Reduction of Rectal Prolapse 

Updated: Mar 22, 2021
Author: Richard S Krause, MD; Chief Editor: Vikram Kate, FRCS, MS, MBBS, PhD, FACS, FACG, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS, FFST(Ed) 



This article describes the manual reduction of rectal prolapse. Rectal prolapse is an uncommon condition that may be encountered by physicians in a number of settings and specialties. The incidence of this condition is bimodal. It occurs in children younger than 1 year but is most commonly encountered in older adults. In adults, a female predominance exists.

A population-based cohort study from England that used Hospital Episode Statistics to evaluate trends in the surgical treatment of rectal prolapse from 2001 to 2012 (N = 25,238; 29,379 operations) reported that the median patient age was 73 years, patients were predominantly female (female-to-male ratio, 7:1), the mean length of hospital stay was 3 days, and the number of patients increased over the study period.[1]  

Predisposing factors for rectal prolapse include the following:

It is important to distinguish between full-thickness prolapse and mucosal prolapse (see the image below).

Diagram depicting clinical difference between true Diagram depicting clinical difference between true (full-thickness) prolapse (left), including all layers of rectum and with circular folds seen on prolapsed intestine, and procidentia, or mucosa-only prolapse (right), in which radial folds are seen in mucosa.

Rectal prolapse can sometimes be confused with intussusception.[2]  When the intussusception prolapses through the anal verge, it can mimic procidentia.


The definitive treatment for recurrent rectal prolapse is surgical rectopexy.[3]  As a temporizing measure, manual reduction of the prolapse is indicated, as well as treatment of any underlying condition (eg, constipation). Surgery may not be needed if the underlying condition can be successfully treated.

Mucosal prolapse is annoying, but many patients can be instructed on how to perform self-reduction easily if prolapse recurs while they are awaiting definitive treatment or in response to treatment of any underlying condition. A full-thickness prolapse may also be reduced by the patient, though this may be more difficult.


Manual reduction is contraindicated, and urgent surgical evaluation indicated, in the rare case of strangulated rectal prolapse, which may lead to perforation. This is recognized on physical examination by the necrotic appearance of the prolapsed tissue.

Technical Considerations

Manual reduction of rectal prolapse has been attempted via several different methods, including steady pressure, application of sugar and salt as hygroscopic agents, and even elastic compression wrap for large incarcerated prolapse. Waller et al demonstrated a novel manual reduction technique that involves intraluminal insertion of saline-soaked packing.[4] The patient is placed in the lateral position, with the knees bent toward the chest. The packing is inserted approximately 15 cm into the rectum, the clinician waits for the prolapse to reduce (which may take a few minutes), and the packing is then slowly retracted without any counter-traction at the anus.

The Thiersch stitch procedure is sometimes used to treat rectal prolapse in elderly patients; it is simple to perform and at times can also be used as a bedside technique. Iida et al, in a study comparing the modified Gant-Miwa-Thiersch procedure (mGMT) with other procedures for rectal prolapse, reported no serious postoperative complications and no operative deaths in 187 patients who underwent mGMT, with a recurrence rate of 7.5% in a period of 13.8 years.[5]


Morrison et al, in a systematic review of management options in pediatric rectal prolapse that included 27 studies (N = 907) dated from 1990 to April 2020, analyzed parameters such as demographic details, interventions, efficacy, complications, and procedures performed.[6] The pooled success rates were calculated on the basis of the procedure. The overall initial success rate was 79.5% for sclerotherapy; ethyl alcohol was the best sclerosing agent, in that it had a high first-injection success rate, caused fewer complications, and was easily available. Among the various surgical repairs that were performed, laparoscopic rectopexy with mesh placement had an overall success rate of 96.1%.


Periprocedural Care

Patient Preparation


In the case of a relaxed cooperative patient, anesthesia may not be needed. In other cases, a local perianal anesthetic or procedural sedation can be used. Although the bowel itself has no pain receptors, apprehension and discomfort may lead to spasm of the anal sphincter, making reduction difficult or impossible until relaxation can be achieved.

No randomized trials have compared anesthetic techniques for this specific procedure. Perianal field block has been described as useful for various rectal procedures. Multiple injections of a local anesthetic are made into the ischiorectal fat immediately peripheral to the external sphincter, with good anesthesia occurring in just a few minutes.[7]  The injections themselves are painful.


The patient should be in either the dorsal lithotomy or the knee-chest position. Children may be less anxious if allowed to remain on the lap of a parent.

Monitoring & Follow-up

Patients should follow up with a primary care provider or a surgeon for further treatment. Patients (or family members) who are capable may be instructed to attempt reduction themselves in case of recurrence.



Manual Reduction of Prolapsed Rectum

Full-thickness rectal prolapse must be distinguished from mucosal prolapse. In mucosal prolapse, the prolapsed tissue has radial folds at the anal junction, whereas a full-thickness prolapse has circular folds in the prolapsed mucosa (see the first image below). In mucosal prolapse (see the second image below), the mucous membrane alone is prolapsed and may be confused with hemorrhoids. In complete or full-thickness prolapse (see the third and fourth images below), all three layers of the rectum are prolapsed.

Diagram depicting clinical difference between true Diagram depicting clinical difference between true (full-thickness) prolapse (left), including all layers of rectum and with circular folds seen on prolapsed intestine, and procidentia, or mucosa-only prolapse (right), in which radial folds are seen in mucosa.
Image demonstrates mucosal prolapse, with radial f Image demonstrates mucosal prolapse, with radial folds seen on mucosa.
Picture of infant with full-thickness rectal prola Picture of infant with full-thickness rectal prolapse. Severe edema and abundant mucus are seen on mucosal surface.
Photograph of severe rectal prolapse with clinical Photograph of severe rectal prolapse with clinically significant edema and mucosal ulceration.

Sphincter relaxation is key to a successful reduction; failure is usually due to inadequate relaxation.

Apply gentle manual pressure distally to slide the distal end of the prolapse into the lumen and through the anal sphincter. The procedure may take several minutes. If mucosal edema makes reduction difficult, sucrose (table sugar) may be used as an osmotic agent to reduce the edema and make reduction easier.[8, 9]  Anecdotally, the use of table salt has been described for the same purpose. If constipation is present, it should be aggressively treated.

Unless gangrenous bowel is reduced and perforation results, no complications are expected. A small amount of bleeding may occur and is not concerning.

The optimal approach for definitive surgical management of complete rectal prolapse has not been established.[10, 3]