History
Patients with rectal prolapse report a mass protruding through the anus (see the image below). Initially, the mass protrudes from the anus only after a bowel movement and usually retracts when the patient stands up. As the disease process progresses, the mass protrudes more often, especially with straining and Valsalva maneuvers such as sneezing or coughing. Finally, the rectum prolapses with daily activities such as walking and may progress to continual prolapse.
As the disease progresses, the rectum no longer spontaneously retracts, and patients may have to replace it manually. This condition may then progress to a point where the rectum prolapses immediately after being replaced and is continuously prolapsed. Rarely, the rectum becomes incarcerated, and patients cannot replace the rectum.
Pain is variable. Some 10-25% of patients also have uterine or bladder prolapse, and 35% may have an associated cystocele. Constipation occurs in 15-65% of cases. There may also be rectal bleeding.
In addition to a protruding mass from the anus, patients often report fecal incontinence (28-88%). Incontinence occurs for two reasons. First, the anus is dilated and stretched by the protruding rectum, disrupting the function of the anal sphincter. Second, the mucosa of the rectum is in contact with the environment and constantly secretes mucus, thus making the patient appear to be chronically wet and incontinent.
A detailed history to evaluate incontinence, constipation, or both is important because it plays a role in determining the appropriate surgical procedure.
Patients with mucosal prolapse have similar problems but not to the same degree. Patients with internal intussusception often report difficulty with defecation and a sensation of incomplete evacuation.
Physical Examination
Physical signs of rectal prolapse include the following:
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Protruding rectal mucosa
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Thick concentric mucosal ring
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Sulcus noted between anal canal and rectum
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Solitary rectal ulcer (10-25%)
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Decreased anal sphincter tone
Rectal prolapse is a clinical diagnosis that physicians should be able to confirm in the office. The patient is asked to sit on a toilet and strain, after which the rectum should prolapse. If it does not prolapse with just straining, the administration of a phosphate enema usually produces the prolapse. In a small child, a glycerin suppository can be used instead.
The protruding mass should show concentric rings of mucosa. In cases of small prolapse, it is sometimes difficult to distinguish between mucosal and full-thickness rectal prolapse. Mucosal prolapse typically exhibits radial folds instead of concentric rings. If these cannot be clinically distinguished, a defecogram (see Workup) may be of help in differentiating these two conditions. A defecogram is unnecessary in the presence of an obvious rectal prolapse.
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Rectal prolapse.
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Full-thickness rectal prolapse.
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Marlex rectopexy for rectal prolapse.
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Delorme mucosal sleeve resection for rectal prolapse.
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Altemeier perineal rectosigmoidectomy for rectal prolapse.
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Perineal rectosigmoidectomy for rectal prolapse. Procedure performed by Tracy Arnell, MD, ColumbiaDoctors, New York, NY. Video courtesy of ColumbiaDoctors (https://www.columbiadoctors.org).
