Rectal Prolapse

Rectal prolapse is rectum protrusion through the anal opening.

Three types

1. Internal (occult) prolapse- when there is intussusception of the rectal wall
2. Mucosal (partial) prolapse- partial-thickness protrusion often associated with hemorrhoids.
3. Complete prolapse- protrusion of all layers of the rectum.

Risk factors

• Female gender
• Age >40 years
• Vaginal delivery
• Prior pelvic surgery
• Raised intraabdominal pressure
• Cystic fibrosis
• Connective tissue disorders
• Anorectal malformations- in children

Clinical features

• A sensation of tissue protruding from the anus that spontaneously reduces or needs manual reduction
• Tenesmus
• A feeling of incomplete evacuation
• Constipation
• Fecal incontinence
• Pruritus Ani and bleeding
• *Pain suggests another diagnosis

Physical Examination– examine while the patient squats or strains

• Mucous prolapse- a double-layered mucous membrane can be palpated
• Full-thickness- concentric mucosal folds are seen, and all four layers can be palpated
• DRE- sphincter weakness

Diagnosis

Primarily a clinical diagnosis

Investigations

1. Video defecography- differentiates the types
2. Anal sphincter manometry- if incontinence is present
3. Dynamic pelvic floor MRI- for pelvic floor strength
4. CT colonography and colonoscopy- to rule out neoplasms and diverticular disease
5. Sweat chloride test- to rule out cystic fibrosis
6. Colonic transit study- for those with a history of constipation
7. Complete blood count- to rule out worm infection

Differential diagnosis

• Prolapsed internal haemorrhoids
• Malignancy
• Solitary rectal ulcer
• Worm infection- trichuriasis

Management

1. Medical-

• Adequate fluid and fibre intake
• Enemas for severe constipation
• Address underlying risk factor
• Pelvic floor exercises
• Taping of buttocks or placing bulky pad against perineum- for old and frail or debilitated patients
• Mucosal prolapse- injection sclerotherapy and digital repositioning of the rectum

2. Surgical- abdominal and perineal approaches

Abdominal;

1. Reduction of perineal hernia and closure of the Cul de sac
2. Resection of the redundant sigmoid colon
3. Fixation of rectum (rectopexy)
4. 2nd and 3rd can be combined

Perineal

1. Tightening anus with prosthetic materials
2. Reefing the rectal mucosa (Delorme procedure)
3. Resecting prolapsed bowel from the perineum

Complications

• Intestinal obstruction
• Recurrence- especially with perineal procedures
• Injury to protruding mass