Rectal Prolapse

Rectal Prolapse (Procidentia)

A rectal prolapse is an umbrella term that refers to the abnormal full-thickness protrusion of the rectum through the anus. It can be easy to confuse rectal prolapse with prolapsed haemorrhoids. One way to differentiate a rectal prolapse from prolapsed haemorrhoids is the direction of mucosal folds – mucosal folds are oriented in a circular direction for rectal prolapse, while in haemorrhoids the folds are oriented radially.

Prolapse is common in older women. Important factors such as chronic constipation and childbirth are associated with prolapse.

Types of rectal prolapse.

Prolapse	Description
Mucosal rectal prolapse	Only the mucosal layer prolapses past anal verge. Noted by radial folds (like prolapsed hemorrhoids). Common in children and treatment is usually conservative. Predisposing factors include malnutrition (loss of fat in the ischiorectal fossa), direct downward course of the rectum in infants and diarrhoea.
Full rectal prolapse (procidentia)	All layers of the rectum prolapse past the anal verge. Noted by circumferential folds. Common in adults and is associated with incontinence. May occur in children with malnutrition. This type requires surgery.

• Patient history
  • Bowel habits (constipation or incontinence – reflects poor anal tone)
• Physical examination
  • Sphincter tone
• Signs and symptoms
  • Mass protruding past anal verge (during defecation and valsava).
    • Spontaneously reduces
    • Radial folds (mucosal) or circumferential folds (full)
  • Fecal incontinence (28-88%)
• Differentials
  • Hemorrhoids: appreciated as a mass with radial folds; may be painful (external) or bleed (internal)
• Investigations
  • Anoscopy or proctosigmoidoscopy; to visualize the rectum. Findings can alter the surgical plan
• Treatment of mucosal rectal prolapse
  • Treat the underlying cause
  • Digital repositioning by the parents
  • Submucosal injection (using 6% phenol in almon oil) or rubber band ligation if digital repositioning fails
• Treatment of full rectal prolapse (procidentia)
  • Altemeier procedure (perineal approach): involves resecting the rectum through the perineum and tightening the anal sphincter. Procedure of choice for incarcerated and strangulated prolapse. Complications include fecal and flatus incontinence due to loss of rectal reservoir.
  • Delomre’s procedure (perineal approach): the mucosa is stripped circumferentially then anastomosed to reduce the prolapse. This has a high recurrence rate
  • Rectopexy(abdominal approach): fix the redundant rectosigmoid in the pelvis by sutures or slings or mesh or fascia) e.g. Ripstein procedure
  • Resection of the redundant sigmoid

Internal rectal prolapse (”Internal intussusception”)

An internal rectal prolapse is the telescoping of the rectum distally, usually not protruding past the anal verge. It is common in paediatric patients.

• Things to consider in paediatric patients with rectal prolapse
  • Whipworm infection
  • Clostridiodes difficile infection
  • Cystic fibrosis in white kids
• Signs and symptoms
  • Urgency to defecate
  • Feeling of rectal fullness
  • “Constipation”
  • Pelvic pain
• Investigations
  • High-resolution ultrasound
  • Pelvic MRI
  • Proctosigmodioscopy: always done, to rule out other anorectal pathologies
  • Additional investigations: stool ova and cysts, c-difficile toxin, sweat chloride studies
• Treatment
  • Treat the underlying cause
  • Stool softeners
  • Increase dietary fibre intake
  • Surgery is rarely indicated