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Rectal Prolapse

Rectal prolapse is when the mucosal layer, or full thickness layer of the rectal tissue, protrudes through the anus. It is often used to describe complete rectal prolapse when in actual sense, it is comprised of three different entities including internal prolapse, mucosal prolapse and full thickness prolapse.


Presentation

The most common presenting complain is a mass protruding from the anus. At first, the mass protrudes only after defecation and it retracts spontaneously. As the disease progresses, it protrudes more often and even during normal daily activities like walking. Eventually there is a full prolapse that may require manual reduction. Sometimes, replacement becomes impossible due to incarceration of the prolapse but this is rare. Some patients may also complain of pain. Other presenting features are prolapse of other pelvic organs, constipation and fecal incontinence [6].

Physical examination will reveal decreased sphincter tone, protruding anal mucosa, thick concentric mucosal rings and sulcus between the rectum and anal canal.

Constipation
  • Its correction of preoperative constipation and avoidance of de novo constipation appear superior to historical functional results of posterior rectopexy.[ncbi.nlm.nih.gov]
  • BACKGROUND: Opioid-induced constipation is commonly seen in pediatrics, especially at the end of life. As patients clinically decline, constipation often leads to increased pain and distress, while its enteral treatment becomes more challenging.[ncbi.nlm.nih.gov]
  • Exclusion criteria were previous major abdominal surgery, slow transit constipation, Hirschsprung's disease, inflammatory bowel disease, pregnancy, and patients on drugs that cause constipation.[ncbi.nlm.nih.gov]
  • Assessment of Constipation Quality of Life (PAC-QOL) scale and the Gastrointestinal Quality of Life Index (GIQLI).[ncbi.nlm.nih.gov]
  • Assessment of Constipation Quality of Life (PAC‐QOL) scale and the Gastrointestinal Quality of Life Index (GIQLI).[doi.org]
Fecal Incontinence
  • Conversely, chronic pelvic pain precluded fecal incontinence improvement (HR, 0.32; 95% CI, 0.135-0.668; P .0017).[ncbi.nlm.nih.gov]
  • The role of internal rectal prolapse in the origin of fecal incontinence remains to be defined. In our institution, laparoscopic ventral rectopexy is offered to patients with high-grade internal prolapse and fecal incontinence.[ncbi.nlm.nih.gov]
  • Abstract BACKGROUND: The role of internal rectal prolapse in the origin of fecal incontinence remains to be defined. In our institution, laparoscopic ventral rectopexy is offered to patients with high-grade internal prolapse and fecal incontinence.[doi.org]
  • Of the 31 patients, 30 presented with fecal incontinence preoperatively. Ten of 30 had new-onset RAI.[ncbi.nlm.nih.gov]
  • The mean duration of rectal prolapse symptoms was 7.8 years; other complaints were: pain, bleeding, mucus discharge, constipation and fecal incontinence. The mean operative time was 134.8 min and the blood loss was little.[ncbi.nlm.nih.gov]
Rectal Pain
  • Rectal Pain Causes Rectal pain has many causes. Common causes are hemorrhoids, anal fissures, and fleeting spasms. Less common causes of may include: Cancer Infection Inflammatory bowel disease Rectal prolapse Foreign bodies in the rectum.[emedicinehealth.com]
  • Anismus, a multiorgan disorder also involving the central nervous system [ 132 ], is a contraindication to STARR that is often ignored [ 122 ]; it may increase rectal pain, but is mainly responsible for persisting constipation.[doi.org]
Dyschezia
  • Pucciani F, Ringressi RM, Giani J (2007) Persistent dyschezia after double stapled transanal rectal resection for outlet obstruction: four case reports. Pelviperineology 26:132–135 Google Scholar 139.[doi.org]
  • Although defecatory problems (dyschezia, tenesmus, rectal bleeding) and incontinence scores improved from baseline in both groups, the trial was too small to detect statistically significant differences between the groups in any of the physiological outcomes[doi.org]
  • Compared with each of the three control groups (dyschezia, rectal prolapse without mucosal change, and rectal prolapse with mucosal change), subjects with solitary ulcer syndrome more frequently had an increasing anal pressure at strain (15 vs. 5, 3,[pelvicfloordigest.org]
Anger
  • […] digestive et endocrinienne, Hôtel-Dieu, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France; Maternité, hôpital Mère-Enfant, CHU de Nantes, 1, place Alexis-Ricordeau, 44000 Nantes, France. 2 Clinique de chirurgie générale et digestive, 49000 Angers[ncbi.nlm.nih.gov]

Workup

  • Since rectal prolapse is a clinical diagnosis as well a symptom of an underlying disease, investigations should be targeted at identifying these underlying conditions.
  • Laboratory tests are usually dictated by the age of the patients and underlying comorbidities. No specific laboratory investigation can aid the diagnosis of rectal prolapse. In children, because of the string association with cystic fibrosis, a sweat chloride test should be performed. Stool examination and culture is also important in this age group [7].
  • A barium enema and colonoscopy should be done to evaluate the colon and identify any other colonic lesions. This is important pre-operatively so the conditions may be addressed together and it also helps in making the choice of procedure.
  • If it is not clinically possible to distinguish rectal prolapse from mucosal prolapse, video defecography is used while rigid sigmoidoscopy can be used to check for additional lesions in the rectum. Anal manometry, Sitz marker study and pudendal nerve terminal motor lucency are other helpful investigations.
Multiple Ulcerations
  • It met with intriguing diversity in the appearance of these lesions from being plain ulcerative to polypoidal and from presenting as an erythematous mucosa to multiple ulcerative lesions.[doi.org]

Treatment

  • Medical treatment involves the use of bulking agents, stool softeners, enemas and suppositories. If there is paradoxical contraction of the pelvic floor muscles, biofeedback retraining may be helpful. Underlying factors like constipation or diarrhea should be managed. Despite all these, the mainstay of treatment is surgical.
  • The surgical approach could be abdominal or perineal and the choice is dictated by patient’s age and comorbidities [8]. 
  • Types of perineal procedures are anal encirclement, Delorme mucosal sleeve resection, Altermeier perineal rectosigmoidoscopy, hemorrhoidectomy, and perineal stapled prolapse resection.
  • Abdominal procedures include suture rectopexy, anterior resection, resection rectopexy, and marlex rectopexy. A fifth type, laparoscopic surgical rectopexy is relatively new and is associated with shorter hospital stay and patients comfort [9].

Prognosis

With appropriate treatment, the prognosis is usually favorable. 90% of pediatric patients do well on conservative management. Post-surgical mortality is also very low but there may be complications like bleeding and dehiscence at the op site as well as mucosal ulceration and necrosis of the rectal wall. Recurrence rate ranges from 0% to 50% depending on the type of corrective procedure employed [5].

Etiology

Even though the cause of this condition remains unclear, over half of the cases have been found to be associated with constipation and chronic straining on defecation. Other factors that may contribute to the development of this condition include previous anal surgery, pregnancy, diarrhea, chronic obstructive pulmonary disease, and benign prostatic hypertrophy. Others are pertussis, parasitic infections like schistosomiasis, neurologic disorder from previous pelvic trauma or spinal tumors and disordered defecation.

Some anatomic features that are present in some patients like patulous anal sphincter, levator diastasis, redundant sigmoid, posterior rectal fixation with a long mesentery and deep anterior Douglas cul-de-sac have been found during surgery for this condition. Whether these features are predisposing factors or results of the condition remains unclear [2].

Epidemiology

Cases of rectal prolapse remain highly unreported and as such, the true incidence is unknown. It has a bimodal peak age of occurrence, occurring mostly in the 4th and 7th decades of life. It is primarily a disease of women as up to 80% of affected individuals are female and it occurs together with prolapse of some other organs, like uterus, and pelvic floor descent.

Pediatric patients can also be affected, most commonly in the first year of life. In pediatric age group, the incidence is distributed evenly among both sexes [3].

Sex distribution
Age distribution

Pathophysiology

  • There are two main theories to explain the pathophysiology of rectal prolapse, although none has been completely agreed upon. 
  • The first theory postulates that it starts as a circumferential internal intussusception of the rectum beginning around 6 – 8 cm proximal to the anal verge. This internal intussusception then progresses to full thickness prolapse as time passes and also due to continued staining. The second theory hold that rectal prolapse is a sliding hernia through a defect in the pelvic fascia. 
  • It is however likely that the pathophysiology of mucosal prolapse differs from that of full thickness prolapse and internal intussusceptions [4].
  • When the connective tissue of the attachments of the rectal mucosa are loosened and stretched, they allow the tissue to prolapse through the anus leading to mucosal prolapse. This often occurs as a continuation of long standing hemorrhoids
  • It may also begin initially with prolapse of the anterior rectal wall from where it progresses to full prolapse.

Prevention

The following may help reduce chances of getting rectal prolapse: avoiding constipation by eating high fiber diet and staying hydrated, Kegel exercises to improve pelvic floor muscles and avoid delaying the urge to defecate [10].

Summary

Rectal prolapse is most commonly a disease of the elderly, especially elderly women. It presents with a wide array of symptoms although it could be asymptomatic in many cases [1].

Patient Information

  • Definition: Rectal prolapse is the protrusion of part or all of the wall of the rectum through the anus. Not all rectal prolapses can be seen with the eyes.
  • Cause: It is caused mainly by constipation and straining while defecating. Some other factors are however associated with developing this condition including pregnancy, childbirth, enlarged prostate, diarrhea, parasitic infections and whooping cough.
  • Symptoms: There is usually a mass protruding from the anus, at first it goes back on its own but as it worsens, it has to be pushed back. Other symptoms are leakage of feces, blood or mucus from the anus as well as passing of very small stools. Patients will also feel the need to empty the rectum frequently. Anal itch, irritation and pain may also be present.
  • Diagnosis: This is usually made after examination by a doctor. Some investigations might however be required to check for other associated conditions, differentiate the type of prolapse and choose the preferred surgical method.
  • Treatment: The definitive treatment is surgery. There are several approaches and the doctor will choose the one which is best for the patient. Medical agents like stool softeners and suppositories maybe used to manage conservatively.

References

Article

  1. Wijffels NA, Collinson R, Cunningham C, Lindsey I. What is the natural history of internal rectal prolapse? Colorectal Dis 2010; 12:822.
  2. Zempsky WT, Rosenstein BJ. The cause of rectal prolapse in children. Am J Dis Child 1988; 142:338.
  3. Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg. 2005;94(3):207-10.
  4. Moschvowitz AV. The pathogenesis, anatomy and cure of prolapse of the rectum. Surg Gynecol Obstet 1912; 15:7.
  5. Altomare DF, Binda G, Ganio E, De Nardi P, Giamundo P, Pescatori M. Long-term outcome of Altemeier's procedure for rectal prolapse. Dis Colon Rectum. Apr 2009;52(4):698-703.
  6. Groff DB, Nagaraj HS. Rectal prolapse in infants and children. Am J Surg 1990; 160:531.
  7. Stein EA, Stein DE. Rectal procidentia: diagnosis and management. Gastrointest Endosc Clin N Am 2006; 16:189.
  8. Ismail M, Gabr K, Shalaby R. Laparoscopic management of persistent complete rectal prolapse in children.J Pediatr Surg. Mar 2010;45(3):533-9.
  9. Marderstein EL, Delaney CP. Surgical management of rectal prolapse. Nat Clin Pract Gastroenterol Hepatol. Oct 2007;4(10):552-61.
  10. Henry LG, Cattey RP. Rectal prolapse. Surg Laparosc Endosc 1994; 4:357.

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Last updated: 2018-06-22 09:09