Case Study: Rectal Protrusion During Defecation in a 30-Year-Old Multiparous Woman

Case at a Glance

A 30-year-old woman, two years postpartum from her second vaginal delivery, presented with concerns about a palpable mass protruding from her anus during defecation. The mass, described as a 'fleshy tube' approximately two inches long, retracts spontaneously after the bowel movement is complete. The case highlights the differential diagnosis between hemorrhoidal prolapse and rectal prolapse in a postpartum patient.

Patient's Story

The patient is a 30-year-old female, G2P2 (two pregnancies, two live births), with a history of two uncomplicated vaginal deliveries, the most recent occurring nearly two years ago. She reported that for an unspecified duration, she has experienced the sensation of tissue 'pushing out' of her anus when sitting on the toilet to have a bowel movement. Upon self-examination, she identified a soft, fleshy, tubular structure, which she estimated to be about two inches in length, emerging from the anal canal during straining. She noted that the tissue fully and spontaneously retracts inside upon standing and relaxing. The patient expressed significant embarrassment and reluctance to seek medical evaluation for this 'private' issue, but was concerned about its potential severity.

Initial Assessment

The patient's history, particularly the multiparity with vaginal deliveries, raises suspicion for pelvic floor weakness. The primary presenting symptom—a reducible mass protruding during defecation—points towards two main differential diagnoses: severe internal hemorrhoids (Grade III) or a partial (mucosal) rectal prolapse. The patient's description of a 'fleshy tube' is consistent with either condition. Her history of anal intercourse from over six years prior was noted but considered unlikely to be a contributing factor to her current symptoms. The key to diagnosis would be a direct physical examination.

The Diagnostic Journey

Given the patient's hesitation to see a physician, initial advice focused on conservative management and education. A healthcare provider consulted online suggested the symptoms were highly indicative of hemorrhoids. The provider recommended a physical examination as the definitive next step, reassuring the patient that such conditions are extremely common in clinical practice and that physicians are accustomed to examining anogenital areas without judgment. A pharmacist also reinforced this, noting the frequency of patient questions related to bowel health, in an effort to normalize the patient's experience and encourage her to seek care.

Final Diagnosis

Pending a formal physical examination, a working diagnosis of Grade III Internal Hemorrhoids was proposed. This grade is characterized by hemorrhoids that prolapse outside the anal canal during defecation or straining but can be reduced either spontaneously (as in this case) or manually. A mucosal rectal prolapse remains a key differential that must be ruled out via an in-person evaluation, likely including anoscopy and observation of the patient during a Valsalva maneuver (straining).

Treatment Plan

The initial treatment plan focused on conservative, non-invasive measures aimed at reducing straining during defecation:

1. Dietary and Lifestyle Modification: The patient was advised to increase daily fiber intake through diet and/or supplements (e.g., psyllium) and to ensure adequate hydration to soften stools and prevent constipation.
2. Behavioral Changes: Avoid prolonged sitting on the toilet to minimize pressure on the rectum.
3. Patient Education: Strong recommendation for an in-person consultation with a primary care physician or colorectal specialist for an accurate diagnosis and to discuss further treatment options if conservative measures fail.

Outcome and Follow-up

The patient was counseled on the importance of a professional medical evaluation to confirm the diagnosis and rule out other pathologies. The immediate outcome depends on her adherence to the recommended conservative therapies. Long-term follow-up with a physician will be necessary to monitor symptoms. If symptoms persist or worsen despite lifestyle changes, procedural interventions such as rubber band ligation, sclerotherapy, or hemorrhoidectomy may be considered.