Rectal Prolapse

Question 1

Define rectal prolapse.

Answer 1

When the rectal mucosa or all layers protrude through the anus.

Question 2

What are the types of rectal prolapse?

Answer 2

Type 1 - partial rectal mucosa protrusion

Type 2 - complete rectal mucosa protrusion i.e. all layers = MORE COMMON

Question 3

What is the aetiology of rectal prolapse?

Answer 3

• Lax sphincter
• Prolonged straining
• Chronic neurological/psychological disorders

Question 4

What are the risk factors for rectal prolapse?

Answer 4

• Increased IAP - e.g. constipation, diarhoea, BPH, pregnancy, chronic cough
• Pelvic floor dysfunction
• Previous surgery
• Parasitic infection
• Neurological disease e.g. previous lower back or pelvic trauma, disc disease, cauda equina syndrome, spinal tumours, MS
• Psychiatric disease

In children - cystic fibrosis, Ehlers-Danlos syndrome, Hirschsprung’s disease, congenital megacolon, malnutrition, rectal polyps.

Question 5

What are the symptoms of rectal prolapse?

Answer 5

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

Mass protruding through the anus which:

• Initially protrudes only after a bowel movement and retracts on standing
• Later protrudes with straining/Valsalva
• Finally protrudes with daily activities such as walking +may have to be replaced manually

Question 6

What are the signs of rectal prolapse on examination?

Answer 6

Protruding mass with concentric rings of mucosa

Decreased anal spincter tone

+/- Rectal ulcer

Protrudes with Valsalva maneouvres

Question 7

How is rectal prolapse managed?

Answer 7

Surgically

Abdominal approach - fix rectum to sacrum (rectopexy) +/- mech insertion +/- rectosigmoidectomy. Laparoscopic is as effective as open repair.

Perineal approach - Delorme’s procedure (resect close to dentate line and suture mucosal boundaries), anal encirclement with a Thiersch wire.

Other:

• Treat contributing factors - e.g. constipation/diarrhoea
• Coping strategies e.g. senna to help with stool consistency, anal plug to reduce incontinence
• Pelvic floor exercises

Question 8

What percentage of those with rectal prolapse get incontinence?

Answer 8

75%

Question 9

What investigations would you do for rectal prolapse?

Answer 9

Diagnosis is clinical

• DRE - assess anal tope
• Colonoscopy +/- sigmoidoscopy- exclude colonic masses or lead points

Other:

• Proctoscopy - prolapse will fill the lumen, assess for anal lesions
• Proctography - contrast into anus and defecation is imaged, only used f there is a suspicion that there is a problem with the dynamics of defecatio
• Anal physiology tests to check layers - defecography, anal manometry, continence tests, electromyography of anal sphincter, pelvic floor and nerve stimulation tests
• Endoanal MRI - elineate the anal sphincter complex

Question 10

What are the complications of rectal prolapse?

Answer 10

• Mucosal ulceration
• Necrosis of rectal wall
• Bleeding and dehiscence at anastomosis
• Recurrence (up to 20%)

Question 11

What is the prognosis with rectal prolapse?

Answer 11

• Depends on age and general well-being of patient
• Spontaneous resolution usually in children - 90% between age 9 months to 3 years will resolve conservatively