RECTAL PROLAPSE

for medical students

1. RECTAL PROLAPSE Kushal Kumar

2. Prolapse of the mucous membrane or the entire rectum outside the anal verge. This condition is common in children and elderly patients. TYPE Partial prolapse Complete prolapse

3. Aetiology Decreased sacral curvature and decreased anal canal tone are the probable causes in infants . Diarrhea, cough, malnutrition are the additional factors in children . It may be due to reduced ischiorectal fossa fat, neurological causes, fibrocystic disease of pancreas or poorly developed pelvis. In adults, it is common in females, common in multipara—repeated birth injuries to perineum results in damage to the perineal nerve supply. It is due to weakening of supporting tissue and levator ani muscle, atony of the sphincter, increased intraabdominal pressure due to any cause like chronic cough, stricture urethra.

4. Partial prolapse Here only mucosa and submucosa of the rectum descends, not more than 3.75 cm. There is no descent of the muscular layer. It is the commonest type of rectal prolapse. Clinical Features History of mass per anum , which can be observed when child is allowed to strain in squatting position. It is pink in colour and circumferential . It differs from piles (differential diagnosis), the piles are not circumferential and are plum or blue coloured (not pink ).

5. Treatment In infants and young children Digital repositioning The parents are taught to replace the protrusion, and any underlying causes are addressed. Submucosal injections If digital repositioning fails after 6 weeks’ trial, injections of 5% phenol in almond oil are carried out under general anaesthestic . As a result of the aseptic inflammation following these injections, the mucous membrane becomes tethered to the muscle coat. Surgery Occasionally , surgery is required and, in such cases, the child is placed in the prone jack-knife position, the retrorectal space is entered, and the rectum is sutured to the sacrum .

6. In adults Local treatments Submucosal injections of phenol in almond oil or the application of rubber bands are sometimes successful in cases of mucosal prolapse. Excision of the prolapsed mucosa When the prolapse is unilateral, the redundant mucosa can be excised or, if circumferential, an endoluminal stapling technique can be used.

7. Complete Prolapse • Also called as procidentia , is less common than partial prolapse It is common in females (6 : 1 :: female : male ). It is due to weakened levator ani and supporting pelvic tissues. The descent is always more than 3.75 cm, contains all layers of the rectum (i.e. including muscular layer). Often descends down up to 10-15 cm . It is often associated with the uterine descent (uterine prolapse ). It is also thought to be as an intussusception of the rectum. Once complete prolapse is more than 5 cm, anteriorly it drags peritoneum as pouch which often contains small intestine. On digital pushing it reduces with gurgling. Patulous anal sphincter is typical with mucus discharge and faecal incontinence

8. Aetiological factors Weak anus, external sphincter and pelvic muscle Lax , mobile rectum Obliterated ano -rectal angle Abnormally mobile rectum with descent

9. Clinical Features Complete descent of the rectum which is red in colour and often painful, as mass per anum . Faecal incontinence is very common. It is due to disruption of the anal sphincter and prolapsed rectal mucosal discharge. Pain per anum . Bleeding can occur because of the congestion Sepsis , discharge, fever, anaemia are other features. P/R examination shows lax sphincter. Anteriorly, peritoneal sac comes down as a pouch which may contain small bowel.

10. Investigations Defecography reveals increased mobility of the rectum from sacral fixation point with redundant mesorectum and funnel formation. It is fluoroscopic and spot filming in lateral projection after instilling radioopaque material into the rectum done in sitting posture over a radiolucent commode . Cinedefecography , triple contrast cinedefecography , dynamic MRI defecography , colpocystodefecography are helpful to delineate complex pelvic floor problems. Defecography abnormalities- megarectum , incontinence, nonrelaxing puborectalis , abnormal perineal descent (2.5 cm), mucosal prolapse, solitary ulcer rectocoele , enterocele . Sigmoidoscopy . • Anal manometry. • Pudendal nerve latency study.

11. Treatment Surgery is required, and the operation can be performed via the perineal or the abdominal approaches. An abdominal rectopexy has a lower rate of recurrence but, when the patient is elderly and very frail, a perineal operation is indicated. As an abdominal procedure risks damage to the pelvic autonomic nerves, resulting in possible sexual dysfunction, a perineal approach is also usually preferred in young men.

12. Perineal approach Thiersch operation This procedure, which aimed to place a steel wire or, more commonly, a silastic or nylon suture around the anal canal, has become obsolete. The reasons for its lack of popularity were that the suture would often break or cause chronic perineal sepsis, or both, or the anal stenosis so created would produce severe functional problems. Delorme’s operation is now the preferred perineal operation.

13. Delorme’s operation In this procedure, the rectal mucosa is removed circumferentially from the prolapsed rectum over its length. The underlying muscle is then plicated with a series of sutures, such that, when these are tied, the rectal muscle is concertinaed towards the anal canal. The anal canal mucosa is then sutured circumferentially to the rectal mucosa remaining at the tip of the prolapse. The prolapse is reduced, and a ring of muscle is created above the anal canal, which prevents recurrence. Altemeier’s procedure This consists of excision of the prolapsed rectum and associated sigmoid colon from below, and construction of a coloanal anastomosis.

14. Abdominal approach The principle of all abdominal operations for rectal prolapse is to replace and hold the rectum in its proper position. They are recommended in patients with complete prolapse who are otherwise in good health. Many variations have been described: in Wells’ operation, the rectum is fixed firmly to the sacrum by inserting a sheet of polypropylene mesh between them; Ripstein’s operation involves hitching up the rectosigmoid junction by a Teflon sling to the front of the sacrum; many surgeons simply suture the mobilised rectum to the sacrum using four to six interrupted non-absorbable sutures – so called sutured rectopexy . Recently, the technique has been performed laparoscopically, thus reducing the operative trauma and limiting the time in hospital.

15. Complications of Surgery Injury to hypogastric nerve causing impotence. Bladder dysfunction . Bleeding from sacral venous plexus . Injury to rectum and colon causing faceal fistula . Constipation after rectopexy is a known complication. Recurrence of prolapse. Improper correction of continence occurs in 50% cases. Infection – proctitis /pelvic abscess, etc

16. Defecographic grading of rectal prolapse N – Normal rectal fixation and sphincter relaxation and rectal emptying. 1 – Nonrelaxed puborectalis . 2 – Mild intussusception 3 – Moderate intussusception. 4 – Severe intussusception . 5 – Prolapse. R – Rectocele.

17. Solitary Rectal Ulcer Syndrome

18. Clinical condition characterized by rectal bleeding, copious mucous discharge, anorectal pain and difficult evacuation SRUS can have single rectal ulcer, multiple ulcers or even no ulcers When present, ulcers usually occur on the anterior rectal wall just above the anorectal ring Ulcers usually appear as shallow lesions with punched out gray-white base that is surrounded by hyperemia Cause unclear, associated with chronic inflammation or trauma (internal intussception or prolapse of the rectum, direct digital trauma, or forces to evacuate hard stool)

19. Management Conservative therapy (e.g. high fiber diet, lifestyle changes etc ) should be tried first Pharmacologic therapy (e.g. anti-inflammatory enemas and suppositories), limited success but worth trying If symptoms persists, localized resection may be considered Patients with prolapse, prolapse need to be treated either with perineal procedures or abdominal procedures

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