If you’ve had kids, we probably don’t have to tell you that hemorrhoids are a common indignity after pregnancy and childbirth. Superficial veins in the lower part of your rectum and anus can swell from the pressure of carrying a fetus and the strain of vaginal labor. These swollen veins can protrude and cause bulging of the sensitive skin around the anus after you poop leading to anal pain, itching, or bleeding.
But what if what protrudes is more than just a bit of tissue? What if things feel more off further inside? It might be something called rectal prolapse.
Read on for information about rectal prolapse, why it occurs, and how you can fix this extremely uncomfortable issue from the — ahem — bottom up.
What is rectal prolapse?
Your rectum is the final segment of your intestine. It’s sometimes referred to as the “rectal vault” because it’s where you store your poop before you…well…poop.
“The rectum sits on top of layers of pelvic floor muscles,” says Ashley Rawlins, a physical therapist specializing in pelvic health and obstetric health. “Along with your pelvic floor muscles, the anus is the ring of muscular tissue that helps hold the poop inside until you’re ready on the toilet.” When the muscles and attachments that support the rectum and hold it in place inside your body become overstretched or weakened over time, your rectum can slip down along with your poop, turning it “inside out.”
When your rectum — or any organ — falls out of place, it’s called a prolapse. There are three different types of rectal prolapse, based on how severe it is:
- Internal prolapse, also known as an intussusception, is when your rectum telescopes into itself but stays inside your body.
- Partial prolapse is when some of your rectal tissue bulges outside of your anus.
- Complete, or external, prolapse is just what it sounds like: The whole rectum comes out.
A prolapse may occur only when you’re pooping or, over time, it may become constant.
Yikes. Am I at risk for rectal prolapse?
Rectal prolapse is fairly uncommon — it only occurs in 0.25% of people overall — but it does happen, and having kids raises your risks. One study noted that rectal prolapse is most frequently seen in women over 50 who have had more than one child.
The main risk factors for rectal prolapse include:
- Injured anus or pelvic floor muscles from something like pregnancy and childbirth or nerve damage from surgery in that area
- Vaginal tears during birth
- If you’ve been a life-long, prolonged strainer when it comes to pooping
- Chronic constipation or diarrhea
- Chronic cough, like with COPD
- Aging and menopause, which can lead to deterioration of collagen structures that support all of our tissues
Overall, being pregnant is one of the top risk factors for prolapse. That’s not surprising, says Rawlins, considering “all of those huge changes that we go through during pregnancy, including the softening of the ligaments and support structures throughout the body, and the added weight of the fetus.”
Add in childbirth and there’s even more potential for injury that you could sustain. Rawlins notes that surgically assisted vaginal births — those that use forceps or vacuum assistance — place even more stress on the body and can cause damage to your pelvic floor support.
How do I know if I have rectal prolapse?
Some symptoms of rectal prolapse are subtle, like pressure or bulging in your anus, or the feeling of pelvic heaviness after you poop, says Rawlins. You might experience pain, itching, or bleeding, like with hemorrhoids.
Fecal incontinence, or leakage of mucus or poop, can also occur, which can feel like something is dripping down and out of your anus (similar to the feeling of a tampon falling out) — or like something is there, but you just can’t clear it.
A full rectal prolapse is definitely more noticeable and can sometimes be painful. “It can look like your insides coming out,” says Rawlins, “with the walls of the rectum protruding through, like pink rings of tissue that look swollen or engorged.”
These signs of prolapse can be scary. If they happen to you, you might be worried that you’re literally falling apart. You aren’t! Rectal prolapse is very treatable and your body will get back to normal. See a doctor as soon as possible and, in the meantime, there are a few things you can do to take care of yourself and feel a bit more at ease:
- With clean hands, you may be able to gently move the tissue back inside of your body
- The mucosal tissue of the rectum is sensitive and may be too tender to be wiped with rough tissue paper after bowel movements. Instead, try cleansing your perineal area with a bidet or peri bottle — a plastic squeeze bottle with a nozzle that's typically given to postpartum patients to use as they heal from childbirth.
- Lay down on your back with your feet up the wall or the headboard of your bed. In this position, gravity will literally unweight the entire lower half of your body and encourage the prolapsed tissue to move back into place. Use this position as often as you need to reduce prolapse-related discomfort.
- Pelvic support belts, worn over soft underwear or pants, can add support to heavy pelvic tissues to provide relief. The Femme Jock for example, provides good support from tailbone to pubic bone.
How is rectal prolapse different from a ProLAPsed hemorrhoid?
It's easy to get these two conditions confused. With both a rectal prolapse and a prolapsed hemorrhoid, tissue from inside of the rectum is coming out of the body.
Here's the difference: A prolapsed hemorrhoid is formed when veins inside the rectum dilate and swell to the point where swollen tissue begins to protrude outside of the anus. With rectal prolapse, the tissue that's protruding out of the anus is part of the weakened rectal wall.
Not sure which you have? With rectal prolapse, you're likely to have accompanying symptoms like fecal incontinence (bowel leaks) or a sense of heaviness or fullness in your bowels. The protruding tissue of a rectal prolapse will also look different from the swollen red mass of a hemorrhoid. With rectal prolapse, you can often see the concentric circles characteristic of the rectum. A prolapsed hemorrhoid will also become harder and more painful as it advances.
How is rectal prolapse treated?
Unlike hemorrhoids, rectal prolapse is unlikely to get better on its own — and it can actually get worse over time. If your case is more severe, like a complete prolapse, your doctor might recommend surgery as the best first option.
For less severe cases, pelvic floor physical therapy can help by:
- improving muscular support
- strengthening the endurance of the pelvic floor muscles
- working on timing anal contractions to prevent leakage
- coordination training to prevent straining and encourage relaxing and opening the pelvic floor muscles when pushing
A pelvic floor physical therapist can also help by checking if your pelvic floor muscles are too tight, too weak to support the rectum, or if you have coordination and timing issues. They can also help to assess the health of the nerves in the area, which help the muscles work properly, and even assist in early sensing of rectal contents to help prevent leakage. If you’ve had holding patterns in the past when it comes to needing to poop, your “drive” to poop might have lessened over time. In a chronically constipated person, the bowel tends to be like a “slightly deflated balloon that doesn’t have as much stretch sensitivity,” Rawlins says. “So it’s not really telling your brain anymore that your body needs to go.”
A pelvic floor physical therapist will also devote time to answering all of your questions and supporting you as you go through the process of healing. They act as an expert in your corner, making sure you have all the knowledge and tools that you need.
So let’s talk about pooping
What if chronic straining on the toilet is contributing to, or worsening, rectal prolapse after your pregnancy or birth?
You’ve got to start with proper bowel care. “Look at your diet, your hydration, your pooping habits,” says Rawlins. “All these things can really help optimize your bowel health in general, especially with less severe cases where tissues aren’t significantly prolapsed.” Doctors might recommend over-the-counter or prescribed stool softeners if bulky stool is contributing to the straining behaviors.
Want to keep your bowels happy? Start here:
- Eat meals at regularly scheduled times
- Eat foods high in fiber, like beans, whole grains, and fruits and veggies, especially leafy greens
- Stay hydrated to balance out your fiber intake
- Get active: Moving your body moves your bowels
- Learn about bowel or abdominal massage to stimulate the bowels
You’re not broken. There is help for rectal prolapse.
Since prolapse tends to get worse over time, sitting on your symptoms is never a good idea. If you think you have any sort of rectal prolapse, get help as soon as possible. See your healthcare provider for an assessment and ask if a referral to physical therapy is right for you. You deserve to feel good in your body and poop without pain or discomfort. We’re here to help!