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Rectal prolapse

Last updated: December 6, 2019

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Rectal prolapse is the protrusion of rectal mucosa (mucosal prolapse) or the entire rectum (full-thickness prolapse) through the anal opening. While mucosal prolapse is more common in children, full-thickness prolapse occurs more commonly in adults. Increased intra-abdominal pressure (e.g., excessive straining as a result of constipation) and weakness of the pelvic floor muscles (e.g., as a result of old age, multiple pregnancies) are risk factors for rectal prolapse. Cystic fibrosis, moreover, is an important risk factor in children. The most commonly presenting complaint is a painless rectal mass that appears on straining. Other symptoms include fecal incontinence and/or constipation and pruritus ani. Inspection of the prolapsed structure helps to determine the type: In partial prolapse, radial folds are typically present in the mucosa, while a complete prolapse exhibits concentric mucosal folds. If clinical examination does not reveal any significant findings, video defecography may be used to confirm the diagnosis. Mucosal prolapse can be treated conservatively with digital reduction or injection sclerotherapy. Full-thickness prolapse, on the other hand, usually requires surgery. Surgery for full-thickness prolapse may be conducted either using an abdominal or a perineal approach, usually determined on a case-by-case basis.

  • Age of onset: bimodal incidence
    • Adults
      • : < 40 years
      • : 60–70 years
    • Children: < 3 years
  • Sex

References:[1][2][3]

Epidemiological data refers to the US, unless otherwise specified.

References:[1][2][3][4][5][6][7][8][9]

Depending on the severity of the rectal prolapse, rectal prolapse may be classified as:

  • Mucosal prolapse (partial prolapse)
    • Protrusion of the rectal mucosa through the anus
    • Typically less than 4 cm in length
    • Much more common in children and infants
  • Full-thickness prolapse (complete prolapse)
    • Usually begins as a rectal intussusception; therefore, all layers of the rectal wall protrude through the anus.
    • > 4 cm in length (usually 10–15 cm long when fully prolapsed)
    • Much more common in adults

Referenes:[1][2][3]

Symptoms

Physical examination

The perineum should ideally be examined while the patient squats or strains.

References:[1][2][3][8][10][11]

  • Definitive diagnosis
    • Rectal prolapse is primarily a clinical diagnosis.
    • Video defecography: to distinguish full-thickness rectal prolapse from mucosal prolapse when the diagnosis is not obvious from clinical examination alone
  • Additional tests

References:[2][3][6][12]

Mucosal prolapse

Full-thickness rectal prolapse

Full-thickness prolapse requires surgical treatment with either an abdominal or perineal approach.

  • Abdominal procedures: laparoscopic rectopexy with/without sigmoidectomy
  • Perineal procedures
    • Short, full-thickness prolapse: Delorme procedure
    • Long, full-thickness prolapse that cannot be treated by abdominal procedures: Altemeier procedure (perineal rectosigmoidectomy)

While surgery is performed electively in most cases, incarcerated rectal prolapse should be treated as a surgical emergency!

In addition to definitive management of rectal prolapse, any underlying risk factors (e.g., constipation) must be addressed in order to prevent recurrence!
References:[1][2][7][10][11][13]

  1. Williams NS, Bulstrode C, O'Connell PR. Bailey & Love's Short Practice of Surgery. CRC Press ; 2013
  2. Rakinic J. Rectal Prolapse. Rectal Prolapse. New York, NY: WebMD. http://emedicine.medscape.com/article/2026460. Updated: December 27, 2016. Accessed: February 23, 2017.
  3. Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. Elsevier ; 2016
  4. Zempsky WT, Rosenstein BJ. The cause of rectal prolapse in children. Am J Dis Child. 1988; 142 (3): p.338-339.
  5. Stern RC, Izant RJ, Boat TF, Wood RE, Matthews LW, Doershuk CF. Treatment and prognosis of rectal prolapse in cystic fibrosis. Gastroenterology. 1982; 82 (4): p.707-710.
  6. Shalkow J. Pediatric Rectal Prolapse. Pediatric Rectal Prolapse. New York, NY: WebMD. http://emedicine.medscape.com/article/931455. Updated: September 19, 2016. Accessed: February 23, 2017.
  7. Le T, Bhushan V, Chen V, King M. First Aid for the USMLE Step 2 CK. McGraw-Hill Education ; 2015
  8. Jenkins B, McInnis M, Lewis C. Step-Up to USMLE Step 2 CK. Lippincott Williams & Wilkins ; 2015
  9. Varma MG, Steele SR. Overview of rectal procidentia (rectal prolapse). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/overview-of-rectal-procidentia-rectal-prolapse.Last updated: June 3, 2015. Accessed: February 23, 2017.
  10. Krause RS. Reduction of Rectal Prolapse. Reduction of Rectal Prolapse. New York, NY: WebMD. http://emedicine.medscape.com/article/80982-overview. Updated: June 19, 2015. Accessed: February 23, 2017.
  11. Varma M, Rafferty J, Buie WD. Practice parameters for the management of rectal prolapse. Dis Colon Rectum. 2011; 54 (11): p.1339-1346. doi: 10.1097/DCR.0b013e3182310f75 . | Open in Read by QxMD
  12. Siafakas C, Vottler TP, Andersen JM. Rectal prolapse in pediatrics. Clin Pediatr. 1999; 38 (2): p.63-72. doi: 10.1177/000992289903800201 . | Open in Read by QxMD
  13. Madiba TE. Surgical management of rectal prolapse. Arch Surg. 2005; 140 (1): p.63. doi: 10.1001/archsurg.140.1.63 . | Open in Read by QxMD
  14. Cystic Fibrosis Symptoms and Treatment. http://www.chp.edu/our-services/transplant/liver/education/liver-disease-states/cystic-fibrosis. Updated: February 23, 2017. Accessed: February 23, 2017.