Rectal Prolapse as a Rare Presentation of Colorectal Cancer: Case Series and Clinical Perspectives

Introduction

Rectal prolapse is the protrusion of all structures of the rectum through the anal and is a is a common condition treated by gastrointestinal surgeons. Rectal prolapse affects all age groups but can be found profoundly in women and elderly patients older than 50 years old.^1–3 The ratio of females to males in rectal prolapse is 9:1, with female predominance, and the incidence increases with age.⁴ Another risk factor is older women with repeated vaginal deliveries with muscle weakness at the pelvic floor and weak anal sphincters.⁵ The risk of rectal prolapse is increasing with an increase in bowel habits, high abdominal pressure, or congenital anomalies. The estimate of rectal prolapse prevalence is 1 in 1000 people.^6–8

The majority of rectal prolapses present as a reducible rectum that can either happen spontaneously or by manual reduction. In some cases, the prolapsed bowel becomes incarcerated and unable to be reduced. Without surgical intervention, the incarcerated bowel will be painful, oedematous, bleeding, strangulated, and perforated.^1,2 On the other hand, the signs of colorectal cancer are changes in bowel habits, intermittent abdominal pain, decreased body weight, abdominal mass, and stools mixed with blood or mucus.⁸ Colorectal cancer with rectal prolapse is uncommon and rarely reported. Rectal cancer is more common to present with rectal prolapse than sigmoid colon cancer. There were two cases of sigmoid cancer with rectal prolapse that have been reported^9,10 and several cases of rectal cancer with rectal prolapse.^6,11–19 All of the cases above are affecting elderly patients; one patient aged 33 years old is presenting rectal prolapse during labour,¹³ and one patient aged 34 years old has rectal prolapse due to chronic constipation and straining.⁶

Despite existing reports, there remains a lack of consensus on the optimal diagnostic and surgical management of patients presenting with both rectal prolapse and underlying malignancy, particularly in elderly individuals with multiple comorbidities. The cases include two elderly patients and one young adult, all treated at our institution. Diagnostic and surgical management approaches vary, depending on clinical context, hospital setting, and available resources. Through these cases, we aim to highlight key diagnostic considerations and advocate for personalized surgical strategies tailored to each patient’s unique presentation.

Material and Methods

Study Setting, Inclusion and Exclusion Criteria

In this case series, we report three cases of rectal prolapse associated with colorectal cancer, and the study is presented in accordance with the SCARE 2020 criteria²⁰ to ensure transparency and methodological rigor. The patients were selected from the Department of Surgery at a tertiary hospital in West Java between 2019 and 2024. All three patients were included, as no other cases were identified during this period, and no exclusion criteria were applied.

Data Collection and Follow Up

Patient data, including imaging (X-rays and abdominal CT scans), surgical procedures, histological findings, and short-term follow-up, were extracted from hospital medical records. Clinical photographs were obtained from the Department of Surgery archive, and long-term follow-up data were retrieved from the colorectal registry. Informed consent was obtained from the patients or their next of kin.

Data Analysis

The data presented were descriptive, no statistical analysis needed.

Case Series

First Case

A 79-year-old Asian female presented to the polyclinic with the chief complaint of a lump protruding from her anus for five days prior to her visit. The lump could not be reduced, either spontaneously or by gentle manual pressure. She reported a history of frequent rectal prolapse over the past three months, a weight loss of five kilograms in the past month, nausea, and occasional vomiting. She denied any history of fever, bloody or mucoid stools, changes in bowel habits, or palpable lumps in the abdominal region. Her past surgical history was unremarkable, with no comorbidities or known drug allergies. On physical examination, the patient appeared stable, afebrile, anicteric, and had vital signs within normal limits. No respiratory or cardiac abnormalities were detected. Local examination revealed a soft, easily bleeding lump at the anus, measuring 7×7 x 6 cm (Figure 1). Laboratory findings were within normal limits. An abdominal computed tomography (CT) scan showed an iso-dense, inhomogeneous mass with clear but irregular borders, measuring 6.49×6.91 x 5.92 cm at the distal rectum. The mass was seen infiltrating the internal and external sphincters, levator ani, perianal fat, ischioanal fossa, and mesorectal fat, with irregular thickening causing luminal narrowing (Figure 2).

Figure 1 Prolapsed rectum with soft, lumpy mass.

Figure 2 Abdominal CT scan showing solid mass in the distal of the rectum to the anus; (A) Coronal view shows mass at the left side of the rectum. (B) The narrowing of the rectum with mass with clear border.

The patient was scheduled for a proctosigmoidectomy with posterior levatorplasty and underwent the procedure under spinal anesthesia. Intraoperatively, the surgeon identified a 6 × 6×6 cm soft, irregular mass located on the left lateral side. The mass had infiltrated the muscularis layer of the rectum and extended to involve the anocutaneous line. First, the anal canal was everted outward using Lone Star hooks with No. 2 silk threads in six directions from the anocutaneous border. The prolapsed rectum was then pulled through the anus, and the proximal part was secured with No. 2 silk sutures at four points—12, 3, 6, and 9 o’clock positions. A circular resection was carefully performed using electrocautery. After resecting the mass and the prolapsed segment of the rectum, the distal remaining rectum was anastomosed to the mobile sigmoid colon using interrupted No. 3 polyglycolic acid (PGA) sutures (Figure 3). The patient was admitted postoperatively to the regular ward with early initiation of diet and mobilization. Wound care was provided using sterile, moist gauze for one day, followed by sitz baths. The specimen was sent for pathological examination (Figure 4). The patient was discharged three days postoperatively. At the one-month follow-up, the wound had healed without complications, and the patient showed no signs of recurrence, wound infection, abdominal pain, or fever. Histological examination showed that the surgical specimen was lined with goblet cell-bearing columnar epithelium, which in one area had transformed into a cancroid mass. Cancer cells had not invaded the muscularis mucosa, and the submucosa appeared within normal limits. The majority of the resected tumor was an adenoma, while less than 20% was confirmed to be well-differentiated adenocarcinoma of the rectum (pT1N0Mx). The histological findings contrasted with the CT results, which suggested that the tumor had infiltrated adjacent structures. A possible explanation is that the tumor was large enough to appear as though it was invading the tissues surrounding the anus. The patient did not receive adjuvant chemotherapy or radiotherapy and was scheduled for surveillance every six months at the polyclinic. The patient passed away 17 months after the surgery due to natural causes unrelated to the cancer.

Figure 3 Intraoperative Finding: (A) The prolapse rectum with mass on the left side. (B) The prolapsed rectum was released and pulled through the anus, showing a normal, non-redundant sigmoid colon. (C) The distal rectum re-joined to the sigmoid colon.

Figure 4 (A) The sutured wound was closed with sterile gauze for one day, then continued with a sitz bath. (B) The removed rectum was sent for pathological examination.

Second Case

A 79-year-old Asian male presented to the emergency department with the chief complaint of a painful, bleeding lump protruding from his anus for two days. The pain worsened when he attempted to push the lump back inside. He reported a history of frequent rectal prolapse over the past month. There was no history of weight loss, loss of appetite, nausea, fever, bloody or mucoid stools, changes in bowel habits, or palpable lumps in the abdominal region. His past surgical history was unremarkable, with no comorbidities or known drug allergies. On physical examination, the patient appeared dehydrated and tachycardic but was afebrile and anicteric. No respiratory or cardiac abnormalities were detected. Local examination revealed a soft, lumpy 4×4 x 3 cm mass at the anus. The prolapsed portion included an edematous, dark, and gangrenous segment of the sigmoid colon (Figure 5), with pain noted on palpation. The patient was diagnosed with strangulated rectal prolapse and scheduled for an emergency laparotomy under general anesthesia.

Figure 5 (A) Strangulated prolapsed sigmoid colon with tumor. (B) Intraoperative finding: the prolapsed portion was unable to be reduced. (C) Post-operative Hartmann procedure. (D) The removed sigmoid colon and the tumour were sent for pathological examination.

Intraoperatively, the prolapsed colon could not be repositioned through the perineal laparotomy approach due to significant edema. Therefore, the prolapsed colon was pulled and resected using electrocautery before repositioning. During laparotomy, the rectum was pulled inside and closed using continuous polyglycolic acid (PGA) sutures. Rectopexy was performed by mobilizing the rectum from the pelvic floor, releasing the peritoneum around the pelvic region. Fixation of the rectum was achieved by suturing it to the sacrum using interrupted non-absorbable sutures. No mesh was used, as the rectum was edematous. The proximal colon was brought out as an end colostomy, completing a Hartmann procedure (Figure 5). Post-operative care: The patient was admitted to a semi-intensive ward for observation and was discharged after six days. At the one-month follow-up, the wound had healed, with only a minor skin infection noted. The patient was recovering well, and histological examination revealed that the majority of the tumor exhibited epithelial transformation into a mass composed of round to oval cells with hyperplastic growth, forming clustered glandular and papillary structures. In approximately one-third of the tumor (measuring 1 cm), cancer cells were observed infiltrating into the submucosal layer. No lymphovascular invasion was identified, confirmed the diagnosis of moderately differentiated adenocarcinoma of the sigmoid colon (pT1N0Mx). He did not receive adjuvant chemotherapy or radiotherapy. The patient was scheduled for surveillance and a Hartmann reversal procedure six months later at the polyclinic. At the time of follow-up, 13 months after surgery, the patient was confirmed to be alive and was contacted for this report, with no signs of recurrence.

Third Case

A 40-year-old Asian male presented to the emergency department with a chief complaint of general weakness, accompanied by a painful lump protruding from his anus for four days prior to admission. He reported a history of frequent rectal prolapses over the past four months. Additionally, he had experienced weight loss over the past two months, along with loss of appetite, nausea, fever, and bloody, mucoid stools. The patient had previously undergone surgical repair for rectal prolapse at a sub-district hospital using the Thiersch procedure (the augmentation of the anal sphincter using a non-absorbable suture), but the prolapse recurred two weeks postoperatively. On physical examination, the patient appeared dehydrated, tachycardic, anemic, and afebrile, with an increased respiratory rate and low systolic blood pressure. Local examination revealed an edematous prolapsed rectum and sigmoid colon (Figure 6). The patient was diagnosed with sepsis due to strangulated rectal prolapse and was scheduled for an emergency laparotomy under general anesthesia.

Figure 6 (A) Strangulated prolapsed sigmoid colon. (B) Intraoperative finding: the prolapsed portion was resected using a perineal approach. (C) Intussusception observed during laparotomy. (D) The resected descending and sigmoid colon, with the tumor identified as the pathological leading point (PLP).

Intraoperatively, the edematous prolapsed colon was resected using monopolar cautery prior to repositioning. During the laparotomy, intussusception of the descending colon into the sigmoid colon was identified. The left lateral white line was opened using bipolar cautery. The left branch of the middle colic artery and the left colic artery were identified and ligated using No. 2 silk sutures. The proximal colon was clamped, and resection of the descending and sigmoid colon was performed. The rectal stump was pulled upward intra-abdominally, closed with continuous PGA 2 sutures, and over-sewn with interrupted No. 2 silk sutures. A retropexy was carried out by mobilizing the rectum from the pelvic floor with dissection of the surrounding peritoneum. The rectum was then secured to the sacrum using interrupted non-absorbable sutures. Mesh placement was avoided due to rectal edema, and the proximal colon was brought out as an end colostomy (Hartmann procedure). A tumor approximately 4 cm in diameter was found in the resected colon, serving as the pathological leading point (PLP) for the intussusception (Figure 6). The patient was admitted to the intensive care unit for postoperative observation. During the hospital stay, the patient developed hospital-acquired pneumonia, which was treated successfully. After 17 days of observation, the patient was discharged. At follow-up, the surgical wound had healed, the stoma was functioning effectively, and the patient was recovering well. Histological analysis shows that the tumor mass consists of round and oval-shaped cells that exhibit hyperplastic growth, are densely packed, and cluster together to form a villous structure. More than 50% of the lesion demonstrates features of a tubular adenoma, with areas of low-grade adenocarcinoma of the descending colon (pT2N0Mx). The patient was undergoing adjuvant chemotherapy with the de Gramont (dG) regimen for high-risk colon cancer, and he passed away eight months after surgery due to hospital-acquired pneumonia and lung complications.

Discussion

This case series highlights a rare but clinically important association between rectal prolapse and underlying colorectal malignancy, with all three cases demonstrating tumors as the pathological leading point (PLP) contributing to prolapse. The clinical presentations varied in severity—from reducible to strangulated prolapse—yet each required surgical intervention tailored to patient condition and oncological considerations. These findings underscore the need for high clinical suspicion and individualized management when adult patients present with rectal prolapse, particularly in the absence of classical risk factors or when associated with systemic symptoms.^1–3

Rectal prolapse is defined as the protrusion of a full-thickness rectal segment through the anus. It is sometimes referred to as rectum and rectosigmoid intussusception. In paediatric patients, rectal prolapse is more common in males but more common in females in elderly individuals, with a prevalence reaching 0.25%.¹⁶ There are many factors related to the development of rectal prolapse; some risk factors included changes in bowel habits, 30–67% related to constipation, 15% related to chronic diarrhoea, a history of anal surgery, chronic obstructive pulmonary disease, chronic cough, and prostate hyperplasia. In women, the risk increased with a history of frequent vaginal deliveries. Anatomical abnormalities such as deep cul-de-sac, redundant colon, wide and loss anal sphincter, widening of the levator ani muscle, and the decreased attachment of the rectal sacral joint might increase the risk for rectal prolapse.^2,5,8 Rectal cancer and sigmoid colon cancer are also major but uncommon causes of rectal prolapse. Because of their proximity, the rectum and sigmoid colon may prolapse through the anus as an intussusception. In adult bowel intussusception, the pathological leading point is mostly associated with intraluminal tumours.^6,7,15

There are several imaging modalities that can help the diagnosis of rectal prolapse with colorectal cancer. Plain abdominal X-rays are usually the first diagnostic tool used to determine the likely location of the lesion. The utility of ultrasonography (USG) in adults is limited by the distance between the mass and location of the probe at the skin and the gas inside the bowel. Abdominal CT scan has become an important imaging tool for establishing the diagnosis, staging, or evaluation of colorectal cancer. Furthermore, CT gives details of tumour size, infiltration, and adherence of the surrounding structure, which can help the surgeon determine the surgical approach.¹⁷

Surgical intervention is the gold standard for rectal prolapse management. However, the majority of adult patients with rectal prolapse are elderly patients, who generally have poor performance status and are comorbid. The first treatment for rectal prolapse is non-surgical treatment, including rehydration, a soft diet or laxative for stool softener, reducing the oedema, perineal exercise, electrical stimulation, sclerosing agent injection, or the use of rubber band ligation. The second treatment is surgery, either abdominal or perineal approaches.^21,22 The aims for surgery in rectal prolapse are diminishing the prolapse with the correction of the anatomy or resection, regaining the normal function of the bowel regarding the incontinence or constipation, and avoiding the creation of de novo bowel dysfunction.^2,22

In the surgical treatment of rectal prolapse, the recurrence rates are lower following abdominal repair than following perineal repair. The current gold standard surgical treatment for rectal cancer is transabdominal total mesorectal excision (TME) and for colon cancer is complete mesocolic excision (CME). It is possible to achieve this with both open and laparoscopic surgery.^17,21,23 Transanal total mesorectal excision for rectal cancer is still showing a high local recurrence rate, so for the palliation consideration, an Altemeier procedure has become more of an option.²⁴

The American Society of Colon and Rectal Surgeons recommends personalised surgical management for patients with rectal prolapse, especially elderly patients who are prone to complications and have more comorbidities. The Altemeier procedure, which involves a transanal resection of the rectum or a perineal rectosimoidectomy and anastomosis of the colon to the anus, is relatively safe for older patients. This procedure avoids the patient from general anaesthesia and laparotomy trauma, allowing the patient early diet, mobility, lesser analgetic need, and earlier hospital discharge. The Altemeier procedure has demonstrated a lower complication rate but higher recurrence rates compared to the abdominal approach, but the addition of levatorplasty can reduce the recurrence rate by up to 7%.^2,6,25 The American College of Surgeons’s National Surgical Quality Improvement Program (NSQIP) recommends the perineal approach for elderly patients to avoid major complications, especially patients with comorbidities.²⁶ The major complications of rectal prolapse surgery include sepsis, kidney failure, embolism-related organ failure, and intraabdominal abses. Whereas minor complications include surgical site infection and urinary tract infection.^26,27 A meta-analysis study shows that perineal surgery for external rectal prolapse is associated with a significantly higher recurrence rate (27.9%) compared to abdominal surgery (15.6%) at a mean follow-up of 30.5 months. Although abdominal procedures may offer better long-term durability, particularly in reducing recurrence, further high-quality randomized controlled trials are essential to determine the optimal surgical approach, especially for patients with recurrent prolapse or significant comorbidities.²⁸

This case series highlights the rare association of rectal prolapse with colorectal cancer, emphasizing the importance of individualized management based on patient age, comorbidities, and disease severity. The three cases demonstrate varying presentations: a reducible rectal prolapse with rectal cancer (Case 1), an irreducible prolapse with sigmoid colon cancer (Case 2), and a complex case of strangulated prolapse with descending colon cancer and systemic complications (Case 3). Each required tailored surgical approaches, including proctosigmoidectomy, Hartmann procedure, and retropexy, with favorable outcomes despite differing complexities. The presence of a tumor as the pathological leading point (PLP) in intussusception was a critical finding in Cases 3, underscoring the need for thorough evaluation of prolapsed segments. Adult intussusception accounts for less than 5% of all intussusception cases and approximately 1% of intestinal obstructions. Notably, around 60% of adult cases are caused by underlying benign or malignant tumors.^29,30 While the perineal approach remains a safer option for frail elderly patients, the abdominal approach ensures complete tumor resection and lower recurrence rates. Regular follow-up, histological analysis, and, where necessary, adjuvant chemotherapy play pivotal roles in optimizing outcomes and managing complications. These cases highlight the need for multidisciplinary care to address the challenges of rectal prolapse complicated by malignancy.

Limitations and Future Research

This case series has several limitations. Most notably, the small sample size and single-center design restrict the generalizability of the findings. The descriptive nature of the study and the absence of a control group prevent statistical comparisons or broader conclusions regarding treatment efficacy. Furthermore, long-term follow-up data were limited, making it difficult to assess recurrence rates, long-term functional outcomes, and survival. Variability in diagnostic and treatment approaches—driven by individual patient factors and resource availability—also introduces potential bias. While CT imaging was instrumental in preoperative planning, discrepancies between radiological and histopathological findings (as seen in Case 1) highlight limitations in imaging accuracy for local tumor invasion.

Future research should aim to address these gaps through larger, multicenter prospective studies that can provide stronger evidence on the prevalence, clinical course, and outcomes of rectal prolapse associated with colorectal cancer. In particular, studies comparing the efficacy, complication rates, and recurrence risk between perineal and abdominal surgical approaches in patients with underlying malignancy are needed. Standardized diagnostic protocols, including routine endoscopic and imaging assessments, should be evaluated for their utility in early malignancy detection. Additionally, incorporating patient-reported outcomes and quality of life measures would provide a more holistic understanding of postoperative recovery and long-term prognosis in this unique patient population.

Conclusion

Rectal prolapse may be associated with colorectal cancer. A patient with rectal prolapse who does not have any predisposing factors should be checked for concomitant cancer. For early diagnosis and surgical planning, CT scans are the primary modality of choice. Prior to surgery, all cases of rectal prolapse should undergo a meticulous evaluation to rule out any underlying malignancy, thereby improving patient management. Individually tailored and prompt surgical treatment for all patients with rectal prolapse is vital. The comorbidities of the patient should be considered to determine the surgical approach with the purpose of lessening the anaesthetic burden and lowering the complications rate.