eMedicine from WebMD
 

eMedicine Specialties > Emergency Medicine > Gastrointestinal

Rectal Prolapse

Lynn K Flowers, MD, MHA, FACEP, Physician Partner, ApolloMD, Atlanta, Georgia

Updated: Nov 5, 2009

Introduction

Background

Rectal prolapse occurs when a mucosal or full-thickness layer of rectal tissue slides through the anal orifice.1 Problems with fecal incontinence, constipation, and rectal ulceration are common.

Full-thickness rectal prolapse.

Full-thickness rectal prolapse.


Pathophysiology

Often, prolapse begins with an internal prolapse of the anterior rectal wall and progresses to full prolapse.

The precise cause of rectal prolapse is not defined; however, a number of associated abnormalities have been found. As many as 50% of prolapse cases are caused by chronic straining with defecation and constipation. A deep pouch of Douglas, weakness of the pelvic floor, and decreased resting anal sphincter pressure also have been associated with rectal prolapse.

In children, rectal prolapse is probably related to certain anatomical features such as the vertical orientation of the rectum, mobility of the sigmoid colon, relative weakness of the pelvic floor muscle, mucosa poorly fixed to submucosa, and redundant rectal mucosa.

Frequency

United States

The incidence of prolapsed rectum in children with cystic fibrosis approaches 20%.

International

The annual incidence of rectal prolapse in Finland was found to be 2.5 per 100,000 population.2

Mortality/Morbidity

  • Untreated rectal prolapse can lead to incarceration and strangulation (rare).
  • More commonly, increasing difficulties with rectal bleeding (usually minor), ulceration, and incontinence occur.

Sex

In the adult population, the male-to-female ratio is 1:6. Although in adults women comprise 80-90% of cases, in the pediatric population, incidence of rectal prolapse is evenly distributed between males and females.

Age

  • Although all ages can be affected, peak incidences are observed in the fourth and seventh decades of life.
  • Pediatric patients usually are affected when younger than 3 years, with the peak incidence in the first year of life.

Clinical

History

  • Constipation (15-65%)
  • Fecal incontinence (28-88%)
  • Mucus drainage
  • Protruding anal mass
  • Rectal bleeding

Physical

  • Protruding rectal mucosa
  • Thick concentric mucosal ring
  • Sulcus noted between anal canal and rectum
  • Solitary rectal ulcer (10-25%)
  • Decreased anal sphincter tone


Rectal prolapse.

Rectal prolapse.


Causes

  • Conditions with increased intra-abdominal pressure
    • Constipation
    • Diarrhea
    • Benign prostatic hypertrophy
    • Chronic obstructive pulmonary disease (COPD)
    • Cystic fibrosis
    • Pertussis (ie, whooping cough)
  • Pelvic floor dysfunction
  • Parasitic infections
    • Amebiasis
    • Schistosomiasis
  • Anatomical features
    • Deep cul-de-sac (ie, pouch of Douglas)
    • Poor posterior fixation of rectum
    • Redundant rectosigmoid
  • Neurologic disorders
    • Previous lower back or pelvic trauma/lumbar disk disease
    • Cauda equina syndrome
    • Spinal tumors
    • Multiple sclerosis

Differential Diagnoses

Hemorrhoids
Pediatrics, Intussusception
Proctitis

Other Problems to Be Considered

Rectal polyps

Workup

Laboratory Studies

  • Rectal prolapse is usually only a symptom, and evaluation should focus on discovery of an underlying disorder.
  • Perform a sweat chloride test for pediatric patients; as many as 11% of children with rectal prolapse have cystic fibrosis.
  • Consider a stool examination and culture for infectious agents, particularly in pediatric patients.

Imaging Studies

  • A barium enema (BE) can assess for concurrent colonic diseases or tumors.
  • Defecography may reveal intussusception of proximal colon or pelvic outlet obstruction.

Other Tests

  • Colonic transit study
  • Anal sphincter manometry (aids in determining the degree of anal sphincter damage)
  • Pudendal nerve terminal motor latency (assesses for neurologic injury or dysfunction)
  • Ultrasonography

Procedures

  • Proctosigmoidoscopy can be an important tool to examine rectal mucosa for ulceration, inflammation, or other contributing colonic disease.

Treatment

Emergency Department Care

  • Generally, a prolapsed rectum can be reduced with gentle digital pressure. Sedation and local perianal anesthesia may aid in the reduction.
  • Significant bowel edema may make manual reduction difficult. The topical application of granulated sucrose to the mucosal surface may reduce bowel edema and allow reduction.
  • Contributing factors, such as constipation and diarrhea, should be addressed and eliminated if possible.
  • Supportive care should be provided according to the clinical picture, particularly in the presence of an irreducible prolapse and with gangrene or rupture of the rectal mucosa.

Consultations

  • Obtain a prompt surgical consultation with a general surgeon or a colorectal surgeon for an irreducible prolapse and for strangulation or gangrene of the prolapsed tissue.
  • In cases of uncomplicated rectal prolapse, arrange surgical follow-up care for further evaluation and definitive treatment.

Follow-up

Further Inpatient Care

  • Emergent rectosigmoidectomy is required if the prolapsed tissue is incarcerated and found to be nonviable.
  • Rupture of the rectum also constitutes a surgical emergency.
  • Obtain a prompt surgical evaluation if anal incontinence is present.

Further Outpatient Care

  • Arrange surgical follow-up care for further evaluation and definitive treatment of uncomplicated rectal prolapse.
  • Laparoscopic surgical rectopexy procedures have been developed that have outcomes as good as those for open procedures but with shorter hospital stays and better patient comfort.3,4

Complications

  • Mucosal ulceration
  • Necrosis of rectal wall
  • Postoperative mortality is low, but recurrence rate can be as high as 15%, regardless of operative procedure.
  • The most common postoperative complications involve bleeding and dehiscence at the anastomosis.

Prognosis

  • Spontaneous resolution usually occurs in children.
  • The prognosis generally is good with appropriate treatment.
  • Of patients with rectal prolapse who are aged 9 months to 3 years, 90% will need only conservative treatment.

Patient Education

  • For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Constipation in Adults, Anal Abscess, Rectal Pain, Rectal Bleeding, and Rectal Prolapse.

Miscellaneous

Special Concerns

  • Pediatric patients
    • Rectal prolapse in children is usually a benign condition that needs evaluation for the underlying condition.
    • Childhood prolapse is most common in children younger than 3 years; mucosal prolapse is more common than complete prolapse (possibly because of poor fixation of the submucosa to the mucosa in pediatric patients).
    • Evaluate pediatric patients for cystic fibrosis; a significant percentage is affected with this disorder.
    • In contrast to adults, children usually can be treated nonsurgically and by managing the underlying condition.

Multimedia

Rectal prolapse.

Media file 1: Rectal prolapse.

Full-thickness rectal prolapse.

Media file 2: Full-thickness rectal prolapse.

References

  1. Gourgiotis S, Baratsis S. Rectal prolapse. Int J Colorectal Dis. Mar 2007;22(3):231-43. [Medline].

  2. Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg. 2005;94(3):207-10. [Medline].

  3. Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg. Jan 2005;140(1):63-73. [Medline].

  4. Marderstein EL, Delaney CP. Surgical management of rectal prolapse. Nat Clin Pract Gastroenterol Hepatol. Oct 2007;4(10):552-61. [Medline].

  5. Abcarian H. Prolapse and procidentia. In: Zuidema GD, ed. Shackelford's Surgery of the Alimentary Tract. 4th ed. WB Saunders Co; 1996:368-85.

  6. Bartolo DC. Rectal prolapse. Br J Surg. Jan 1996;83(1):3-5. [Medline].

  7. Boccasanta P, Rosati R, Venturi M, Montorsi M, Cioffi U, De Simone M, et al. Comparison of laparoscopic rectopexy with open technique in the treatment of complete rectal prolapse: clinical and functional results. Surg Laparosc Endosc. Dec 1998;8(6):460-5. [Medline].

  8. Coburn WM 3rd, Russell MA, Hofstetter WL. Sucrose as an aid to manual reduction of incarcerated rectal prolapse. Ann Emerg Med. Sep 1997;30(3):347-9. [Medline].

  9. Demirbas S, Ogün I, Celenk T, Akin ML, Erenoglu C, Yldz M. Early outcomes of laparoscopic procedures performed on military personnel with total rectal prolapse and follow-up. Surg Laparosc Endosc Percutan Tech. Aug 2004;14(4):194-200. [Medline].

  10. Fengler SA, Pearl RK, Prasad ML, Orsay CP, Cintron JR, Hambrick E, et al. Management of recurrent rectal prolapse. Dis Colon Rectum. Jul 1997;40(7):832-4. [Medline].

  11. Heine JA, Wong WD. Rectal prolapse. In: Mazier WP, ed. Surgery of the Colon, Rectum, and Anus. Harcourt Brace & Co; 1995:515-33.

  12. Hull TL, Milsom JW. Pelvic floor disorders. Surg Clin North Am. Dec 1994;74(6):1399-413. [Medline].

  13. Jacobs LK, Lin YJ, Orkin BA. The best operation for rectal prolapse. Surg Clin North Am. Feb 1997;77(1):49-70. [Medline].

  14. Siafakas C, Vottler TP, Andersen JM. Rectal prolapse in pediatrics. Clin Pediatr (Phila). Feb 1999;38(2):63-72. [Medline].

  15. Williams JG, Madoff RD. Perineal repair for rectal prolapse. In: Problems in General Surgery. Vol 9. 1992:732-8.

Keywords

rectal prolapse, rectal prolapse symptoms, rectal prolapse causes, rectal prolapse treatment, constipation, rectal pain, rectal bleeding, rectal ulceration, prolapsed rectum, fecal incontinence

Contributor Information and Disclosures

Author

Lynn K Flowers, MD, MHA, FACEP, Physician Partner, ApolloMD, Atlanta, Georgia
Lynn K Flowers, MD, MHA, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Summa Health System
Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Jonathan Adler, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Further Reading

© 1994- by Medscape.
All Rights Reserved
(http://www.medscape.com/public/copyright)