Basics
Description
- 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 common
- Partial thickness or mucosal prolapse:
- Only mucosal layer protrudes through anus
- Occult (internal) prolapse or rectal intussusception:
- Rectal wall prolapse without protrusion through the anus
- May be difficult to diagnose
Etiology
- Cause unclear and multifactorial:
- Chronic constipation/excessive straining
- Laxity of sphincter:
- Pelvic floor trauma/weakness; childbearing
- Neurologic 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:
- NPO
- IV fluids
- Prepare 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 pain
- Self-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 softeners
- Increase fluid intake
- Increase 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