Rectal prolapse

Question 1

What is a rectal prolapse?

Answer 1

• Protrusion of mucosal or full thickness layer of rectal tissue out of the anus
• Quite uncommon
• Mainly older females

Question 2

Two types of rectal prolapse

Answer 2

• Partial thickness - rectal mucosa protrudes out the anus
• Full thickness - rectal wall protrudes out the anus

Question 3

Pathophys of rectal prolapse - full vs partial

Answer 3

• Full prolapse - form of sliding hernia through a defect of fascia in pelvis - this may be caused by chronic straining secondary to constipation, cough or multiple vaginal deliveries
• Partial thickness - loosening and stretching of connective tissue that attaches rectal mucosa to rectal wall - related to long standing haemorrhoidal disease

Question 4

RF for rectal prolapse

Answer 4

• Increasing age
• Female gender
• Multiple deliveries
• Straining
• Anorexia
• Previous traumatic vaginal delivery

Question 5

Symptoms of rectal prolapse

Answer 5

• Rectal mucus discharge
• Faecal incontinence
• PR bleeding
• Visible ulceration

Question 6

Extra symptoms of full thickness prolapse - initial

Answer 6

Starts internally so can initially present with:
* Rectal fullness
* Tenesmus
* Repeated defecation

Question 7

Examination for rectal prolapse

Answer 7

• May not always be evident - get patient to strain
• DRE identifies weakened anal sphincter
• If internal suspected - defecating proctography (MRI wile defecating) and EUA may be needed

Question 8

Conservative management rectal prolapse

Answer 8

• If unfit for surgery or minimal symptoms
• Increasing dietary fibre and fluid intake
• Minor mucosal prolapses can be banded - BUT prone to recurrence

Question 9

Surgical management for rectal prolapse two approaches

Answer 9

Definitive management:
* Perineal approach or
* Abdominal approach

Question 10

Perineal approach surgery

Answer 10

• Delormes operation - prolapsed lining of rectal mucosa is removed and underlying muscle reinforced with plicated sutures (deep sutures)
• Altemeiers op - resection of abundant prolapsed bowel to restore original anatomy

Question 11

Abdominal approach

Answer 11

• Laparoscopically usually, robotically or open
• Rectopexy - rectum mobilised and fixed onto sacral prominence via sutures or mesh

Question 12

Which op is better?

Answer 12

• No difference in post op outcomes
• Perineal procedures preferred in older patients as considered safer