Rectal Prolapse

Rectal Prolapse

Definition: the mucosa (partial/ type 1), or all layers (complete/ type 2- more common) protrude through the anus.

Image result for rectal prolapse

Aetiology/ risk factors:

Incomplete prolapse- seen in both adults and children and associated with excessive straining, constipation and haemorrhoids.

Complete prolapse- occurs mainly in adults, and associated with weak pelvis and anal musculature. Constipation, advanced age, chronic straining, sphincter paralysis, neurological conditions e.g. MS, cystic fibrosis in children.

Epidemiology: relatively common

Peak incidence in children < 3 years and elderly (6x more in elderly females)

Symptoms:

-protruding anal mass, may require digital replacement

-constipation

-faecal incontinence (in 75%)

-PR mucus or bleeding

-may present as emergency, with irreducible or strangulated prolapse

Signs:

-prolapse may be seen on straining

-may be ulcerated or necrosed if vascular supply compromised

-decreased anal sphincter tone (on PR exam)

Investigations:

-proctosigmoidoscopy

-defecating proctogram (mechanics of a patient’s defecation are visualized in real time using a fluoroscope)

Image result for rectal prolapse defecating proctogram

-barium enema

-anal sphincter manometry (used to measure contractility in the anus), pudendal nerve studies (main nerve of the perineum)

-sweat chloride test for cystic fibrosis- in children, ∼10% will have CF

Management:

Conservative–  treat constipation with laxatives, increase fibre in diet (usually sufficient in children)

Emergency-

-acute prolapse may be manually reduced after adequate analgesia

-if bowel is gangrenous = excision by rectosigmoidectomy

Surgical

Incomplete prolapse = submucosal injection sclerotherapy with phenol in oil, mucosal banding or haemorrhoidectomy

Abdominal approach- fix rectum to sacrum (rectopexy) +/- mesh insertion +/- rectosigmoidectomy.

Perineal approach- Delorme’s procedure (resect close to dentate line and suture mucosal boundaries), anal encirclement with a Thiersch wire.

Complications:

-mucosal ulceration

-rectal bleeding

-incontinence

-rarely, strangulation and necrosis of prolapsed bowel

Prognosis: spontaneous resolution usually occurs in children. Generally good in adults with appropriate treatment, although there is a 15% recurrence rate.

References: Cheese & Onion, Rapid Surgery

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