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Rectal Prolapse

- Adults - Diastasis of levator ani - Loose endopelvic fascia - Sacral nerve root damage (diabetes, neoplasm) - Weak anal sphincter (internal or external) - Abnormally deep pouch of Douglas - Lack of normal mesorectum - Lateral ligament weakness - Pudendal neuropathy - Redundant sigmoid colon - Loss of rectal-sacral attachments - Chronic constipation and colonic dysmotility (2)[A]

- High-fiber diet - Stool softeners; avoid constipation and straining. - Stool softeners (docusate), stimulant laxatives (senna, bisacodyl suppositories) - Lactulose - Polyethylene glycol (Miralax, Glycolax)

- Helpful primarily when added to suture rectopexy in those with constipation - Consider in those with redundant sigmoid colons. - Avoid devascularization of distal rectum. - Diverting colostomy may be required in severe cases. - Perineal procedures: submucosal injection (sclerotherapy) of 5% phenol, 30% saline, or 25% glucose (or other sclerosants) in four quadrants under general anesthesia (outpatient) - Linear electrocauterization (inpatient or outpatient) - Posterior sagittal rectal suspension and levator repair - Delorme procedure (mucosal stripping of prolapsed rectum with plication of underlying muscle) - Perineal rectosigmoidectomy - Thiersch wire (outpatient procedure; may be modified by using Marlex or Silastic strip or other strong suture material instead of wire); used more commonly in children, older patients, and poor-risk adults - Gracilis sling procedure - Stapled transanal resection

para>Common problem in the elderly

Pediatric Considerations

Idiopathic type is most common in children.

ETIOLOGY AND PATHOPHYSIOLOGY

The anatomic basis for prolapse is a weak pelvic floor.

  • ChildrenIdiopathic (most common)Abnormal innervation of levator ani complex, puborectalis, anal sphincter, or abnormal anatomic relation of these muscles
  • AdultsDiastasis of levator aniLoose endopelvic fasciaSacral nerve root damage (diabetes, neoplasm)Weak anal sphincter (internal or external)Abnormally deep pouch of DouglasLack of normal mesorectumLateral ligament weaknessPudendal neuropathyRedundant sigmoid colonLoss of rectal-sacral attachmentsChronic constipation and colonic dysmotility (2)[A]

Genetics

Unknown

GENERAL PREVENTION

Avoid constipation and diarrhea.

COMMONLY ASSOCIATED CONDITIONS

  • Cystic fibrosis (CF)
  • Myelomeningocele
  • Chronic constipation (25 " 50%) or diarrhea
  • Imperforate anus
  • Nerve damage (stroke or diabetes)
  • Fecal incontinence (50 " 75%)
  • Vaginal vault or uterine prolapse (13 " 30%)
  • Mental retardation
  • Marfan syndrome
  • Ehlers-Danlos disease
  • Urinary incontinence (found in 25 " 35% of patients with rectal prolapse)
  • Renal calculi (particularly bladder stones)
  • Nutritional disorders
  • Progressive systemic sclerosis
  • Chronic constipation or diarrhea

DIAGNOSIS

HISTORY

Common historical elements

  • Presence of palpable or visible rectal mass
  • Rectal pain, bleeding, or soiling
  • Prior anorectal surgery
  • Spinal cord injury or defect
  • Constipation and strainingFeeling of incomplete evacuationRectal and urinary incontinence (50 " 75% of adult patients)Rectal bleeding or discharge

Pediatric Considerations

Sensation of anal mass in children

PHYSICAL EXAM

  • Children
  • AdultsVisible mass of rectal mucosa or rectal wallPoor anal sphincter tone on rectal examReproduce prolapse with straining.

DIFFERENTIAL DIAGNOSIS

  • Intussusception
  • Rectal polyps
  • Prolapsed incarcerated internal hemorrhoids (3)[A]

Initial Tests (lab, imaging)

  • Anorectal manometry
  • Cinedefecography
  • Electromyography
  • Colon transit study (for colon dysmotility, as patient with slow transit are prone to failure to surgical therapy) (4)[B]
  • Sigmoidoscopy or colonoscopy in recurrent prolapse to rule out rectal masses
  • MRI of lumbosacral spine to evaluate for occult spinal canal defects
  • Pudendal nerve conduction studies (increased nerve conduction periods indicates nerve damage)
  • Anorectal testing for pelvic floor dyssynergia

Follow-Up Tests & Special Considerations

  • Evaluate for CF with genetic screening and sweat chloride evaluation.
  • Barium enema may be useful in selected cases of recurrent rectal prolapse.

TREATMENT

GENERAL MEASURES

  • For acute cases: Prompt manual reduction. If there are signs of bowel compromise (e.g., gangrene), emergency surgery is indicated.
  • Place patient in lithotomy position or knee-chest position to help relax anal sphincter.
  • If rectal mucosa is edematous and hinders reduction, apply sucrose (table sugar) on mucosa, acts as osmotic agent to reduce edema.
  • Treat diarrhea or constipation.
  • Conservative management in children is successful in most (92%) cases.

MEDICATION

First Line

  • High-fiber diet
  • Stool softeners; avoid constipation and straining.Stool softeners (docusate), stimulant laxatives (senna, bisacodyl suppositories)LactulosePolyethylene glycol (Miralax, Glycolax)

SURGERY/OTHER PROCEDURES

Surgery can correct prolapse, restore or improve continence, and improve constipation and impaired evacuation.

  • Abdominal (open vs. laparoscopic) and perineal procedures
  • Perineal procedures avoid general anesthesia and are typically preferred for high-risk/frail patients. Laparoscopic approach with or without sigmoid resection are increasingly safe in elderly patients (5)[C].
  • Abdominal approach has low recurrence compared to perineal approach (3)[A].
  • Abdominal proceduresRectopexy (suture vs. mesh)Transabdominal proctopexy may also be done laparoscopically (suture material, absorbable mesh, and nonabsorbable mesh may be used).Laparoscopic rectopexy may give equivalent results with shorter hospital stay and decreased cost; long-term outcomes are still unclear.Advantages of laparoscopic rectopexy are short term. Long-term outcomes equal to abdominal approach.
  • Recent studies comparing robotic rectopexy to laparoscopic rectopexy show limited improvement of postoperative outcomes with robotic procedure (6)[A].Transabdominal Ripstein procedure (suspend rectum from sacrum)Anterior resection of sigmoid colon (rarely used alone)
  • Helpful primarily when added to suture rectopexy in those with constipation
  • Consider in those with redundant sigmoid colons.
  • Avoid devascularization of distal rectum.Diverting colostomy may be required in severe cases.Perineal procedures: submucosal injection (sclerotherapy) of 5% phenol, 30% saline, or 25% glucose (or other sclerosants) in four quadrants under general anesthesia (outpatient)Linear electrocauterization (inpatient or outpatient)Posterior sagittal rectal suspension and levator repairDelorme procedure (mucosal stripping of prolapsed rectum with plication of underlying muscle)Perineal rectosigmoidectomyThiersch wire (outpatient procedure; may be modified by using Marlex or Silastic strip or other strong suture material instead of wire); used more commonly in children, older patients, and poor-risk adultsGracilis sling procedureStapled transanal resection
  • Surgery for recurrent rectal prolapse: Choice of procedure depends on previous repair.
  • Stapled transanal rectal resection (STARR) procedure (3)[A]Isolated internal prolapse or rectocele

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

  • Inpatient care for open surgical procedures
  • Inpatient care may for extensive perineal dissection or for pain control.
  • Inpatient care for patients with incarceration or evidence of ischemia/gangrene

ONGOING CARE

Biofeedback improves postoperative function, especially in patients with pelvic floor dyssynergia.

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Monthly visits until possible need for surgery has been determined or until prolapse has resolved

DIET

  • High-fiber (25 g/day) diet
  • 100% bran granules
  • Adequate hydration

PATIENT EDUCATION

  • Reassure parents of infants with prolapse regarding benign nature of problem and high rate of spontaneous resolution.
  • Dietary modifications (fluid/fiber)
  • Teach measures to avoid constipation.
  • Teach family/patient how to reduce prolapse.

PROGNOSIS

  • Spontaneous resolution is expected in most children with idiopathic prolapse.
  • Recurrence rate is 5 " 10% following most procedures.
  • Sclerotherapy frequently needs to be repeated.
  • Overall, good prognosis with treatment

COMPLICATIONS

  • Mucosal ulcerations
  • Necrosis of rectal wall
  • Persistent or recurrent prolapse
  • Constipation and pain. Postoperative constipation rates are similar between open and laparoscopic repair.
  • Recurrence of rectal prolapse
  • Fecal incontinence
  • Incarceration or gangrene (rare)
  • Spontaneous rupture and evisceration

REFERENCES

11 Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg. 2005;140(1):63 " 73.22 Melton GB, Kwaan MR. Rectal prolapse. Surg Clin North Am. 2013;93(1):187 " 198.33 Au-Yeung CL, Selvasekar CR. Rectal prolapse and surgery for incontinence. Surgery (Oxford). 2014;32(8):435 " 438.44 El Muhtaseb MS, Bartolo DC, Zayiae D, et al. Colonic transit before and after resection rectopexy for full-thickness rectal prolapse. Tech Coloproctol. 2014;18(3):273 " 276.55 Poylin V, Bensley R, Nagle D. Changing approaches to rectal prolapse repair in the elderly. Gastroenterol Rep (Oxf). 2013;1(3):198 " 202.66 Rondelli F, Bugiantella W, Villa F, et al. Robot-assisted or conventional laparoscoic rectopexy for rectal prolapse? Systematic review and meta-analysis. Int J Surg. 2014;12(Suppl 2):S153 " S159.

ADDITIONAL READING

  • Bachoo P, Brazzelli M, Grant A. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev. 2000;(2):CD001758.
  • Belizon A, Levitt M, Shoshany G, et al. Rectal prolapse following posterior sagittal anorectoplasty for anorectal malformations. J Pediatr Surg. 2005;40(1):192 " 196.
  • Cadeddu F, Sileri P, Grande M, et al. Focus on abdominal rectopexy for full-thickness rectal prolapse: meta-analysis of literature. Tech Coloproctol. 2012;16(1):37 " 53.
  • Formijne Jonkers HA, Draaisma WA, Wexner SD, et al. Evaluation and surgical treatment of rectal prolapse: an international survey. Colorectal Dis. 2013;15(1):115 " 119.
  • Hammond K, Beck DE, Margolin DA, et al. Rectal prolapse: a 10-year experience. Ochsner J. 2007;7(1):24 " 32.
  • Sajid MS, Siddiqui MR, Baig MK. Open vs laparoscopic repair of full-thickness rectal prolapse: a re-meta-analysis. Colorectal Dis. 2010;12(6):515 " 525.
  • Shalaby R, Ismail M, Abdelaziz M, et al. Laparoscopic mesh rectopexy for complete rectal prolapse in children: a new simplified technique. Pediatr Surg Int. 2010;26(8):807 " 813.
  • Varma M, Rafferty J, Buie W. Practice parameters for the management of rectal prolapse. Dis Colon Rectum. 2011;54(11):1339 " 1346.

SEE ALSO

Hemorrhoids; Intussusception

CODES

ICD10

K62.3 Rectal prolapse

ICD9

569.1 Rectal prolapse

SNOMED

  • Rectal prolapse (disorder)
  • Incomplete rectal prolapse
  • Complete rectal prolapse

CLINICAL PEARLS

  • Rectal prolapse most commonly involves females in their 5th decade.
  • In children, rectal prolapse is most common in children <3 years and typically resolves spontaneously.
  • High-fiber diet and adequate oral hydration help prevent recurrence.