Basics
Description
There are three types of rectal prolapse: ‚
- Complete: Full thickness of rectum prolapses through anus (2 layers of rectum with an intervening peritoneal sac, which may contain small bowel).
- Incomplete/mucosal: prolapse limited to only 2 layers of mucosa
- Concealed: internal intussusception of upper rectum into lower, with no extrusion into the anus
Epidemiology
- Most cases occur in children <4 years of age around time of toilet training; equal incidence in boys and girls
- In older children and adults, strong (6-fold) female predilection
- Common in developing countries, perhaps because of poor nutrition and parasitic infection; less common in the Western world
Risk Factors
- Cystic fibrosis
- Typically presents between 6 months and 3 years of age in patients with cystic fibrosis (CF)
- Incidence is 20%.
- Presentation in children with CF >5 years of age is rare.
Etiology
Exact etiology uncertain, but the following are usually related findings and predisposing conditions: ‚
- Excessive straining with bowel movements from constipation and toilet training (hips and knees flexed) is the most common cause in the Western world.
- Diarrhea; may be more of a cause in tropical and subtropical countries
- Infections: hookworms and other parasitic infections
- Malnutrition; can cause loss of the ischiorectal fat pad
- Complication of past surgery, such as imperforate anus repair
- Complete prolapse is rare in children, but when it occurs, it may be related to poor fixation of rectum to sacrum and to weak pelvic and anal musculature.
- CF
- Ulcerative colitis
- Hirschsprung disease
- Ehlers-Danlos syndrome
- Meningomyelocele
- Pertussis
- Rectal polyp
- Pneumonia
- Anorexia
- Rectal neoplasm
Genetics
- Inheritance patterns depend on associated underlying etiologies.
- No known inheritance pattern for idiopathic rectal prolapse.
Diagnosis
History
- Signs and symptoms:
- Protrusion of rectal layers through anus, usually found during defecation or attempted defecation
- Although the history of rectal prolapse may be evident, it is often difficult to elicit on examination, and by the time the patient is seen after a prolapse at home, it may already be spontaneously reduced. Thus, the assumption of the diagnosis may have to rest primarily on the parental history.
- Although usually benign, rectal prolapse is distressing to both the parents and the child.
- Assess for symptoms of CF, risk factors for CF, or for symptoms of other associated conditions (infection, malnutrition, etc.).
- Suggest pictures to be taken by family when it occurs.
- Often reduces spontaneously; if not, can instruct parents to attempt reduction manually
- Rectal prolapse may cause some discomfort during bowel movements.
- Trauma to the recurrently prolapsed mucosa may lead to ulceration and mucus discharge.
Physical Exam
- Usually, prolapse is not seen on examination while the patient is at rest, unless it is irreducible (dark or bright red mass protruding from child 's anus without discomfort).
- May see poor anal tone and/or large anal orifice, especially within hours after the prolapse
- In complete rectal prolapse, concentric mucosal rings can be seen, whereas incomplete (mucosal) prolapse reveals radial folds.
- If clinician sees >5 cm of rectum emerging, it is most likely a complete prolapse.
- Asking the patient to strain may allow the mucosa to prolapse. However, this may be challenging in young patients.
- If prolapsed mucosa visualized, insert a finger around the prolapsing apex of the intussusception, between it and the lining of the anal canal.
- Will appear different from a polyp, which is generally plum-colored and does not involve the entire anal circumference
Diagnostic Tests & Interpretation
Lab
- Sweat test
- All children with rectal prolapse should have a sweat test to rule out CF.
- Complete CF genetic testing can be considered but is more costly.
- Stool cultures for bacterial and parasitic infestations
- Other tests for the aforementioned conditions as clinically indicated
Imaging
- Evacuation proctography
- A barium enema is given, and movement of barium is observed under fluoroscopy during defecation.
- This study may reveal an internal prolapse not easily recognizable on physical examination.
- This study is not commonly used in children because full cooperation is essential.
- Consider AP/lateral lumbosacral imaging to evaluate for spinal fusion anomalies.
Differential Diagnosis
- Tumors
- Prolapsing rectal tumor
- Trauma
- Sexual abuse (e.g., result of anal penetration)
- Metabolic
- CF: From 10 to 50% of patients diagnosed with CF, >4 years of age have experienced rectal prolapse (either at the time of the diagnosis or as a past event), but few individuals with rectal prolapse have CF.
- Anatomic abnormality (such as absence of Houston valves in infants)
- Solitary rectal ulcer syndrome: An uncommon benign condition usually affecting older children that involves rectal bleeding on defecation is common.
- Prolapsing polyp
- Large hemorrhoids
- Colonic intussusception
- Constipation
- Ehlers-Danlos syndrome
- Hirschsprung disease
- History of imperforate anus
- Pertussis/pneumonia
- Ulcerative colitis
- Meningomyelocele
Treatment
Medication
- Stool softeners (i.e., docusate, polyethylene glycol) to relieve constipation or medication with the associated condition
- In patients with CF, optimization of pancreatic enzyme supplementation. Associated with significant improvement in rectal prolapse in this population
Additional Treatment
General Measures
- Rectal prolapse in children <4 years of age has strong tendency to resolve spontaneously over time (90%).
- Patients who develop rectal prolapse at >4 years of age have less certain prognosis.
- Patients who present with a prolapsed rectum should undergo manual reduction in a prone position:
- Parents should be provided with gloves and lubricant and taught how to reduce the prolapse.
- The prolapsed bowel may be grasped with lubricated gloved fingers and pushed back in with gentle steady pressure.
- If the bowel has become edematous, firm steady pressure for several minutes may be necessary to reduce the swelling and allow for reduction.
- Digital rectal examination should always follow this procedure to verify complete reduction.
- If the prolapse immediately recurs, it may be reduced again and the buttocks taped together for several hours.
- The prolapse will resolve more successfully and quickly if the patient is treated for constipation:
- This should include both dietary manipulations (e.g., increased fiber, hydration) and improved defecation methods.
- It also will usually require the use of supplemental aids such as laxatives (polyethylene glycol).
- A small child should try to defecate with his or her hips at 90 degrees, his or her buttocks at toilet seat level, and on an appropriately sized toilet.
- In the rare case of stool infection with diarrhea as the underlying etiology, the appropriate therapy for that infection should be instituted.
Surgery/Other Procedures
Numerous (>130) approaches have been attempted and advocated with varying degrees of enthusiasm, suggesting that none is perfect. Across all procedures, including as follows, efficacy is higher in older patients >4 years old: ‚
- Perianal sutures: poor results and high complication rate
- Delorme procedure: Rectal mucosa is excised, and underlying rectal muscle is plicated with sutures.
- Laparoscopic suture rectopexy: Rectal wall is exposed and then sutured to the fascia of the sacral promontory; 5% full thickness recurrence rate
- Abdominal rectopexy: Rectum is mobilized and attached to the sacrum by prosthetic material. Although the procedure provides good results, it has a high complication rate of constipation (>50%).
- Anterior resection rectopexy: resection of the sigmoid loop and upper rectum; good results, but again, high complication rate
- Perineal resection: perineal rectosigmoidectomy with a coloanal anastomosis; good results
- Circumferential injection procedures (90 " “100% success rate): injection of phenol, oil, hypertonic saline, dextrose 50% solution (500 g/L), or ethyl alcohol to promote adhesion and stabilization of the rectum
- Lockhart " “Mummery operation (near 100% success): Mesh pack is placed temporarily in the retrorectal space (8 " “10 days) to promote adhesions that stabilize rectum.
Inpatient Considerations
Initial Stabilization
Palliative ‚
- Reassurance of patient and/or family and caregivers
- Teaching around techniques of manual reduction
- Education regarding pros and cons of surgery, which may appear to offer more definite solution, but are not without risk and may lead to further complications. In most cases, it may be more prudent to allow time and medical management to solve the problem.
Ongoing Care
Follow-up Recommendations
Ongoing Treatment
- Treatment of constipation should continue indefinitely, or until the child has demonstrated regular bowel habits on a high-fiber diet on his or her own without evidence of prolapse for at least several months.
- Intermittent parental observation to ensure child is avoiding straining with defecation
Diet
- Increase consumption of liquids.
- Add larger amounts of fiber to diet (goal: 5 g + age in years = total g/day fiber intake).
Prognosis
- With proper medical management, there is an excellent prognosis, defined as resolution without surgery.
- May require months to years on a good dietary and behavioral regimen
Complications
- In some older patients who may also have an overactive external sphincter, the need to generate high rectal pressures to defecate, together with the rectal prolapse, may cause venous congestion and solitary rectal ulcer syndrome.
- Repetitive trauma to mucosa can produce proctitis.
- Surgical complications of repair
- Frequent recurrence
Additional Reading
- Akkoyun ‚ I, Akbiyik ‚ F, Soylua ‚ SG. The use of digital photos and video images taken by a parent in the diagnosis of anal swelling and anal protrusions in children with normal physical exam. J Pediatr Surg. 2011;46(11):2132 " “2134. ‚ [View Abstract]
- Antao ‚ B, Bradley ‚ V, Roberts ‚ JP, et al. Management of rectal prolapse in children. Dis Colon Rectum. 2005;48(8):1620 " “1625. ‚ [View Abstract]
- Chan ‚ WK, Kay ‚ SM, Laberge ‚ JM, et al. Injection sclerotherapy in the treatment of rectal prolapse in infants and children. J Pediatr Surg. 1998;33(2):255 " “258. ‚ [View Abstract]
- Laituri ‚ CA, Garey ‚ CL, Fraser ‚ JD, et al. 15-year experience in the treatment of rectal prolapse in children. J Pediatr Surg. 2010;45(8):1607 " “1609. ‚ [View Abstract]
- Potter ‚ DD, Bruny ‚ JL, Allshouse ‚ MJ, et al. Laparoscopic suture rectopexy for full-thickness anorectal prolapse in children: an effective outpatient procedure. J Pediatr Surg. 2010;45(10):2103 " “2107. ‚ [View Abstract]
- 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. ‚ [View Abstract]
- Siafakas ‚ C, Vottler ‚ TP, Andersen ‚ JM. Rectal prolapse in pediatrics. Clin Pediatr (Phila). 1999;38(2):63 " “72. ‚ [View Abstract]
Codes
ICD09
ICD10
SNOMED
- 57773001 Rectal prolapse (disorder)
- 197213004 Complete rectal prolapse
- 71663002 Incomplete rectal prolapse
FAQ
- Q: What should I do if my child has a rectal prolapse but I cannot reduce it?
- A: You should wrap the prolapse in moist towels and bring your child to the emergency department. Physicians there will try to reduce it. Rarely, if a prolapse is irreducible and left for a period of time, it can cause bowel ischemia and may require surgery.
- Q: My child has rectal prolapse and now he is supposed to have a sweat test to determine whether he has CF. Is this very likely?
- A: No. Although it is important to rule out this disease, most patients with rectal prolapse do not have CF. However, many children with CF suffer from rectal prolapse.
- Q: My child, who has rectal prolapse, is in day care. How will I know if he is having the prolapse?
- A: You should inform someone in the school (a teacher or guardian) of his condition, and he or she should check the child for prolapse after a bowel movement. Although, if present, it usually resolves spontaneously, the teacher should inform you so you can do a manual reduction, if necessary.