Pediatric Rectal Prolapse Clinical Presentation
- Author: Jaime Shalkow, MD, FACS; Chief Editor: Carmen Cuffari, MD more...
Rectal prolapse presents as a red ring of mucosa protruding from the rectum after straining (see the image below). It is often associated with tenesmus and mucus or bloodstained clothing. Constipation is present in 25-50% of individuals; up to 75% of patients have fecal incontinence.
Prolapse initially occurs with defecation and straining, but as the pelvic floor musculature becomes more lax, it can recur with the mildest straining, in upright position, or even spontaneously at rest. Most cases reduce spontaneously; however, the parents (or patient) may need to manually reduce the prolapsed bowel.
History of neonatal stooling problems or cases of cystic fibrosis in family members should be sought. The clinician should ask about excessive straining due to constipation or diarrhea (most common), prolonged toilet sitting with hips and knees flexed, and operative correction of imperforate anus. Inquire about history of the following:
Patients with rectal prolapse frequently have an associated dysfunction, either fecal incontinence (50%) or constipation (15-65%). Excessive pushing during defecation induces mucosal injury of the anterior rectal wall, which may lead to a solitary rectal ulcer.
Frequently, physical examination findings are normal. Parents provide a history of a dark or bright-red mass protruding from the child’s anus, although the child appears to be pain free or in minimal discomfort.
Because most prolapses spontaneously reduce before arrival for evaluation, a brief examination of the patient in a sitting or squatting position and observation for recurrence of prolapse is recommended. (Other positions, such as jackknife or left lateral decubitus are frequently inadequate to reproduce the prolapse.) Images taken by the caretaker during an acute episode of prolapse aid in confirming the diagnosis.
The prolapsed rectum is a pouting, swollen rosette. In false or mucosal prolapse, the mucosa shows radial folds at the anal junction, whereas a full-thickness or complete prolapse has circular folds (see the images below). If the prolapse is present upon examination, feeling the prolapsed mucosa between fingers allows the examiner to distinguish between mucosal and full-thickness rectal prolapse.
A prolapsed rectal polyp appears as a plum-colored mass that does not involve the entire anal circumference.
Digital examination can also distinguish prolapse from rectal intussusception. In the case of prolapsed intussusception, a finger can be passed into the space between the anal wall and the protruding mass. With rectal prolapse, inserting a finger into this space is not possible.
Since the diagnosis of anal protrusions in children may be difficult because the protrusion often occurs only after defecation and is usually invisible during the consultation, the parents can aid in the diagnosis by sending the surgeon a digital picture of the condition.[30, 31, 32]
Complications of rectal prolapse include the following:
Incarceration - Entrapment of the prolapsed intestine making it irreducible; it may lead to strangulation of the prolapsed segment
Strangulation and gangrene - When the prolapse is not reduced in a timely fashion, the resulting edema further precludes its reduction; the impaired blood flow to the mucosa endangers the viability of the prolapsed segment, mandating emergency resection
Ulceration and hemorrhage - Trauma over the exposed mucosa produces ulceration, bleeding, and mucous discharge; this occurs in approximately 12% of patients; treatment involves correction of straining and defecation habits
Prolapse rupture - Excoriation of the mucosa can perforate the prolapsed intestine; urgent surgery is indicated
Incontinence - Observation for 6-12 months is appropriate because it is likely to resolve spontaneously
Cancer risk - No clear correlation between colorectal tumors and rectal prolapse has been established; however, a study in adults demonstrated a 4.2-fold increase in the relative risk for rectal cancer in patients with rectal prolapse 
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