity have been reported for perineal and laparoscopic/abdominal approaches, so that patients with substantial symptoms should be referred for consideration for surgery. We review evidence from epidemiological studies, observation …

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