Rectal Prolapse

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.

• May occur with bowel movements or independently. In the elderly, rectal prolapse initially only occurs with defaecation and then retracts spontaneously.
• Later may occur merely on standing thus interfering with patient's quality of life.¹

• 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.²
• In children, rectal prolapse occurs most often in patients younger than 3 years, and especially in the first year of life.²

Risk factors²

• Increased intra-abdominal pressure, e.g. constipation, diarrhoea, benign prostatic hypertrophy, pregnancy, severe or chronic cough (e.g. chronic obstructive pulmonary disease, cystic fibrosis, whooping cough)
• Previous surgery
• Pelvic floor dysfunction
• Parasitic infections, e.g. amoebiasis, schistosomiasis
• Neurological disease, e.g. previous lower back or pelvic trauma, lumbar disc disease, cauda equina syndrome, spinal tumours, multiple sclerosis
• Psychiatric disease

In children rectal prolapse may be associated with cystic fibrosis, Ehlers-Danlos syndrome, Hirschsprung's disease, congenital megacolon, malnutrition and polyps.

• 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 manually replace it.
• Pain, constipation, faecal incontinence, mucus discharge 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.
• Can usually differentiate a rectal prolapse from a haemorrhoid by the presence of symmetrical circumferential folds occurring with a rectal prolapse.

• Barium enema: Evaluate the entire colon prior to surgery for rectal prolapse to exclude any other colonic lesions that should be simultaneously addressed. Evaluation can be accomplished by colonoscopy or barium enema. Barium enema is a better indicator of the redundancy of the colon.
• 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.
• Anal rectal manometry is sometimes used to evaluate the anal sphincter muscles. In almost all patients, the results show 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 most surgeons do not use this test.
• 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.

• Affected adult women may also have uterine or bladder prolapse, or an associated cystocoele.

• Rectal prolapse can usually be reduced with gentle digital pressure. Sedation and local perianal anaesthesia may help the reduction.
• Contributing factors, such as constipation and diarrhoea, should be treated.
• Prompt surgical referral is recommended for an irreducible prolapse and for strangulation or gangrene of the prolapsed tissue.²
• Partial prolapse often responds to conservative measures but occasionally requires excision of prolapsed mucosa.
• Emergency rectosigmoidectomy is required if the prolapsed tissue is incarcerated and found to be non-viable.²
• If occurs on standing or incontinence develops, most common surgical repair is Delorne's operation which involves excision of the rectum and sigmoid colon via the perineum together with anastomosis of the colon to the anus.³ Altemeier's procedure is an alternative perineal procedure popular in the USA.⁴
• Two abdominal operations are suture fixation rectopexy and resection rectopexy. In these 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. Laparoscopic repair is currently under study.⁵

Non-drug

• Children: gently replace using water-soluble lubricant. Advise parents on need for high fibre diet and inadvisability of straining on stool. A mild laxative may be required, and very occasionally a submucosal injection of a sclerosant.
• Elderly: often well tolerated and concealed with patient manually reducing 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.

Surgical⁶

• Abdominal procedures: usually performed in younger, healthier patients whose life expectancy is longer:
  • Anterior resection (not often performed):
    • Patients with rectal prolapse and constipation often have a redundant colon, and resection of it is thought to improve constipation and cure rectal prolapse.
    • The rectum is mobilised to the level of the lateral ligaments, and the redundant sigmoid colon is resected.
    • The left colon is then anastomosed to the top of the rectum so that the rectum is held in place and can no longer prolapse.
  • Marlex rectopexy (Ripstein procedure):
    • The entire rectum is mobilised.
    • A non-absorbable material, e.g. Marlex mesh or an Ivalon sponge, is then fixed to the presacral fascia.
    • The rectum is then placed on tension and the material is partially wrapped around the rectum to keep it in position.
    • The anterior wall of the rectum is not covered with the sponge or mesh in order to prevent a circumferential obstruction.
    • The Marlex mesh or sponge causes an inflammatory reaction that scars and fixes the rectum into place.
    • This procedure should not be performed on patients who have a large component of constipation or a very redundant sigmoid colon because the symptoms are likely to worsen.
  • Suture rectopexy:
    • Essentially the same as a Marlex rectopexy except that the rectum is fixed to the presacral fascia with suture as opposed to mesh or an Ivalon sponge.
  • Resection rectopexy (Frykman Goldberg procedure):
    • Is a combination of the anterior resection and the Marlex rectopexy and is a good option for patients with a significant component of constipation.
    • The rectum is completely mobilised.
    • The redundant sigmoid colon is then resected and the remaining colon is anastomosed to the top of the rectum.
    • The lateral ligaments or the rectal fascia are then sutured to the presacral fascia with the rectum on tension, which keeps the rectum in place and prevents further rectal prolapse.
    • The rectopexy is accomplished with suture instead of non-absorbable mesh because the bowel is opened for the anastomosis and the mesh may become contaminated.
• 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 contraindication to general anaesthetic:
  • Anal encirclement (Thiersch wire):
    • A non-absorbable band is placed subcutaneously around the anus. The purpose of this procedure is to keep the rectum from prolapsing by restricting the size of the anal lumen.
    • The therapy is effective in mechanically preventing the rectum from prolapsing, but it does not treat the underlying disorder.
    • Complications from the procedure include obstruction with faecal impaction and erosion of the material leading to infection.
    • This procedure is no longer commonly performed and is usually reserved for patients with the highest surgical risks.
  • Delorme mucosal sleeve resection:
    • A circumferential incision is made through the mucosa of the prolapsed rectum near the dentate line.
    • Using electrocautery, the mucosa is stripped from the rectum to the apex of the prolapse and excised.
    • The denuded prolapsed muscle is then pleated with a suture. The transected edges of the mucosa are then sutured together.
    • This procedure is often used for small prolapses but may also be used for large ones.
  • Altemeier perineal rectosigmoidectomy:
    • A full-thickness circumferential incision is made in the prolapsed rectum at about 1-2 cm from the dentate line.
    • The hernia sac is then entered, and the prolapse is delivered.
    • The mesentery of the prolapsed bowel is serially ligated until no further redundant bowel can be pulled down.
    • The bowel is transected and hand sewn to the distal anal canal or stapled using a stapler.
    • Plication of the levator ani muscles anteriorly may help improve continence.
• Surgery for mucosal prolapse:
  • Mucosal prolapse is treated with a haemorrhoidectomy.

Surgical treatment for children⁷

• Surgical intervention is usually reserved for failed conservative management in children younger than 4 years who have tried non-surgical management for longer than 1 year.
• Surgery may also be used in cases of complicated rectal prolapse, e.g. recurrent rectal prolapse that requires manual reduction, painful prolapse, ulceration, and rectal bleeding.
• There are many different operations used, including:
  • Circumferential injection procedures (90-100% success rate); injection procedures use a sclerosant to promote adhesion formation, which stabilises the rectum.
  • Thiersch operation (90% success rate); synthetic materials are used to create a perianal sling to support the rectum.
  • Lockhart-Mummery operation (approximately 100% success rate); mesh gauze packing is placed temporarily in the retrorectal space to promote adhesions that stabilise the rectum.
  • Cauterisation treatment (approximately 80% success rate); the prolapsed rectum is cauterised to produce inflammation and scarring that prevents prolapse.
  • Abdominal rectopexy (75% success rate); endoscopic or open approach. The perirectal tissues are attached to the presacral area to assure correct anatomical positioning and tissue adherence.
  • Ekehorn rectopexy (100% success rate); 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 well-being of the patient.
• Approximately 10% of patients who experience rectal prolapse as children continue to experience it in their adult lives.
• Spontaneous resolution usually occurs in children.
• Of the children with rectal prolapse who are aged 9 months to 3 years, 90% will need only conservative treatment.²
• For children older than 4 years who first experience prolapse, a much lower rate of spontaneous resolution exists.