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Rectal prolapse is the protrusion of either the rectal mucosa or the entire wall of the

rectum. Partial prolapse involves only the mucosa and usually only protrudes by a
few centimetres. Complete prolapse involves all layers of the rectal wall.

Prolapses of the rectum occur either with bowel movements or independently.


In the elderly, rectal prolapse initially only occurs with defecation and then
retracts spontaneously.

More advanced rectal prolapses may occur when standing and so greatly
interfere with the patient's quality of life.

Epidemiology

Uncommon but the true incidence is unknown because of under-reporting,


especially in the elderly population.

It is most common in the elderly but can occur in all ages, including children.
[1]

Complete prolapse in adults is most common in elderly females. [2]

In children, rectal prolapse occurs most often in patients between 1 and 3


years of age.[3]

Risk factors

Increased intra-abdominal pressure - eg, constipation, diarrhoea, benign


prostatic hypertrophy, pregnancy, severe or chronic cough (eg, chronic
obstructive pulmonary disease, cystic fibrosis, whooping cough). [4]

Previous surgery.[5]

Pelvic floor dysfunction.[6]

Parasitic infections - eg, amoebiasis, schistosomiasis.[7]

Neurological disease - eg, previous lower back or pelvic trauma, lumbar disc
disease, cauda equina syndrome, spinal tumours, multiple sclerosis. [5]

Psychiatric disease.[8]

In children, rectal prolapse may be associated with cystic fibrosis, Ehlers-Danlos


syndrome, Hirschsprung's disease, congenital megacolon, malnutrition and rectal
polyps.
Presentation

Mass protruding through the anus:

Initially only after a bowel movement and usually retracts when the
patient stands up.

Later the mass protrudes more often, especially with straining and
Valsalva manoeuvres such as sneezing or coughing.

Finally, the rectum prolapses with daily activities such as walking and
may progress to continual prolapse.

Patients may have to replace it manually.


Pain, constipation, faecal incontinence, discharge of mucus or rectal bleeding

may occur.

If seen on examination, the protruding mass should show concentric rings of


mucosa, which are classic signs of rectal prolapse.

Examination may also reveal a rectal ulcer and decreased anal sphincter
tone.

Differential diagnosis

Rectal prolapse must be differentiated from prolapse of an intussusception or


a rectal polyp.

Rectal prolapse can usually be differentiated from a haemorrhoid by the


presence of symmetrical circumferential folds occurring with a rectal prolapse.

Investigations

Barium enema and/or colonoscopy: To evaluate the entire colon prior to


surgery for rectal prolapse to exclude any other colonic lesions.

Other investigations to assess underlying conditions include stool microscopy


and cultures for gastrointestinal infection and sweat test for cystic fibrosis.

Anal physiology tests are sometimes used to distinguish between mucosal


and full-thickness prolapse and may be useful in patients about to undergo
surgery. They include defecography, anal manometry, continence tests,
electromyography of the anal sphincter and the pelvic floor and nerve
stimulation tests.[9]

Rigid proctosigmoidoscopy should be performed to assess the rectum for


additional lesions, especially solitary rectal ulcers. These ulcers are present in
about 10-25% of patients with either internal or full-thickness prolapse. [10]

Associated diseases

Affected adult women may also have uterine or bladder prolapse, or an


associated cystocele.

Management

Rectal prolapse can usually be reduced with gentle digital pressure. Sedation
and local perianal anaesthesia may help the reduction.

Contributing factors should be treated - eg, constipation or diarrhoea.

Prompt surgical referral is recommended for an irreducible prolapse and for


strangulation or gangrene of the prolapsed tissue. [11]

Partial prolapse often responds to conservative measures but occasionally


requires excision of prolapsed mucosa.

Conservative treatment

Children: gently replace using water-soluble lubricant. Advise parents on the


need for a high-fibre diet and inadvisability of straining on stool. A mild laxative
may be required. Very occasionally a submucosal injection of a sclerosant is
also indicated.

Elderly: often well tolerated and concealed with the patient manually reducing
the prolapse. In those unfit for surgery, a subcutaneous circumanal rubber ring
may be fitted. However, this often fails either because it is too tight or too loose,
resulting in constipation or recurrent prolapse.

Surgical treatment

Emergency rectosigmoidectomy is required if the prolapsed tissue is


incarcerated and non-viable.[11]

Mucosal prolapse is treated with a haemorrhoidectomy. Stapled


haemorrhoidopexy offers an alternative to conventional surgery.[12]

Abdominal procedures:[8]

Abdominal procedures are preferred for all patients fit for abdominal
surgery.

Abdominal procedures include anterior resection (not often performed),


Marlex rectopexy (Ripstein procedure), suture rectopexy and resection
rectopexy (Frykman-Goldberg procedure). [13]

In suture fixation rectopexy and resection rectopexy, the rectum is


mobilised and the mesorectum sutured to the sacral promontory and the
presacral fascia. In resection rectopexy, a sigmoid colectomy is also
performed.[13]

Perineal procedures:[13]

Perineal procedures have a higher recurrence rate but a lower


morbidity rate and are often performed in the elderly or in patients who have
a contra-indication to general anaesthetic.

Perineal procedures include anal encirclement (Thiersch's wiring


procedure), Delorme's mucosal sleeve resection and Altemeier's perineal
rectosigmoidectomy.

The most common procedure is Delorme's operation.[8] Altemeier's


procedure is an alternative perineal procedure advocated by some
surgeons particularly for the elderly due to its low incidence of recurrence
and continence complications.[14]

Laparoscopic repair is currently under study but laparoscopic surgical


rectopexy procedures have shown outcomes as good as for open procedures.
[15]

A combined laparoscopic-perineal procedure has been developed. [16]

Surgical treatment for children[17][18]

Surgical intervention is usually reserved for failed conservative management


in children younger than 4 years who have tried non-surgical management for
longer than one year.[19]

Surgery may also be used in cases of complicated rectal prolapse - eg,


recurrent rectal prolapse that requires manual reduction, painful prolapse,
ulceration and rectal bleeding.

There are many different operations used, including:

Circumferential injection procedures: injection procedures use a


sclerosant to promote adhesion formation, which stabilises the rectum.

Thiersch's operation: synthetic materials are used to create a perianal


sling to support the rectum.

Lockhart-Mummery's operation: mesh gauze packing is placed


temporarily in the retrorectal space to promote adhesions that stabilise the
rectum.

Cauterisation treatment: the prolapsed rectum is cauterised to produce


inflammation and scarring that prevents prolapse.

Abdominal rectopexy: endoscopic or open approach. The perirectal


tissues are attached to the presacral area to assure correct anatomical
positioning and tissue adherence.

Ekehorn's rectopexy: a suture is placed in the rectal ampulla through


the lowest part of the sacrum to induce inflammation and adhesions
between the rectal wall and perirectal wall.

One study reported that the use of laparoscopy in the management of


complete rectal prolapse (using sutures, mesh, resection or levatorplasty) is
safe, effective and associated with improved functional outcome. [20]

Complications

Mucosal ulceration.[21]

Necrosis of rectal wall.[4]

The most common postoperative complications are bleeding and dehiscence


at the anastomosis.[5]

Postoperative recurrence rate can be as high as 20%, regardless of operative


procedure.[5]

Prognosis

The prognosis for elderly patients presenting with rectal prolapse is variable
and depends on the nature of any underlying or associated problems and the
age and general well-being of the patient.

Spontaneous resolution usually occurs in children but approximately 10% of


children who experience rectal prolapse continue to experience it in their adult
lives.[22]

Of the children with rectal prolapse who are aged 9 months to 3 years, 90%
will need only conservative treatment. For children who first experience prolapse
when older than 4 years, a much lower rate of spontaneous resolution occurs.
[18]

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Further reading & references

Lee JL, Yang SS, Park IJ, et al; Comparison of abdominal and perineal
procedures for complete rectal prolapse: an analysis of 104 patients. Ann Surg
Treat Res. 2014 May;86(5):249-55. doi: 10.4174/astr.2014.86.5.249. Epub 2014
Apr 24.

Heidary B, Phang TP, Raval MJ, et al; Transanal endoscopic microsurgery: a


review. Can J Surg. 2014 Apr;57(2):127-38.

1.

Fox A, Tietze PH, Ramakrishnan K; Anorectal conditions: rectal prolapse. FP


Essent. 2014 Apr;419:28-34.

2.

Kairaluoma MV, Kellokumpu IH; Epidemiologic aspects of complete rectal


prolapse. Scand J Surg. 2005;94(3):207-10.

3.

Puri B; Rectal prolapse in children: Laparoscopic suture rectopexy is a


suitable alternative. J Indian Assoc Pediatr Surg. 2010 Apr;15(2):47-9. doi:
10.4103/0971-9261.70634.

4.

Goldstein SD, Maxwell PJ 4th; Rectal prolapse. Clin Colon Rectal Surg. 2011
Mar;24(1):39-45. doi: 10.1055/s-0031-1272822.

5.

Hammond K, Beck DE, Margolin DA, et al; Rectal prolapse: a 10-year


experience. Ochsner J. 2007 Spring;7(1):24-32.

6.

O'Brien DP 4th; Rectal prolapse. Clin Colon Rectal Surg. 2007


May;20(2):125-32. doi: 10.1055/s-2007-977491.

7.

AlGhamdi HM, Parashar SA, Kawaja S, et al; Rectal prolapse associated with
extensive anorectal condyloma acuminata. Saudi J Gastroenterol. 2009
Jan;15(1):62. doi: 10.4103/1319-3767.45064.

8.

Makineni H, Thejeswi P, Rai BK; Evaluation of Clinical Outcomes after


Abdominal Rectopexy and Delorme's Procedure for Rectal Prolapse: A
Prospective Study. J Clin Diagn Res. 2014 May;8(5):NC04-7. doi:
10.7860/JCDR/2014/7787.4353. Epub 2014 May 15.

9.

Cho HM; Anorectal physiology: test and clinical application. J Korean Soc
Coloproctol. 2010 Oct;26(5):311-5. doi: 10.3393/jksc.2010.26.5.311. Epub 2010
Oct 31.

10.

Kim D; Prolapse and Intussusception, American Society of Colon and Rectal


Surgeons 2014.

11.

Voulimeneas I, Antonopoulos C, Alifierakis E, et al; Perineal


rectosigmoidectomy for gangrenous rectal prolapse. World J Gastroenterol.
2010 Jun 7;16(21):2689-91.

12.

Tjandra JJ, Chan MK; Systematic review on the procedure for prolapse and
hemorrhoids (stapled hemorrhoidopexy). Dis Colon Rectum. 2007
Jun;50(6):878-92.

13.

Shin EJ; Surgical treatment of rectal prolapse. J Korean Soc Coloproctol.


2011 Feb;27(1):5-12. doi: 10.3393/jksc.2011.27.1.5. Epub 2011 Feb 28.

14.

Ris F, Colin JF, Chilcott M, et al; Altemeier's procedure for rectal prolapse:
analysis of long-term outcome in 60 patients. Colorectal Dis. 2012
Sep;14(9):1106-11. doi: 10.1111/j.1463-1318.2011.02904.x.

15.

Sajid MS, Siddiqui MR, Baig MK; Open vs laparoscopic repair of full-thickness
rectal prolapse: a re-meta-analysis. Colorectal Dis. 2010 Jun;12(6):515-25. doi:
10.1111/j.1463-1318.2009.01886.x.

16.

La Greca G, Sofia M, Primo S, et al; Laparoscopic implementation of the


Altemeier procedure for recurrent rectal prolapse. Technical note. Int J Surg
Case Rep. 2014;5(7):347-9. doi: 10.1016/j.ijscr.2014.04.011. Epub 2014 Apr 15.

17.

Laituri CA, Garey CL, Fraser JD, et al; 15-Year experience in the treatment of
rectal prolapse in children. J Pediatr Surg. 2010 Aug;45(8):1607-9. doi:
10.1016/j.jpedsurg.2010.01.012.

18.

Flum AS, Golladay ES, Teitelbaum DH; Recurrent rectal prolapse following
primary surgical treatment. Pediatr Surg Int. 2010 Apr;26(4):427-31. doi:
10.1007/s00383-010-2565-x. Epub 2010 Feb 21.

19.

Antao B, Bradley V, Roberts JP, et al; Management of rectal prolapse in


children. Dis Colon Rectum. 2005 Aug;48(8):1620-5.

20.

Ismail M, Gabr K, Shalaby R; Laparoscopic management of persistent


complete rectal prolapse in children. J Pediatr Surg. 2010 Mar;45(3):533-9. doi:
10.1016/j.jpedsurg.2009.09.013.

21.

Sengar M, Neogi S, Mohta A; Prolapse of the rectum associated with


spontaneous rupture of the distal colon and evisceration of the small intestine
through the anus in an infant. J Pediatr Surg. 2008 Dec;43(12):2291-2. doi:
10.1016/j.jpedsurg.2008.09.003.

22.

Jan Rakinic et al; Rectal Prolapse, eMedicine, May 2013

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