Diagnostic Considerations

Other differential diagnoses include the following:

Prolapsing rectal polyp: Appears with defecation and reduces spontaneously; the lesion does not involve the entire circumference; patients with recurring rectal prolapse with no apparent cause or history of rectal bleeding should undergo proctosigmoidoscopy to rule out polyps.

Ileocecal intussusception: Differential diagnosis should be clear based on history and physical examination findings. Patients with intussusception are often much more ill appearing on presentation and complain of severe abdominal pain.

Submucosal venous congestion secondary to straining: May manifest as an intermittently appearing anal lesion and might be confused with rectal prolapse.
Hemorrhoids: Seldom seen in pediatric patients except in the setting of portal hypertension
Rectal tumors – Uncommon in children.

Other rare sequelae of rectal prolapse include solitary rectal ulcer syndrome ^[31] and inflammatory cloacogenic polyp. Both are due to ischemia and quite rare in children. In patients with history of significant bleeding, endoscopy should be considered to identify the source^[34].

Workup

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Media Gallery

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 muscles (closes the anorectal canal as a sling).
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, with circular mucosal folds, and mucosa-only prolapse (right), in which radial folds are seen.
Thiersch procedure. Perianal subcutaneous sutures create mechanical barrier for prolapse.
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.
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.
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.
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.

of 13

Author

Jaime Shalkow, MD, FACS Pediatric Surgical Oncologist, ABC Cancer Center; Associated Researcher, Anahuac University, Mexico

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

Disclosure: Nothing to disclose.

Coauthor(s)

Pablo Magaña Mainero, MD General and Laparoscopic Surgeon, ABC Medical Center; Assistant Director, General Hospital of Mexico “Dr Eduardo Liceaga”, Mexico

Pablo Magaña Mainero, MD is a member of the following medical societies: American College of Surgeons, Mexican Association for Endoscopic Surgery, Mexican Association of General Surgery, Mexican Hepato Pancreato Biliary Association

Disclosure: Nothing to disclose.

Andrés Olivares Ronces, MD Assistant Surgeon, Centro Médico ABC Campus Observatorio, Mexico

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. for: Abbott Nutritional, Abbvie, speakers' bureau.

Additional Contributors

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.

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.

Issac Octavio Vargas Olmos Universidad Anahuac, Mexico

Disclosure: Nothing to disclose.

Shahida Bibi, MD Resident Physician, Department of Surgery, Bronx-Lebanon Hospital Center

Disclosure: Nothing to disclose.

Acknowledgements

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