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Pediatric Rectal Prolapse Workup

  • Author: Jaime Shalkow, MD, FACS; Chief Editor: Carmen Cuffari, MD  more...
Updated: Oct 06, 2015

Approach Considerations

The primary care physician should initially approach rectal prolapse as a symptom rather than a specific disease entity and should always search for an underlying disorder. Anatomic causes such as Hirschsprung disease and history of imperforate anus repair should be sought. Inquire about a history of constipation, diarrhea, parasitic infections, polyps, or anal stenosis.

Cystic fibrosis is an important cause of rectal prolapse in children. Clinical clues to cystic fibrosis include oily, malodorous, or floating stools; poor growth; wheezing or other respiratory symptoms; and digital clubbing. The absence of respiratory symptoms and normal findings upon physical examination do not exclude this possibility. Results of sweat chloride testing and genetic testing confirm the diagnosis.

High-resolution ultrasonography and magnetic resonance imaging (MRI) provide excellent depiction of the pelvic anatomy and are helpful to illustrate functional changes. Barium enema, proctosigmoidoscopy, video defecography, anal manometry, electromyography, and anal endosonography may also be useful.


Laboratory Tests

Sweat chloride test

Since the potentially disastrous consequences of missing the diagnosis of cystic fibrosis, and because of the improved prognosis associated with early diagnosis and institution of treatment, the sweat chloride test is indicated in all patients who present with rectal prolapse without an underlying anatomic abnormality.

The incidence of rectal prolapse in patients with cystic fibrosis ranges from 11-23% (20% in patients with cystic fibrosis aged 6 months to 3 years).

Stool evaluation for ova and parasites

Rectal prolapse has been associated with Escherichia coli 0157:H7 infection; antibiotic-associated colitis; Entamoeba histolytica infection; and Giardia, Salmonella, Shigella, and Trichuris infection. Consider a workup for other associated illnesses in the appropriate setting as clinically indicated.


Magnetic Resonance Imaging

MRI can be used both for a multicompartmental dynamic assessment of the pelvic floor—referred to as dynamic MRI defecography—and for the anatomic analysis of the internal anal sphincter (IAS) and external anal sphincter (EAS)—referred to as static MRI.[35]


Barium Enema

Sigmoid intussusception rarely presents as rectal prolapse in pediatric patients. In 1990, Ashcraft et al highlighted the importance of preoperative diagnosis for prevention of inappropriate initial treatment and postoperative recurrence.[36] In their series of 46 patients, 2 children required subsequent sigmoid resection. Preoperative barium enema with a defecating view revealed a coiled-spring appearance typical of sigmoid intussusception.

A contrast enema study may be adequate to search for polyps or other leading points.


Video Defecography

Video defecography (ie, videofluoroscopy of the barium-filled rectum during defecation) can be used to identify rectal prolapse or intussusception or to disclose significant pathology (enterocele, rectocele, sigmoid intussusception) and thereby guide surgical treatment.[37, 38, 39] It is considered unnecessary for full-thickness rectal prolapse.[40]



Endoscopic evaluation is useful to rule out rectal polyps in patients with recurring rectal prolapse or history of rectal bleeding. It allows for tissue samples and identifies a leading point in the case of intussusception.


Other Tests

Anal manometry

The clinical and cost benefits of routine preoperative anal manometry, pudendal nerve motor latency, colonic transit, and defecography are unclear. Anal manometry shows low resting pressure; patients with coexisting fecal incontinence also have low squeezing pressures. However, after surgery, the resting pressure or sphincter length may not change or improve. Squeeze pressure may improve.[40]


Electromyography has provided insights into the pathogenesis of fecal incontinence; however, it has no place in the clinical workup for this entity, and hardly any research has been done so far. Abnormalities can be found in patients with a rectal prolapse, but these results do not predict continence after rectopexy.[40]

Anal endosonography

Anal endosonography may show asymmetry and thickening of the internal anal sphincter and submucosa. Demonstration of a sphincter defect might be useful if a sphincter reconstruction is being considered.[40]

Contributor Information and Disclosures

Jaime Shalkow, MD, FACS Director, National Pediatric Cancer Program, National Center for Pediatric and Adolescent Health (CeNSIA); Attending Pediatric Surgical Oncologist, Cancer Center at the American British Cowdray Medical Center

Jaime Shalkow, MD, FACS is a member of the following medical societies: American College of Surgeons, International Society of Paediatric Surgical Oncology, Pacific Association of Pediatric Surgery, Mexican Association of Pediatric Surgery, Mexican Society of Oncology, Mexican Association of Pediatrics

Disclosure: Nothing to disclose.


Brian F Gilchrist, MD Surgeon-in-Chief of Pediatric Surgery, The Floating Hospital for Children at Tufts-New England Medical Center; Associate Professor, Department of Surgery, Tufts University School of Medicine

Brian F Gilchrist, MD is a member of the following medical societies: American College of Surgeons, American Pediatric Surgical Association, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Jose Ignacio Guzman, MD Medical Staff, Medical and Surgical Patient Care, General Hospital of Mexico; Medical Staff, Pediatric Surgical Oncology, National Institute of Pediatrics, Mexico

Disclosure: Nothing to disclose.

Joyce Vazquez-Braverman, MD Instructor of ACLS, BLS, and Heartsavers, American Heart Assocation

Joyce Vazquez-Braverman, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

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, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.


Robert Baldassano, MD Director, Center for Pediatric Inflammatory Bowel Disease, Children's Hospital of Philadelphia; Professor, Department of Pediatrics, Division of Gastroenterology and Nutrition, University of Pennsylvania School of Medicine

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.

Deborah F Billmire, MD Associate Professor, Department of Surgery, Indiana University Medical Center

Deborah F Billmire, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Phi Beta Kappa, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Rebeccah Brown, MD Associate Director of Trauma Services, Associate Professor, Department of Clinical Surgery and Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati Hospital

Rebeccah Brown, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, and American Medical Women's Association

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.

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.

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.

Harsh Grewal, MD, FACS, FAAP Professor of Surgery and Pediatrics, Temple University School of Medicine; Chief, Section of Pediatric Surgery, Temple University School of Medicine

Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, and SouthwesternSurgical Congress

Disclosure: Nothing to disclose.

Marc S Lessin, MD Consulting Surgeon, Children's Surgical Associates, PC

Marc S Lessin, MD is a member of the following medical societies: American College of Surgeons and American Pediatric Surgical Association

Disclosure: Nothing to disclose.

B UK 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 UK 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.

Maria Rebello Mascarenhas, MBBS Associate Professor of Pediatrics, University of Pennsylvania School of Medicine; Section Chief of Nutrition, 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.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Image of young patient with full-thickness rectal prolapse with multiple circular folds seen on exposed mucosa.
Photograph of severe rectal prolapse with clinically significant edema and mucosal ulceration.
Picture of infant with full-thickness rectal prolapse. Severe edema and abundant mucus are seen on mucosal surface.
Levator ani muscle is shown in red. It includes ileococcygeus (stretches during defecation and labor), pubococcygeus (maintains integrity of pelvic floor), and puborectalis (closes anorectal canal as sling) muscles.
Deep, superficial, and subcutaneous external sphincter.
Anatomy of internal and external anal sphincter mechanisms.
Image demonstrates mucosal prolapse, with radial folds seen on mucosa.
Diagram depicting clinical difference between true (full-thickness) prolapse (left), including all layers of rectum and with circular folds seen on prolapsed intestine, and procidentia, or mucosa-only prolapse (right), in which radial folds are seen in mucosa.
Thiersch procedure. Perianal subcutaneous sutures create mechanical barrier for prolapse.
Lomas and Cooperman modified Thiersch procedure by performing right anterior and left posterior radial incisions, encircling anus with Marlex mesh stripe, and tying it around finger placed on anal canal. Care must be taken to avoid perforating posterior vaginal wall or anterior rectal wall. Skin is closed, with mesh left subcutaneously.
Ripstein procedure is designed to maintain normal posterior rectal curvature by attaching it to presacral fascia, thus avoiding straight tube that intussuscepts during straining. (A) Rectum is mobilized down to coccyx. (B) Marlex mesh is placed around rectum while this is tensed upward and sutured to presacral fascia with nonabsorbable material. Mesh loop must be loose enough to prevent postoperative constipation. (C) Sagittal view shows suspended rectum. (D) Peritoneum is closed with a continuous absorbable suture.
Intraoperative photograph of 12-year-old girl with recurrent rectal prolapse and mucosal ulceration with profuse bleeding. She had long sigmoid colon, which was resected; end-to-end anastomosis was performed. This photograph depicts anastomosed rectum fixed to presacral fascia with mesh. Nonabsorbable sutures retain mesh to serosa. Note that mesh is slightly loose to allow for child's growth. Uterus and its ligaments can be seen in front of rectum. Iliac vessels remain intact on each side.
Ivalon sponge procedure. (A) Rectum is mobilized. Meticulous hemostasis is mandatory to prevent hematoma that predisposes patient to prosthetic material infection. (B) Ivalon rectangular sponge made of polyvinyl alcohol is sutured to sacral periosteum. (C) Rectum is retracted upward, and sponge is wrapped around it and tied to anterior surface. Portion of anterior rectal wall is left free to prevent luminal obliteration. (D) Peritoneum is closed with continuous absorbable suture.
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