History
Rectal prolapse presents as a red ring of rectal mucosa protruding through the anus after straining (see the image below). It is often associated with tenesmus and mucus or bloodstained clothing. Constipation is present in 25-50% of individuals; up to 75% of patients have fecal incontinence.
Photograph of severe rectal prolapse with clinically significant edema and mucosal ulceration.
Sarmast et al reported prolapse of a mass (96%), bleeding after defecation (36.6%), diarrhea (23.9%), prolapsed rectum (14.1%), and constipation (6%) as the most common signs and symptoms in their cohort. [29]
Prolapse initially occurs with defecation and straining, but as the pelvic floor musculature becomes laxer, it can recur with the mildest straining, in upright position, or even spontaneously at rest. Most cases reduce spontaneously; however, the parents (or patient) may need to manually reduce the prolapsed bowel.
History of neonatal stooling problems or cases of cystic fibrosis in family members should be sought. The clinician should ask about excessive straining due to constipation or diarrhea (most common), prolonged toilet sitting with hips and knees flexed, and operative correction of imperforate anus. Inquire about history of the following:
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Surgical correction of anorectal malformation (ARM)
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Ehlers-Danlos Syndrome
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Hirschsprung disease
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Congenital megacolon
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Polyps
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Pneumonia
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Pertussis
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Malnutrition/anorexia
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Myelomeningocele
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Parasitic infection
Patients with rectal prolapse frequently have an associated dysfunction, either fecal incontinence (50%) or constipation (15-65%). Excessive pushing during defecation induces mucosal injury of the anterior rectal wall, which may lead to a solitary rectal ulcer [31] .
Rectal prolapse is not uncommon after the surgical correction of anorectal malformations (27%) [6] , being more frequent in patients with "high" ARM´s [32] . These authors also found that the severity of the malformation, muscle quality, associated vertebral or spinal anomaly, and postoperative constipation, were factors associated with the development of rectal prolapse [32] .
Physical Examination
Frequently, physical examination findings are normal. Parents provide a 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.
Because most prolapses spontaneously reduce before arrival for evaluation, a brief examination of the patient in a sitting or squatting position and observation for recurrence of prolapse is recommended. (Other positions, such as jackknife or left lateral decubitus are frequently inadequate to reproduce the prolapse). Images taken by the caretaker during an acute episode aid in confirming the diagnosis.
The prolapsed rectum is a pouting, swollen rosette. In false or mucosal (partial) prolapse, the mucosa shows radial folds at the anal junction, and it is usually quite small, whereas a full thickness or complete prolapse has circular folds (see the images below). If the prolapse is present upon examination, feeling the prolapsed mucosa between fingers allows the examiner to distinguish between mucosal and full thickness rectal prolapse.
Diagram depicting clinical difference between true (full-thickness) prolapse (left), including all layers of rectum, with circular mucosal folds, and mucosa-only prolapse (right), in which radial folds are seen.
A prolapsed rectal polyp appears as a plum-colored mass that does not involve the entire anal circumference. Digital examination can also distinguish prolapse from rectal intussusception. In the case of prolapsed intussusception, a finger can be passed into the space between the anal wall and the protruding mass. With rectal prolapse, inserting a finger into this space is not possible. The triad of abnormal perineal descent, enterocele, and recto-rectal intussusception which progresses to recto-anal intussusception before becoming a full thickness rectal prolapse, is not necessarily seen in all patients, but must always be considered prior to surgical intervention [31] .
Complications
Complications of rectal prolapse include:
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Incarceration: Entrapment of the prolapsed intestine making it irreducible; it may lead to strangulation of the prolapsed segment.
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Strangulation and gangrene: When the prolapse is not reduced in a timely fashion, the resulting edema further precludes its reduction; the impaired blood flow to the mucosa endangers the viability of the prolapsed segment, mandating emergency resection.
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Ulceration and hemorrhage: Trauma over the exposed mucosa produces ulceration, bleeding, and mucous discharge; occurs in about 12% of patients; treatment involves correction of straining and defecation habits.
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Prolapse rupture: Excoriation of the mucosa can perforate the prolapsed intestine; urgent surgery is indicated
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Incontinence: Observation for 6-12 months is appropriate because it is likely to resolve spontaneously.
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Cancer risk: No clear correlation between colorectal tumors and rectal prolapse has been established; however, a study in adults demonstrated a 4.2 fold increase in the relative risk for rectal cancer in patients with rectal prolapse [33]
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Image of young patient with full-thickness rectal prolapse with multiple circular folds seen on exposed mucosa.
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Photograph of severe rectal prolapse with clinically significant edema and mucosal ulceration.
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Picture of infant with full-thickness rectal prolapse. Severe edema and abundant mucus are seen on mucosal surface.
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Levator ani muscle is shown in red. It includes ileococcygeus (stretches during defecation and labor), pubococcygeus (maintains integrity of pelvic floor), and puborectalis muscles (closes the anorectal canal as a sling).
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Deep, superficial, and subcutaneous external sphincter.
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Anatomy of internal and external anal sphincter mechanisms.
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Image demonstrates mucosal prolapse, with radial folds seen on mucosa.
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Diagram depicting clinical difference between true (full-thickness) prolapse (left), including all layers of rectum, with circular mucosal folds, and mucosa-only prolapse (right), in which radial folds are seen.
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Thiersch procedure. Perianal subcutaneous sutures create mechanical barrier for prolapse.
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Lomas and Cooperman modified the Thiersch procedure by performing right anterior and left posterior radial incisions, encircling the anus with a Marlex mesh stripe, and tying it around a finger placed on the anal canal. Care must be taken to avoid perforating the posterior vaginal or anterior rectal walls. The skin is closed, and the mesh left subcutaneously.
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Ripstein procedure is designed to maintain normal posterior rectal curvature by attaching it to the presacral fascia, thus avoiding the straight tube that intussuscepts during straining. (A) Rectum is mobilized down to the coccyx. (B) Marlex mesh is placed around rectum while this is tensed upward and sutured to the presacral fascia with nonabsorbable sutures. 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.
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Intraoperative photograph of a 12-year-old girl with recurrent rectal prolapse and mucosal ulceration with profuse bleeding. She had a long sigmoid colon, which was resected; end-to-end anastomosis was performed. This photograph depicts anastomosed rectum fixed to presacral fascia with mesh. Non-absorbable sutures retain the mesh to the serosa. Note that the 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.
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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 the anterior sacral surface. A portion of the anterior rectal wall is left free to prevent luminal obliteration. (D) Peritoneum is closed with continuous absorbable suture.
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- Overview
- Presentation
- DDx
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- Treatment
- Approach Considerations
- Manual Reduction
- Conservative Management
- Indications for Surgical Treatment
- Selection of Surgical Approach
- Injection Sclerotherapy
- Open Abdominal and Perineal Surgical Procedures
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