Rectal prolapse and its presentations .pptx

Rectal prolapse

1. Rectal prolapse Dr Massam

2. Objectives At the end of this session, students are expected to be able to: Define r ectal prolapse Identify different causes and risk factors of rectal prolapse. Describe the classifications of rectal prolapse Describe clinical features of rectal prolapse

3. Objectives Describe the differential diagnoses of rectal prolapse Identify the investigations rectal prolapse Describe the treatment of rectal prolapse Describe the complications of rectal prolapse

4. Introduction Definition : E version of whole thickness of the lower part of rectum to the anal canal. R ectal prolapse is the abnormal movement of the rectal mucosa down to or through the anal opening .

5. Rectal Prolapse

6. Introductio n cont. Prolapse of the rectum ( procidentia ) is an uncommon condition in which the full thickness of the rectal wall prolapses through the anal canal Typically , the extruded rectum can be identified by concentric rings of mucosa, in contrast to prolapsing hemorrhoids .

7. Introduction cont .. T he disorder is best considered an extension of intussusception The intussusception usually starts in the lower rectum anteriorly , at a level about 8 cm from the anal verge, although the starting point may be at the rectosigmoid junction

8. Risks/ associated factors H istory of straining associated with intractable constipation or, less commonly, chronic diarrhea Patients with dementia, mental retardation, or schizophrenia Prolapse of the rectum predominates in female patients, with a female/male ratio of 5:1 or 6:1

9. Risks/associated factor Cont . A natomic defects Abnormally deep rectovaginal or rectovesical pouch Lax and atonic musculature of the pelvic floor Lack of normal fixation of the rectum and an elongated mesorectum Unusually redundant sigmoid colon Lax and atonic anal sphincter

10. Classification According to the nature of prolapse Incomplete(partial) rectal prolapse Prolapse of rectal mucosa only Complete rectal prolapse Involving all layers

11. Incomplete, Mucosal prolapse Complete rectal prolapse

12. Clinical features Anorectal discomfort during defecation Sensation of obstructed bowel movements or defecation and can lead to increased straining T he feeling of incomplete evacuation are common Some patients require digital evacuation of the stool in the rectum

13. Clinical features Cont.. Occult prolapse or solitary rectal ulcer syndrome is a presenting with rectal bleeding and tenesmus . In an overt prolapse, initially the protrusion occurs only during or after defecation As the problem becomes more pronounced, the protrusion may be precipitated by coughing, exertion, or walking

14. Differential diagnosis Hemorrhoids Intussusception Proctitis Rectal polyps

15. Investigation Physical examination reveals a patulous(very relaxed anus) anus with decreased sphincter tone Anoscopy or rigid proctoscopy may demonstrate associated conditions, such as erythema on the anterior rectal wall

16. Investigations Cont.. Although minimally useful for the diagnosis of prolapse, colonoscopy is indicated particularly among patients who have had family history of colorectal cancer Diagnosis is confirmed by a characteristic histologic appearance of submucosal glands on biopsy

17. Treatment Conservative treatment Acute prolapse should be reduced with steady manual pressure to prevent incarceration and strangulation

18. Treatment cont. Surgical treatment T rans-abdominal approach like transabdominal rectosigmoid resection and suture rectopexy . Transanal approach like Perineal rectosigmoidectomy T ransperineal approach include procedures like the modified Delorme procedure is another

19. Complications Untreated rectal prolapse Risk of damage to the rectum, such as ulceration and bleeding Incarceration – the rectum can’t be manually pushed back inside the body Strangulation of the rectum – the blood supply is reduced Death and decay (gangrene) of the strangulated section of the rectum

20. Complications After surgery Injury to hypogastric nerve causing impotence Bladder dysfunction Bleeding from sacral venous plexus Injury to rectum and colon causing fistula Constipation after rectopexy Reccurence Infection

21. Key points Rectal prolapse is the abnormal movement of the rectal mucosa down to or through the anal opening . Rectal prolapse is common in people with history of straining associated with intractable constipation and those with psychiatric illnesses. Acute prolapse is normally reduced manually without requiring surgery

22. Review questions 1. What is rectal prolapse ? 2. What are the causes of rectal prolapse ? 3. What are the clinical features of rectal prolapse ? 4. Outline management of rectal prolapse ? 23

23. References S.DAS,A Manual on clinical surgery 2011 Bailey &Love’s short Practice of Surgery 26 th Edition SRB_s Manual of Surgery Surgery Notes from Prof. Aziz, compiled by Dr. Ndile 2003.MNH,Pg 61-66.