Rectal prolapse is the protrusion of either the rectal mucosa or the entire wall of the rectum. Partial prolapse involves only the mucosa and usually only protrudes by a few centimetres. Complete prolapse involves all layers of the rectal wall.
- Prolapses of the rectum occur either with bowel movements or independently. In the elderly, rectal prolapse initially only occurs with defecation and then retracts spontaneously.
- More advanced rectal prolapses may occur when standing and so greatly interfere with the patient's quality of life.
- Uncommon, but the true incidence is unknown because of under-reporting, especially in the elderly population.
- Mainly occurs in the elderly and in young children.
- Complete prolapse in adults is most common in elderly females.
- In children, rectal prolapse occurs most often in patients younger than 3 years, and especially in the first year of life.
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- Increased intra-abdominal pressure, eg constipation, diarrhoea, benign prostatic hypertrophy, pregnancy, severe or chronic cough (eg chronic obstructive pulmonary disease, cystic fibrosis, whooping cough).
- Previous surgery.
- Pelvic floor dysfunction.
- Parasitic infections, eg amoebiasis, schistosomiasis.
- Neurological disease, eg previous lower back or pelvic trauma, lumbar disc disease, cauda equina syndrome, spinal tumours, multiple sclerosis.
- Psychiatric disease.
- Mass protruding through the anus:
- Initially only after a bowel movement and usually retracts when the patient stands up.
- Later the mass protrudes more often, especially with straining and Valsalva manoeuvres such as sneezing or coughing.
- Finally, the rectum prolapses with daily activities such as walking and may progress to continual prolapse.
- Patients may have to replace it manually.
- Pain, constipation, faecal incontinence, discharge of mucus or rectal bleeding may occur.
- If seen on examination, the protruding mass should show concentric rings of mucosa, which are classic signs of rectal prolapse.
- Examination may also reveal a rectal ulcer and decreased anal sphincter tone.
- Rectal prolapse must be differentiated from prolapse of an intussusception or a rectal polyp.
- Rectal prolapse can usually be differentiated from a haemorrhoid by the presence of symmetrical circumferential folds occurring with a rectal prolapse.
- Barium enema and/or colonoscopy: To evaluate the entire colon prior to surgery for rectal prolapse to exclude any other colonic lesions.
- Other investigations to assess underlying conditions include stool microscopy and cultures for gastrointestinal infection and sweat test for cystic fibrosis.
- In cases of small prolapse, it is sometimes difficult to distinguish between mucosal and full-thickness rectal prolapse. If these cannot be clinically distinguished, a defaecogram may be of help in differentiating these two conditions. A defaecogram is unnecessary in the presence of an obvious rectal prolapse.
- Rigid proctosigmoidoscopy should be performed to assess the rectum for additional lesions, especially solitary rectal ulcers. These ulcers are present in about 10-25% of patients with either internal or full-thickness prolapse.
Anal rectal manometry is sometimes used to evaluate the anal sphincter muscles. In nearly all patients with rectal prolapse, there is a decrease in resting pressure in the internal sphincter and an absence of the anorectal inhibitory reflex. The significance of these results is unclear and this test is rarely used.
- Affected adult women may also have uterine or bladder prolapse, or an associated cystocele.
- Rectal prolapse can usually be reduced with gentle digital pressure. Sedation and local perianal anaesthesia may help the reduction.
- Contributing factors should be treated, eg constipation or diarrhoea.
- Prompt surgical referral is recommended for an irreducible prolapse and for strangulation or gangrene of the prolapsed tissue.
- Partial prolapse often responds to conservative measures but occasionally requires excision of prolapsed mucosa.
- Children: gently replace using water-soluble lubricant. Advise parents on the need for a high-fibre diet and inadvisability of straining on stool. A mild laxative may be required. Very occasionally a submucosal injection of a sclerosant is also indicated.
- Elderly: often well tolerated and concealed with the patient manually reducing the prolapse. In those unfit for surgery, a subcutaneous circumanal rubber ring may be fitted. However, this often fails either because it is too tight or too loose, resulting in constipation or recurrent prolapse.
- Emergency rectosigmoidectomy is required if the prolapsed tissue is incarcerated and nonviable.
- Mucosal prolapse is treated with a haemorrhoidectomy.
- Abdominal procedures:
- Abdominal procedures are usually performed in younger, healthier patients.
- Abdominal procedures include anterior resection (not often performed), Marlex rectopexy (Ripstein procedure), suture rectopexy and resection rectopexy (Frykman Goldberg procedure)
- In suture fixation rectopexy and resection rectopexy, the rectum is mobilised and the mesorectum sutured to the sacral promontory and the presacral fascia. In resection rectopexy, a sigmoid colectomy is also performed.
- Perineal procedures:
- Perineal procedures have a higher recurrence rate but a lower morbidity rate and are often performed in the elderly or in patients who have a contra-indication to general anaesthetic.
- Perineal procedures include anal encirclement (Thiersch wire), Delorme's mucosal sleeve resection and Altemeier's perineal rectosigmoidectomy.
- The most common procedure is the Delorne's operation. Altemeier's procedure is an alternative perineal procedure popular in the USA.
- Laparoscopic repair is currently under study but laparoscopic surgical rectopexy procedures have shown outcomes as good as for open procedures.
Surgical treatment for children
- Surgical intervention is usually reserved for failed conservative management in children younger than 4 years who have tried nonsurgical management for longer than 1 year.
- Surgery may also be used in cases of complicated rectal prolapse, eg recurrent rectal prolapse that requires manual reduction, painful prolapse, ulceration, and rectal bleeding.
- There are many different operations used, including:
- Circumferential injection procedures: injection procedures use a sclerosant to promote adhesion formation, which stabilises the rectum.
- Thiersch operation: synthetic materials are used to create a perianal sling to support the rectum.
- Lockhart-Mummery operation: mesh gauze packing is placed temporarily in the retrorectal space to promote adhesions that stabilise the rectum.
- Cauterisation treatment: the prolapsed rectum is cauterised to produce inflammation and scarring that prevents prolapse.
- Abdominal rectopexy: endoscopic or open approach. The perirectal tissues are attached to the presacral area to assure correct anatomical positioning and tissue adherence.
- Ekehorn's rectopexy: a suture is placed in the rectal ampulla through the lowest part of the sacrum to induce inflammation and adhesions between the rectal wall and perirectal wall.
- Mucosal ulceration.
- Necrosis of rectal wall.
- The most common postoperative complications are bleeding and dehiscence at the anastomosis.
- Postoperative recurrence rate can be as high as 15%, regardless of operative procedure.
- The prognosis for elderly patients presenting with rectal prolapse is variable and depends on the nature of any underlying or associated problems and the age and general wellbeing of the patient.
- Spontaneous resolution usually occurs in children but approximately 10% of children who experience rectal prolapse continue to experience it in their adult lives.
- Of the children with rectal prolapse who are aged 9 months to 3 years, 90% will need only conservative treatment. For children who first experience prolapse when older than 4 years, a much lower rate of spontaneous resolution occurs.
Further reading & references
- Flowers LK; Rectal Prolapse (emergency medicine), eMedicine, Nov 2009
- Poritz LS; Rectal Proloapse (general surgery), eMedicine, Apr 2010
- Watkins BP, Landercasper J, Belzer GE, et al; Long-term follow-up of the modified Delorme procedure for rectal prolapse. Arch Surg. 2003 May;138(5):498-502; discussion 502-3.
- Kairaluoma MV, Viljakka MT, Kellokumpu IH; Open vs. laparoscopic surgery for rectal prolapse: a case-controlled study assessing short-term outcome. Dis Colon Rectum. 2003 Mar;46(3):353-60.
- Kimmins MH, Evetts BK, Isler J, et al; The Altemeier repair: outpatient treatment of rectal prolapse. Dis Colon Rectum. 2001 Apr;44(4):565-70.
- Flowers LK; Rectal Prolapse, eMedicine, Nov 2009
- Friedlander JA et al; Rectal prolpase, eMedicine, Dec 2008
|Original Author: Dr Colin Tidy||Current Version: Dr Colin Tidy||Peer Reviewer: Dr Adrian Bonsall|
|Last Checked: 19/04/2012||Document ID: 573 Version: 23||© EMIS|
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