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Rectal Prolapse, Emergency Medicine

Basics

Description

- Occult (internal) prolapse or rectal intussusception: - Rectal wall prolapse without protrusion through the anus - May be difficult to diagnose

- Cause unclear and multifactorial: - Chronic constipation/excessive straining - Laxity of sphincter: - Pelvic floor trauma/weakness; childbearing - Neurologic disease

- Stabilization generally not needed in simple prolapse - Incarcerated or ischemic prolapse: - NPO - IV fluids - Prepare for surgery

- Reduced rectal prolapse - Stable and tolerating PO - Instructions to treat the presumed underlying cause: - Correct constipation: - Stool softeners - Increase fluid intake - Increase dietary fiber

  • Full-thickness evagination of the rectal wall outside the anal opening
  • 3 types of rectal prolapse:Full-thickness prolapse:Protrusion of the rectal wall through the anal canal; the most commonPartial thickness or mucosal prolapse:Only mucosal layer protrudes through anusOccult (internal) prolapse or rectal intussusception:Rectal wall prolapse without protrusion through the anusMay be difficult to diagnose

Etiology

  • Cause unclear and multifactorial:Chronic constipation/excessive strainingLaxity of sphincter:Pelvic floor trauma/weakness; childbearingNeurologic disease
  • More common in women, peak in 7th decade
  • Very rare after age 4 yr
  • True rectal prolapse unusual in children; more likely partial or intussusception
  • Consider chronic diarrhea, parasites, cystic fibrosis (CF), malnutrition as contributing causes

Diagnosis

Signs and Symptoms

  • Dark red mass protrudes from the rectum
  • Possible mucous or bloody discharge
  • Sensation of rectal mass
  • Tenesmus
  • Constipation or incontinence

History

  • History with emphasis on bowel obstruction and duration of prolapse
  • Often progressive symptoms over time with self-reducing prolapse initially

Physical Exam

  • Rectal exam must differentiate prolapse from polyps, hemorrhoids, and intussusception.
  • True prolapse shows dark red mass at the anal verge with or without mucus; circumferential circular folds in beefy mucosa of protruding rectum.
  • Mucosal prolapse rarely greater than a few centimeters of protrusion; will not contain circular folds of muscular layer
  • Internal hemorrhoids identified by folds of mucosa radiating out like spokes in wheel
  • Prolapsed polyps and hemorrhoids do not involve the entire rectal mucosa and do not have a hole in the center.
  • Intussusception identified by complaints of intermittent, severe abdominal pain; may appear more ill:Examiners finger can be passed between the apex of the prolapsed bowel and the anal sphincter; whereas, in rectal prolapse the protruding mucosa is continuous with the perianal skin

Essential Workup

Careful physical exam

Diagnosis Tests & Interpretation

Lab

  • No lab test necessary for uncomplicated prolapse
  • Preoperative testing for incarcerated rectal prolapse, going to OR

Imaging

No imaging is necessary for uncomplicated prolapse

Differential Diagnosis

  • Prolapsed internal hemorrhoids
  • Prolapsed rectal polyp
  • Intussusception
  • Other rectal mass

Treatment

Pre-Hospital

  • Position of comfort
  • Prevent mucosal desiccation with moist gauze
  • Avoid trauma to mucosa

Initial Stabilization/Therapy

  • Stabilization generally not needed in simple prolapse
  • Incarcerated or ischemic prolapse:NPOIV fluidsPrepare for surgery

Ed Treatment/Procedures

Manual reduction of rectal prolapse:

  • Place in knee-chest position
  • Apply gentle steady pressure for 5 " 15 min
  • Invert mucosa through lumen from distal
  • Sedation as needed to relax sphincter
  • Finger may be placed in rectum to guide reversal of prolapse
  • Prolapse very large or difficult to reduce:Apply 1/2 " 1 cup sugar to reduce swelling and assist manual reduction
  • Prolapse recurs immediately after reduction:Apply pressure dressing with lubricant, gauze, tape; buttock may be taped together for several hours
  • If prolapse incarcerated or ischemic, or if manual reduction fails or prolapse frequently recurs:Admission for emergent surgical correction
  • Constriction of blood flow to rectum by anal sphincter can lead to ischemia, venous obstruction and thrombosis, full-thickness necrosis, possible loss of gut
  • Timely reduction decreases risk
  • Surgical intervention required for ischemic mucosa
  • Most common complication of spontaneous or manual reduction:Localized painSelf-limited mucosal bleeding

Medication

Sedation and pain medication only as needed

Follow-Up

Disposition

Admission Criteria

  • Necrotic or ischemic mucosa
  • Inability to reduce acute prolapse or frequently recurs

Discharge Criteria

  • Reduced rectal prolapse
  • Stable and tolerating PO
  • Instructions to treat the presumed underlying cause:Correct constipation:Stool softenersIncrease fluid intakeIncrease dietary fiber
  • Avoid prolonged sitting or straining

Discharge Criteria

Refer for workup including:

  • Search for leading lesion
  • Refer for definitive surgical repair of recurrent prolapse
  • Testing for CF in children

Followup Recommendations

Colorectal follow-up

Pearls and Pitfalls

  • Perform careful physical exam to differential rectal prolapse from polyps, hemorrhoids, and intussuscepted bowel
  • For large or difficult to reduce rectal prolapse, apply sugar to reduce swelling and assist in manual reduction

Additional Reading

  • Demirel AH, Ongoren AU, Kapan M, et al. Sugar application in reduction of incarcerated prolapsed rectum. Indian J Gastroenterol. 2007;26(4):196 " 197.
  • Gourgiotis S, Baratsis S. Rectal prolapse. Int J Colorectal Dis. 2007;22(3):231 " 243.
  • Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg. 2005;94(3):207 " 210.
  • Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg. 2005;140(1):63 " 73.
  • Melton GB, Kwaan MR. Rectal prolapse. Surg Clin North Am. 2013;93(1):187 " 198.

See Also (Topic, Algorithm, Electronic Media Element)

Hemorrhoid

Codes

ICD9

569.1 Rectal prolapse

ICD10

K62.3 Rectal prolapse

SNOMED

  • 57773001 Rectal prolapse (disorder)
  • 71663002 Incomplete rectal prolapse
  • 197213004 Complete rectal prolapse