Rectal prolapse is a condition in which the rectal wall moves downward from its normal position. Depending on how far the rectum descends, the condition can range from an internal form that remains inside the rectum to a complete prolapse that protrudes through the anus.
Understanding the grades of rectal prolapse can help explain the severity and location of the prolapse. However, grading is not based only on symptoms. Doctors may use clinical examination and, when appropriate, imaging such as defecography to determine how far the rectal wall descends.
One commonly used radiological classification is the Oxford Rectal Prolapse Grading System, which divides rectal prolapse into five grades. Grades I and II describe lower-grade internal prolapse, Grades III and IV represent higher-grade internal prolapse extending toward or into the anal canal, and Grade V represents external rectal prolapse.
At Chirag Global Hospitals, Bangalore, rectal prolapse is among the colorectal conditions evaluated and treated through its proctology and colon care services.
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What Is Rectal Prolapse?
Rectal prolapse occurs when the rectal wall slips downward from its normal position.
It can occur in different forms.
Internal Rectal Prolapse
The rectal wall folds or telescopes inward but does not protrude outside the anus. This is also referred to as rectal intussusception.
External Rectal Prolapse
The rectal wall extends through the anal canal and becomes visible outside the body.
The symptoms and treatment can vary considerably between these forms.
How Are the Grades of Rectal Prolapse Classified?
The Oxford grading system classifies prolapse according to how far the rectal wall descends, particularly in relation to the rectum, rectocele, and anal canal.
The five grades are:
| Grade | Classification | General description |
| Grade I | High rectal | Internal prolapse remains high within the rectum |
| Grade II | Low rectal | Internal prolapse descends toward the level of a rectocele but not onto the anal canal |
| Grade III | High anal | Prolapse reaches the upper part of the anal canal |
| Grade IV | Low anal | Prolapse descends into the anal canal |
| Grade V | External | Rectal prolapse protrudes through the anus |
The first four grades describe internal prolapse, while Grade V represents overt external prolapse.
Grade I Rectal Prolapse: High Rectal
Grade I is the earliest category in the Oxford grading system.
In this grade, the prolapsing rectal wall remains relatively high within the rectum and does not descend beyond the upper level of an associated rectocele.
Because the prolapse remains internal, a person may not see anything protruding from the anus.
Possible symptoms include:
- Difficulty completely emptying the bowel
- A sensation of incomplete evacuation
- Straining during bowel movements
- Constipation
- Pelvic or rectal pressure
- A feeling that stool is getting stuck
Some people with internal prolapse may have relatively mild symptoms.
The presence of Grade I prolapse on imaging does not automatically mean that a person requires surgery.
Grade II Rectal Prolapse: Low Rectal
In Grade II, the internal prolapse descends farther than Grade I, reaching the level of a rectocele but not extending onto the anal canal.
It remains an internal form of prolapse.
Symptoms may resemble those of Grade I but can become more noticeable in some patients.
Possible symptoms include:
- Repeated straining
- Difficulty evacuating stool
- Incomplete bowel emptying
- Constipation
- A sensation of pressure in the rectum
- Need to change position while passing stool
- Occasionally, the need for manual assistance to empty the bowel
However, symptoms vary considerably from one person to another.
A higher grade does not necessarily mean that symptoms will always be more severe.
Grade III Rectal Prolapse: High Anal
Grade III represents a higher-grade internal prolapse.
At this stage, the prolapsing rectal wall descends onto the anal canal.
This is classified as a recto-anal intussusception rather than a purely recto-rectal intussusception.
Patients may experience more noticeable difficulty with bowel evacuation.
Possible symptoms include:
- Persistent straining
- Obstructed defecation
- Incomplete bowel emptying
- Rectal pressure
- Difficulty passing stool
- Mucus discharge
- Fecal leakage in some cases
Some patients may also experience a sensation of something moving downward during bowel movements.
Grade IV Rectal Prolapse: Low Anal
In Grade IV, the prolapsing rectal wall descends further into the anal canal.
It remains an internal prolapse but is considered a high-grade form.
Symptoms may include:
- Significant difficulty passing stool
- Repeated straining
- Incomplete evacuation
- Mucus discharge
- Fecal urgency
- Fecal leakage
- Rectal discomfort
- A sensation of tissue descending during defecation
The extent of symptoms depends on the individual’s anatomy and associated pelvic-floor problems.
Grade IV does not mean that surgery is automatically required. Treatment decisions are based on symptoms, examination findings, associated conditions, and the overall impact on quality of life.
Grade V Rectal Prolapse: External Prolapse
Grade V represents external or overt rectal prolapse.
In this stage, the rectal wall passes through the anal canal and protrudes outside the anus.
Unlike Grades I–IV, which are internal forms, Grade V can be visible externally.
A person may notice:
- A red or pink mass coming out of the anus
- Tissue protruding during bowel movements
- Tissue that may initially return inside after defecation
- Increasing difficulty controlling bowel movements
- Mucus discharge
- Rectal discomfort
- Irritation or bleeding
In more advanced cases, the protruding tissue may remain outside and become difficult to push back.
External rectal prolapse requires medical assessment.
Are Grades I to IV and Grade V the Same Type of Prolapse?
No.
This is an important distinction when discussing the grades of rectal prolapse.
Grades I and II
These are generally classified as recto-rectal internal intussusception, where the prolapsing rectum remains within the rectum.
Grades III and IV
These are recto-anal internal intussusception, where the prolapse reaches or enters the anal canal.
Grade V
This is external rectal prolapse, where the prolapsed rectal tissue protrudes beyond the anus.
Does Every Grade of Rectal Prolapse Need Surgery?
No.
Treatment depends on several factors, including:
- Grade
- Symptoms
- Severity
- Bowel function
- Fecal incontinence
- Associated pelvic-floor conditions
- Previous treatments
- Overall health
For some patients with internal prolapse, conservative treatment may be considered first.
This may involve:
- Managing constipation
- Improving stool consistency
- Avoiding excessive straining
- Bowel habit training
- Pelvic-floor rehabilitation
- Biofeedback in selected patients
Published expert literature supports individualized treatment and notes that nonoperative measures may include bowel optimization, habit training, and pelvic-floor physical therapy in appropriate patients.
Can Rectal Prolapse Get Worse Over Time?
Rectal prolapse can persist or progress in some patients, particularly when contributing factors such as chronic constipation and repeated straining continue.
An internal prolapse may cause increasing difficulty with evacuation or other bowel symptoms.
External prolapse may become more difficult to reduce and can cause increasing irritation, bleeding, or continence problems.
This does not mean every internal prolapse will inevitably progress to external prolapse. The course varies between individuals.
Conclusion
The grades of rectal prolapse describe how far the rectal wall descends from its normal position. Under the Oxford system, Grades I and II represent internal rectal prolapse that remains within the rectum, Grades III and IV extend toward or into the anal canal, and Grade V represents external rectal prolapse protruding through the anus.
Importantly, the grade does not tell the entire story. Symptoms, bowel function, continence, associated pelvic-floor problems, and overall health all influence treatment decisions.
Persistent constipation, difficulty emptying the bowel, fecal leakage, rectal bleeding, or tissue protruding from the anus should be evaluated by a qualified specialist rather than self-graded.
For patients in Bangalore experiencing symptoms suggestive of rectal prolapse, Chirag Global Hospitals provides proctology and colorectal evaluation and lists rectal prolapse among its treatment services.
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Frequently Asked Questions About the Grades of Rectal Prolapse
How many grades of rectal prolapse are there?
The commonly referenced Oxford Rectal Prolapse Grading System has five grades, from Grade I through Grade V. Grades I–IV describe internal prolapse, while Grade V represents external prolapse.
What is Grade 1 rectal prolapse?
Grade I is a high rectal internal prolapse. The prolapsing rectal wall remains above the level of an associated rectocele.
What is Grade 2 rectal prolapse?
Grade II is a low rectal internal prolapse that descends to the level of a rectocele but does not reach the anal canal.
What is Grade 3 rectal prolapse?
Grade III is a high anal internal prolapse in which the prolapsing rectal wall reaches the anal canal.
What is Grade 4 rectal prolapse?
Grade IV is a low anal internal prolapse that descends into the anal canal.
What is Grade 5 rectal prolapse?
Grade V represents external rectal prolapse, where the rectal wall protrudes through and beyond the anus.
Which grade of rectal prolapse is the most advanced?
In the Oxford system, Grade V represents external or overt rectal prolapse. However, treatment decisions cannot be based on grade alone.
Can Grade I rectal prolapse cause symptoms?
Yes. Even internal, lower-grade prolapse can be associated with difficulty evacuating stool, constipation, incomplete bowel emptying, or other pelvic-floor symptoms.
Does Grade V rectal prolapse always require surgery?
External rectal prolapse often requires specialist assessment and may require surgical treatment, but the appropriate approach depends on the individual’s health, symptoms, and clinical findings.
Can constipation cause rectal prolapse?
Chronic constipation and repeated straining can contribute to the development or worsening of rectal prolapse, although rectal prolapse usually has multiple contributing factors.
