eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Rectal Prolapse

Author: Joel A Friedlander, DO, MBe, Instructor, Department of Pediatrics, University of Pennsylvania School of Medicine; Fellow, Pediatric Gastroenterology, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia
Coauthor(s): Maria Rebello Mascarenhas, MBBS, Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Section Chief, Division of Gastroenterology and Nutrition, Director, Nutrition Support Service, Children's Hospital of Philadelphia; Leon M Garner, DO, MPH, Staff Physician, Department of Emergency Medicine, North Broward Medical Center; Frank Cunningham, Jr, MD, FAAP, FACEP, Director, Division of Emergency Pediatrics, Assistant Professor, Department of Pediatrics, University of Medicine and Dentistry of New Jersey
Contributor Information and Disclosures

Updated: Dec 1, 2008

Introduction

Background

Rectal prolapse is the protrusion of a few or all layers of the rectal mucous membrane through the anus. In the pediatric population, rectal prolapse is most commonly a self-limited and benign condition. Always consider rectal prolapse as a presenting sign of an underlying condition and not a discrete disease entity unto itself.

Pathophysiology

Rectal prolapse was more common 50 years ago than now, and this decreased occurrence is thought to be due to improved nutrition and hygiene in industrialized countries. Prolapse of the rectum may involve only the mucosa, which is the least serious form and is most common in the pediatric population, or it may involve all layers of the rectum protruding through the anus (procidentia).

Most cases of childhood prolapse occur in patients younger than 4 years, with the highest incidence in the first year of life. Anatomic considerations related to this early presentation include the vertical course of the rectum along the straight surface of the sacrum and coccyx, the relatively low position of the rectum in relation to other pelvic organs, the increased mobility of the sigmoid colon, the relative lack of support by the levator ani muscle, the loose attachment of the rectal mucosa to the underlying muscularis, and the absence of Houston valves in about 75% of infants.

Predisposing factors include increased intra-abdominal pressure due to straining (as often occurs in toilet training and constipation), diarrhea, parasitic and neoplastic disease, cystic fibrosis, malnutrition (loss of ischiorectal fat pad), ulcerative colitis, Hirschsprung disease, Ehlers-Danlos syndrome, meningomyelocele, pertussis, rectal polyp, and postsurgical repair of an anorectal malformation.

Although cystic fibrosis is not a likely diagnosis in patients who present with rectal prolapse, a sweat test is indicated in all patients who present without an underlying anatomic abnormality. Rectal prolapse occurs in 20% of patients with cystic fibrosis who are aged 6 months to 3 years.

Frequency

United States

Pediatric rectal prolapse is an uncommon entity in the United States and other industrialized countries.1

International

Pediatric rectal prolapse is more common in tropical and underdeveloped countries, where diarrhea and parasitic infection play much greater roles.

Mortality/Morbidity

Most prolapses spontaneously reduce. Failure to reduce may lead to venous stasis, edema, and possibly ulceration. Long-standing or frequent recurrent prolapse may lead to proctitis.

Race

No racial predilection is noted.

Sex

Incidence is evenly distributed between males and females in the pediatric population. This is in contrast to the adult population, in whom rectal prolapse is 6 times more common in women.

Age

In the pediatric population, rectal prolapse is most common in patients younger than 4 years. The highest incidence is in the first year of life.

Clinical

History

  • Excessive straining due to constipation or diarrhea (most common)
  • Prolonged sitting on a child's "potty," with hips and knees flexed
  • Operative correction of an imperforate anus
  • Known history of the following:
    • Cystic fibrosis
    • Ehlers-Danlos syndrome
    • Hirschsprung disease
    • Congenital megacolon
    • Polyps
    • Pneumonia
    • Pertussis
    • Malnutrition/anorexia
    • Meningomyelocele
    • Parasitic infection
    • Rectal neoplasm

Physical

Because most prolapses spontaneously reduce prior to arrival for evaluation, a brief examination of the patient in a squatting position and observation for recurrence of prolapse is recommended.

  • Most frequently, the patient presents with normal findings upon physical examination.
  • Parents often provide 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.
  • If a mass is found at the time of examination, differentiate it from a prolapsing rectal polyp, which appears plum-colored and does not involve the entire anal circumference.
  • Consider intussusception.
    • Findings upon a digital examination of the anus and rectum can differentiate prolapse of an intussusception from prolapse of the rectum. If an intussusception prolapses, a finger can be passed into a space between the anal wall and the mucosa of the protruding mass.
    • With prolapse, inserting a finger into this space is not possible.

Causes

  • Increased intra-abdominal pressure - Straining due to constipation, toilet training, protracted coughing (pertussis), excessive vomiting
  • Parasitic and neoplastic disease
  • Malnutrition
    • Worldwide, this is possibly the most common condition associated with pediatric rectal prolapse.
    • Loss of ischiorectal fat reduces perirectal support.
  • Cystic fibrosis
    • This accounts for about 11% of rectal prolapse cases in industrialized countries.
    • Sweat test is indicated in all cases unless an underlying anatomic variant can be found to explain the prolapse.
  • Ulcerative colitis
  • Ehlers-Danlos syndrome
  • Rectal neoplasm
  • Previously repaired anorectal anomaly

More on Rectal Prolapse

Overview: Rectal Prolapse
Differential Diagnoses & Workup: Rectal Prolapse
Treatment & Medication: Rectal Prolapse
Follow-up: Rectal Prolapse
References
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References

  1. Corman ML. Rectal prolapse in children. Dis Colon Rectum. Jul 1985;DA - 19850830(7):535-9. [Medline].

  2. Tou S, Brown SR, Malik AI, Nelson RL. Surgery for complete rectal prolapse in adults. Cochrane Database System Reviews [serial online]. 4:CD001758. [Medline]. Available at http://proxy.library.upenn.edu:2206/cochrane/clsysrev/articles/CD001758/frame.html.

  3. Antao B, Bradley V, Roberts JP, Shawis R. Management of rectal prolapse in children. Dis Colon Rectum. Aug 2005;48(8):1620-5. [Medline].

  4. El-Sibai O, Shafik A. Cauterization-plication operation in the treatment of complete rectal prolapse. Techniques in Coloproctology. 2002;6(1):51-54. [Medline].

  5. Behrman R, Kleigman R, Jenson H. Rectal prolapse. In: Nelson Textbook of Pediatrics. 16th ed. Philadelphia, Pa: WB Saunders and Co; 2000:1182.

  6. Chan WK, Kay SM, Laberge JM, et al. Injection sclerotherapy in the treatment of rectal prolapse in infants and children. J Pediatr Surg. Feb 1998;33(2):255-8. [Medline].

  7. Koivusalo A, Pakarinen M, Rintala R. Laparoscopic suture rectopexy in the treatment of persisting rectal prolapse in children: a preliminary report. Surg Endosc. Jun 2006;20(6):960-3. [Medline].

  8. Nwako F. Rectal Prolapse in Nigerian Children. Internattional Surgery. 1975;60(5):284-285. [Medline].

  9. Reyes H, Block G, Moossa A, eds. Rectal prolapse. In: Operative Colorectal Surgery. Philadelphia, PA: WB Saunders and Co; 1994:573-8.

  10. Rowe M. Rectal prolapse. In: Essentials of Pediatric Surgery. St. Louis, MO: Mosby-Year Book; 1995:600-1.

  11. Severijnen R, Festen C, van der Staak F, Rieu P. Rectal prolapse in children. Neth J Surg. Dec 1989;41(6):149-51. [Medline].

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

  13. Spiro H, Atterbury C. Rectal prolapse. In: Clinical Gastroenterology. 4th ed. New York, NY: McGraw-Hill Book Co; 1993:820-1.

  14. Steele SR, Goetz LH, Minami S, et al. Management of recurrent rectal prolapse: surgical approach influences outcome. Dis Colon Rectum. Apr 2006;49(4):440-5. [Medline].

  15. Walker W, Durie, PR, Hamilton JR, eds. Rectal prolapse. In: Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management. 2nd ed. St. Louis, MO: Mosby-Year Book; 1996:581-2.

  16. Zempsky WT, Rosenstein BJ. The cause of rectal prolapse in children. Am J Dis Child. Mar 1988;142(3):338-9. [Medline].

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Further Reading

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Keywords

rectal prolapse, rectum prolapse, rectal mucosa prolapse, procidentia of rectum, Hirschsprung disease, Ehlers-Danlos syndrome, excessive straining, cystic fibrosis, intussusception, manual reduction, abdominal rectopexy, Ekehorn rectopexy, diarrhea, meningomyelocele, pertussis, rectal polyp, congenital megacolon, pneumonia, whipworm

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Contributor Information and Disclosures

Author

Joel A Friedlander, DO, MBe, Instructor, Department of Pediatrics, University of Pennsylvania School of Medicine; Fellow, Pediatric Gastroenterology, Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Philadelphia
Joel A Friedlander, DO, MBe is a member of the following medical societies: American Academy of Pediatrics, American Association for the Study of Liver Diseases, American College of Osteopathic Pediatricians, American Gastroenterological Association, American Medical Association, American Osteopathic Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Coauthor(s)

Maria Rebello Mascarenhas, MBBS, Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Section Chief, Division of Gastroenterology and Nutrition, Director, Nutrition Support Service, Children's Hospital of Philadelphia
Maria Rebello Mascarenhas, MBBS is a member of the following medical societies: American Gastroenterological Association, American Society for Parenteral and Enteral Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Leon M Garner, DO, MPH, Staff Physician, Department of Emergency Medicine, North Broward Medical Center
Leon M Garner, DO, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American College of Osteopathic Emergency Physicians
Disclosure: Nothing to disclose.

Frank Cunningham, Jr, MD, FAAP, FACEP, Director, Division of Emergency Pediatrics, Assistant Professor, Department of Pediatrics, University of Medicine and Dentistry of New Jersey
Frank Cunningham, Jr, MD, FAAP, FACEP is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Medical Editor

Robert Baldassano, MD, Director, Center for Pediatric Inflammatory Bowel Disease, Division of Gastroenterology and Nutrition, Associate Professor, Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania
Robert Baldassano, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

B U K Li, MD, Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin
B U K Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, State University of New York, Downstate Medical Center College of Medicine; Distinguished Lecturer, New York Medical College, School of Public Health
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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