Rectal Prolapse

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.

Children
- Idiopathic (most common)
- Abnormal innervation of levator ani complex, puborectalis, anal sphincter, or abnormal anatomic relation of these muscles
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]

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 straining
- Feeling of incomplete evacuation
- Rectal and urinary incontinence (50 " 75% of adult patients)
- Rectal bleeding or discharge

Pediatric Considerations

Sensation of anal mass in children

PHYSICAL EXAM

Children
- Protruding mass
Adults
- Visible mass of rectal mucosa or rectal wall
- Poor anal sphincter tone on rectal exam
- Reproduce 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)
- Lactulose
- Polyethylene 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 procedures
- Rectopexy (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 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
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.

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.

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