eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Rectal Prolapse

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
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

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
  • Trichuriasis (whipworm)
  • Polyps
• 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

Differential Diagnoses

Other Problems to Be Considered

Rectal polyp
Postsurgical repair of anorectal anomaly
Meningomyelocele

Workup

Laboratory Studies

• Sweat chloride test
  • The estimated incidence of rectal prolapse in patients with cystic fibrosis ranges from 11-23%.
  • Cystic fibrosis should be ruled out in patients who present with rectal prolapse, even if no other signs of the disease are present.
• Stool for ova and parasites, culture: Rectal prolapse has been associated with Escherichia coli 0157:H7; antibiotic-associated colitis; Entamoeba histolytica; and Giardia, Salmonella, Shigella, and Trichuris species.
• Other: Consider workup for other associated illnesses in the appropriate setting as clinically indicated.

Other Tests

• Patients who experience recurrent rectal prolapse with no diagnosed underlying causes should undergo proctosigmoidoscopy to rule out rectal polyps.

Treatment

Medical Care

• Patients who present with a prolapsed rectum should undergo manual reduction. Parents should be provided with gloves and lubricant and taught how to reduce the prolapse. However, prolapses often spontaneously reduce without reduction techniques.
  • The prolapsed bowel may be grasped with lubricated gloved fingers and pushed back in with gentle steady pressure.
  • If the bowel has become edematous, firm steady pressure for several minutes may be necessary to reduce the swelling and allow for reduction.
  • Digital rectal examination should always follow this procedure to verify complete reduction.
  • If the prolapse immediately recurs, it may be reduced again and the buttocks taped together for several hours.
• The more difficult cases of reduction and the recurrent cases of prolapse are less likely to respond to conservative management. If possible, the underlying cause of the prolapse must be treated. Treating the underlying cause allows conservative management to be successful.
  • Conservative management is started in children younger than 4 years and in children older than 4 years who have noncomplicated, nonrecurrent rectal prolapse. This management is aimed at treating the cause and reducing straining. It often works well in children younger than 4 years and prevents recurrence. In children older than 4 years, conservative management should be attempted for 1 year before surgical management is chosen.
  • Constipation should be treated with dietary modification (total dose per day is 5 g of fiber plus an additional gram for each year of age; dose for adults is 20 g once or twice daily) and stool softeners (eg, polyethylene glycol) to reduce straining.
  • Infectious diarrhea or parasitic infestation should be appropriately treated.
  • A change in bowel habits, such as switching from a "potty" chair to an adult commode or vice versa, may help prevent recurrence.

Surgical Care

Currently, more than 130 operative procedures for the treatment of rectal prolapse and the prevention of its recurrence are recognized. In 2008, a Cochrane Database Review of the small studies available in the adult literature found that all reparative procedures have similar clinical outcomes with various degrees of risk.²  Listed below is information on a few of the most commonly used procedures. These aggressive repairs are usually reserved for failed conservative management in children younger than 4 years who have tried nonsurgical management for longer than 1 year. They are also used in cases of complicated rectal prolapse. These include recurrent rectal prolapse that requires manual reduction, painful prolapse, ulceration, and rectal bleeding. The procedures work better in children younger than 4 years but include the possible complications of surgery.³

• Circumferential injection procedures (90-100% success rate): Injection procedures use either phenol in oil, isotonic sodium chloride, D50, or ethyl alcohol as a sclerosant to promote adhesion formation, which stabilizes the rectum. Possible complications include injury to nerves, injury to surrounding tissue, and possible injury from sclerosing agents that may be carcinogenic.
• Thiersch operation (90% success rate): Known as a sling procedure, this operation uses synthetic materials to surgically create a perianal sling to support the rectum.
• Lockhart-Mummery operation (approximately 100% success rate): Mesh gauze packing is placed temporarily in the retrorectal space (8-10 d) to promote adhesions that stabilize the rectum.
• Cauterization treatment (approximately 80% success rate):⁴ In this procedure, the prolapsed rectum is cauterized in a linear fashion extending to the submucosa in 4 quadrants. This produces perirectal inflammation and scarring that prevents prolapse.
• Abdominal rectopexy (75% success rate): Endoscopic or open approach is possible. The perirectal tissues are attached to the presacral area to assure correct anatomical positioning and tissue adherence.
• Ekehorn rectopexy (100% success rate): A suture is placed in the rectal ampulla through the lowest part of the sacrum to induce inflammation and adhesions. This induces adhesions between the rectal wall and perirectal wall to effectively perform a sacrorectopexy.

Consultations

• Surgical consultation is recommended in patients who meet any of the following criteria:
  • Recurrent prolapse with mucosal ulceration
  • Failure to reduce the prolapse despite adequate sedation
  • Recurrent rectal prolapse associated with severe pain and discomfort despite intensive medical treatment
  • Failure of conservative management
  • Full-thickness rectal prolapse in patients with meningomyelocele, exstrophy of the bladder, and postsurgical changes following pull-through operations for imperforate anus and Hirschsprung disease

Diet

• Adequate fluid intake to maintain soft stool

Medication

Stool softeners

In addition to dietary modification, stool softeners help to decrease bowel movement straining secondary to constipation.

Polyethylene glycol solution (Miralax)

Osmotic stool softener. For treatment of occasional constipation. In theory, less risk of dehydration or electrolyte imbalance with isotonic polyethylene glycol compared with hypertonic sugar solutions. Laxative effect generated because polyethylene glycol is not absorbed and continues to hold water by osmotic action through small bowel and colon, resulting in mechanical cleansing.
Supplied with measuring cap marked to contain 17 g of laxative powder when filled to indicated line. May require 2-4 d (48-96 h) to produce bowel movement.

Dosing

Adult

17 g dissolved in 8 oz of water PO qd prn for up to 2 wk

Pediatric

10-20 kg: 8.5 g (1/2 capful) dissolved in 4 oz of a clear liquid PO qd for up to 2 wk
>20 kg: Administer as in adults

Interactions

May decrease PO medication absorption, thereby decreasing effectiveness

Contraindications

Documented hypersensitivity; colitis; ileus; megacolon; bowel perforation; gastric retention; GI obstruction

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in ulcerative colitis, electrolyte abnormalities, or hot loop polypectomy; do not use >2 wk

Mineral oil

Lubricates intestine and facilitates passage of stool by decreasing water absorption from intestine.

Dosing

Adult

15-45 mL/d PO qd once or in divided doses

Pediatric

<2 years: Contraindicated because of risk of lipoid pneumonia
2-4 years: 0.5-1 tablespoonful (7.5-15 mL) PO qd initially
>4 years: 1 tablespoonful (15 mL) PO bid
May gradually titrate upward until soft stool is passed without straining

Interactions

Decreases effect of docusate sodium and may decrease absorption of warfarin, PO contraceptives, anticonvulsants, and fat-soluble vitamins

Contraindications

Documented hypersensitivity; severe gastroesophageal reflux; vomiting; aspiration pneumonias; choking episodes; young children (ie, <1-2 y) due to the risk of lipoid pneumonia

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Prolonged administration may produce a deficiency of fat-soluble vitamins; do not administer with food or meals because it may cause aspiration leading to lipid pneumonitis

Lactulose (Cephulac, Cholac, Constulose)

Osmotic agent and ammonium detoxicant. Produces osmotic effect in colon that results in distention and promotes peristalsis.

Dosing

Adult

15-30 mL/d PO; may increase to 60 mL/d prn

Pediatric

1-3 years: Data limited; 1-1.5 teaspoonfuls (5-7.5 mL) PO qd initially
>3 years: 3 teaspoonfuls (15 mL) PO qd initially
May gradually titrate upward until soft stool is passed without straining

Interactions

Decreases effects of neomycin, laxatives, and antacids; coadministration with coumarin derivative related to warfarin (eg, phenprocoumon, acenocoumarol) increases anticoagulation effect

Contraindications

Documented hypersensitivity; galactosemia and patients who require a galactose-free diet; allergy to milk protein (contains trace amounts of lactose)

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in diabetes mellitus and monitor for electrolyte imbalance

Follow-up

Further Inpatient Care

• Inpatient management of rectal prolapse is usually reserved for patients in whom surgical therapy is necessary.

Further Outpatient Care

• All pediatric rectal prolapses should be approached as possible symptoms of another underlying disease process or disorder.
  • Evaluate the child for cystic fibrosis.
  • Evaluate whether or not the child has exhibited signs of constipation or diarrhea.
  • If sweat test results are negative and bowel regimen has been normal, consider proctosigmoidoscopy to rule out rectal polyps or lesions.

Complications

• Ulceration of mucosa
• Frequent recurrence despite surgical correction
• Complications of surgical repair procedures such as nerve damage, infection, or incontinence

Prognosis

• Approximately 10% of patients who experience rectal prolapse as children continue to experience it in their adult lives.
• Approximately 90% of children aged 9 months to 3 years who experience rectal prolapse respond to conservative management by age 6 years.
• Spontaneous resolution is much less likely in children who first experience prolapse when they are older than 4 years.

Patient Education

• Instruct parents how to manually reduce a prolapse and to seek immediate help from a health care provider if reduction fails.
• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article Rectal Prolapse.

Miscellaneous

Medicolegal Pitfalls

• Rectal prolapse must be differentiated from prolapse of an intussusception or rectal polyp.
• Pediatric patients with rectal prolapse must be evaluated to rule out cystic fibrosis.

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. 16^th 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. 4^th 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. 2^nd 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].

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

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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