At a glance
Rectal prolapse affects women significantly more often than men. While exact figures vary between studies, women account for the majority of adult rectal prolapse cases, with prevalence increasing notably after menopause.
This guide explores the specific factors that contribute to this gender difference, what women commonly describe about the experience, and the particular considerations for assessment and management in women.
Why women are more affected
Childbirth and pelvic floor injury
Vaginal delivery is one of the most commonly identified contributing factors. During childbirth:
- The pelvic floor muscles are stretched significantly
- The pudendal nerve, which controls pelvic floor function, can be compressed or damaged
- The fascial supports of the rectum can be weakened
- Multiple vaginal deliveries, prolonged labour, forceps delivery, and large birth-weight babies increase the risk
The effects of childbirth on pelvic floor function may not become apparent for years or decades. Many women who develop rectal prolapse in their sixties or seventies trace contributing factors back to deliveries earlier in life.
Menopause and hormonal changes
Oestrogen plays a role in maintaining the elasticity and strength of pelvic tissues. After menopause:
- Declining oestrogen levels affect collagen quality in pelvic support structures
- Tissues become less elastic and more prone to weakening
- Muscle mass and tone naturally decrease
- These changes affect all pelvic floor structures, not just the rectum
Pelvic anatomy
The female pelvis is wider than the male pelvis, with a larger pelvic outlet. This anatomical difference:
- Provides less bony support for the pelvic organs
- Creates a wider opening through which prolapse can occur
- Makes the pelvic floor muscles responsible for a greater proportion of pelvic organ support
Chronic constipation
Constipation is more prevalent in women than men. Chronic straining during bowel movements:
- Creates repeated downward pressure on the pelvic floor
- Stretches the rectal supports over time
- Is one of the most modifiable risk factors for rectal prolapse
Hysterectomy
Some research suggests that previous hysterectomy may increase the risk of rectal prolapse, potentially because the removal of the uterus changes the support dynamics of the pelvic organs. The relationship is complex and not fully established, but it is a factor that clinicians may consider.
What women commonly describe
The discovery
Women often describe discovering rectal prolapse with shock and confusion:
- Feeling something protruding from the anus during or after a bowel movement
- Initially mistaking it for a hemorrhoid
- Anxiety about what the protrusion is
- Difficulty talking about it — even more so than other colorectal symptoms
Associated symptoms
Women with rectal prolapse commonly report a cluster of related symptoms:
- Difficulty fully emptying the bowel (incomplete evacuation)
- Needing to use pressure to support the perineum or vaginal area during bowel movements (splinting)
- Mucus discharge or moisture
- A sensation of heaviness or “something dropping” in the pelvic area
- Urgency or difficulty controlling bowel movements
- Similar symptoms affecting the bladder — urgency, leakage, difficulty emptying
The connection to other pelvic floor issues
Many women with rectal prolapse also experience:
- Cystocele (bladder prolapse) — the bladder bulging into the vaginal wall
- Uterine prolapse — the uterus descending into the vaginal canal
- Urinary incontinence — stress or urge incontinence
- Pelvic floor dysfunction — overactive or underactive pelvic floor muscles
These conditions share root causes, and addressing them comprehensively matters. A consultation that only looks at the rectum may miss the bigger picture.
Assessment considerations
For women with rectal prolapse, a thorough assessment typically involves:
- Colorectal assessment — examining the prolapse, assessing sphincter function, and discussing surgical options
- Gynaecological assessment — checking for other forms of pelvic organ prolapse
- Pelvic floor assessment — evaluating muscle function and tone, often by a specialist pelvic floor physiotherapist
- Urological assessment — if bladder symptoms are present
This multi-disciplinary approach ensures that treatment addresses all contributing factors rather than just the rectal prolapse in isolation.
Management approaches
Management for women follows the same broad options as for anyone with rectal prolapse, with some additional considerations:
Conservative measures
- Pelvic floor physiotherapy — particularly important for women, addressing the broader pelvic floor rather than just the rectal component
- Stool management — fibre, hydration, and avoiding straining
- Pessary — some women use a vaginal pessary to support the pelvic organs, which can indirectly support the rectum
- Weight management — excess weight increases pelvic floor pressure
Surgical considerations
When surgery is needed, the approach may need to account for:
- Other pelvic organ prolapse that needs addressing simultaneously
- The overall state of the pelvic floor
- Previous gynaecological or abdominal surgery
- Planned future pregnancies (though most cases occur post-menopause)
- Combined procedures — some surgeons address rectal and other pelvic organ prolapse in a single operation
Prevention and risk reduction
While not all risk factors are modifiable, women can reduce their risk:
- Consistent pelvic floor exercises, particularly after childbirth and during menopause
- Managing constipation and avoiding chronic straining
- Maintaining a healthy weight
- Seeking help for pelvic floor symptoms early rather than waiting for prolapse to develop
- Discussing hormone replacement therapy with their GP if appropriate