eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Rectal Prolapse: Treatment & Medication

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

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.

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

May decrease PO medication absorption, thereby decreasing effectiveness

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

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.

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

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

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

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.

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

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

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

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

More on Rectal Prolapse

Overview: Rectal Prolapse
Differential Diagnoses & Workup: Rectal Prolapse
Treatment & Medication: Rectal Prolapse
Follow-up: Rectal Prolapse
References
[ CLOSE WINDOW ]

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].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

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

[ CLOSE WINDOW ]

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.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.