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1. STATE LAL BAHADUR SHASTRI HOMOEOPATHIC
MEDICAL COLLEGE AND HOSPITAL
PRAYAGRAJ
DEPARTMENT OF SURGERY
PRESENTATION ON: RECTAL PROLAPSE
GUIDED BY-
DR. MUKESH KUMAR
SRIVASTAVA SIR
(H.O.D., Department Of
Surgery)
SUBMITTED BY-
DEEPALI PRASAD
ROLL NO. 27
B.H.M.S. 3RD PROF.
BATCH- 2019

2. ACKNOWLEDGEMENT
I would like to express my sincere
gratitude to my Teacher Dr. Mukesh
Kumar Srivastava Sir (H.O.D. Dept. of
Surgery) for providing me this
opportunity and his invaluable guidance
and support to do this project.
I Would also like to extend my special
thanks to our Principal Dr. Hemlata Ma’am
for providing the facilities required to do
my project.

3. INDEX
 DEFINITON
 TYPES
 BEAHRS CLASSIFICATION
 PARTIAL PROLAPSE
- CAUSES
- CLINICAL FEATURES
- TREATMENT
 COMPLETE PROLAPSE
- CAUSES
- CLINICAL FEATURES
- PATHOGENESIS
- DIFFERENTIAL DIAGNOSIS
- COMPLICATIONS
- TREATMENT
 HOMOEOPATHIC THERAPEUTICS
 BIBLIOGRAPHY

4. DEFINITION
Prolapse of the mucous membrane or the entire rectum outside
the anal verge. This condition is common in children and
elderly patients.

5. TYPES
Prolapse can be of two types:
(a) Partial Prolapse
(b) Complete /Total Prolapse

6. BEAHRS CLASSIFICATION
1. Incomplete- mucosal prolapse
2. Complete- full thickness rectal
prolapse
1st degree-concealed
2nd degree-externally visible on
straining
3rd degree-visible without straining

7. A. PARTIAL PROLAPSE
• In this variety the protrusion is
between 1.25 and 3.75 cm outside the
anal verge.
• It is usually a mucosal prolapse.
• There is no descent of the muscular
layer.
• It is the commonest type of rectal
prolapse.

8. FIGURE: PARTIAL PROLAPSE

9. • CAUSES OF PARTIAL
PROLAPSE
1. In infants, it is due to undeveloped sacral
curve and in children it can be secondary
to habitual constipation.
2. It can follow an attack of whooping cough
and excessive straining.
3. It can follow an attack of diarrhoea
resulting in loss of fat in the ischiorectal
fossae, which supports the rectum.
4. In adults, it is common in females mostly
due to torn perineum caused by obstetric
trauma.

10. • CLINICAL FEATURES OF
PARTIAL PROLAPSE
1. History of mass per anum, which can be
observed when child is allowed to
strain in squatting position.
2. It is pink in colour and circumferential.
3. It differs from piles, the piles are not
circumferential and are plum or blue
coloured (not pink).

11. • TREATMENT OF PARTIAL
PROLAPSE
IN INFANTS AND YOUNG CHILDREN
➢ Digital repositioning: Partial prolapse is temporary.
The mother is advised to push the prolapse inside after
lubricating with lignocaine jelly.
➢ Submucosal injection: Injection of ethanolamine
oleate into the submucosa of the rectum. It causes
aseptic fibrosis. Thus mucosa gets tethered to the
other layers.
➢ Surgery: occasionally required, the child is placed in
the prone jack-knife position, the retrorectal space is
entered, and the rectum is sutured to the sacrum.

12. 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 prolapsed mucosa: When the prolapse is
unilateral, the redundant mucosa can be excised, or
if circumferential, an endoluminal stapling technique
can be used.

13. B. COMPLETE/TOTAL
PROLAPSE
• Full thickness prolapse is also called
procidentia.
• It is defined as protrusion of the rectum
for more than 3.75 cm outside the anal
verge. Very often, it is the entire rectum
which protrudes out on straining,
sometimes along with the peritoneal sac.
• Often, it is associated with prolapse
uterus.

14. FIGURE: COMPLETE PROLAPSE

15. • CAUSES OF COMPLETE
PROLAPSE
1. Weak anus, external sphincter and pelvic muscle as age advances.
Common in elderly women who are multipara due to repeated
birth injuries to the perineum.
2. Excessive straining causes weakness of the supports of the
rectum.
3. Defective collagen maturation results in failure of rectal support
by levator and pelvic fascia.
4. Presence of deep rectovesical pouch and excessive mobility of the
rectum predisposes to prolapse.
5. Many people believe that prolapse of the rectum starts as an
intussusception in the first stage, initiated by certain factors such
as diarrhoea, constipation and disorder of the pelvic floor. The
process starts with anterior wall of the rectum, where supporting
tissues are weakest(Broden-Snellman theory).

16. • CLINICAL FEATURES OF
COMPLETE PROLAPSE
1. Female-male ratio is 6:1.
2. Constipation is an important feature of rectal prolapse.
3. Excessive mucus discharge causing irritation to the perianal skin.
Tenesmus is also common.
4. On asking the patient to strain at stool, the rectum descends
down, which clinches the diagnosis.
5. Some degree of incontinence of faeces and flatus is always
present. It gives rise to urgency and perianal soiling.
6. Rectal examination- lax anal sphincter and wide gaping on
straining.
7. Procidentia.
8. Recurrent attacks of prolapse and negligence in seeking medical
attention can give rise to gangrene.

17. • PATHOGENESIS
INTERNAL INTUSSUSCEPTION
Prolapse rectum
▪ Rectal fullness
▪ Incomplete evacuation
Solitary rectal ulcer
▪ Rectal bleeding
▪ Tenesmus
▪ Mucus discharge
Progressive incontinence
Pain
prolapse
Further progression
Descending perineum syndrome
Irreducible prolapse Ischaemia
Gangrene

18. • DIFFERENTIAL
DIAGNOSIS
▪ Large third degree haemorrhoids-not
circumferential and are blue in colour.
▪ Large polypoid tumour.
▪ Prolapse of sigmoid colon.
• COMPLICATIONS
▪ Proctitis, ulceration and rarely bleeding.
▪ Gangrene of the rectum.

19. • TREATMENT OF COMPLETE
PROLAPSE
Medical Management-prior to surgery, patients not
fit for surgery or patients who refuse surgery
i. Adequate fluid and fibre intake.
ii. Enemas and suppositories for severe
contipation.
Surgical Procedures-
i. Perineal procedures-preferred for high risk
patients.
ii. Abdominal procedures-preferred for standard
risk patients.

20. I. PERINEAL PROCEDURES
a) Delorme’s Procedure(reefing the rectal
musoca): In this, the prolapse is
completely everted, mucosa is stripped
and muscle coat is plicated. Mucosal
continuity is maintained by suturing
anal canal mucosa below to the rectal
mucosa above. This is an easy operation
to do in elderly patients. However,
relapse rates are high and it does not
correct the defect.

21. FIGURE: DELORME’S PROCEDURE

22. b) Altemeier’s Procedure: In this operation,
full thickness of the prolapsed rectum
with part of sigmoid is excised followed
by anastomosis of part of the sigmoid to the
anal canal from below. To improve
continence, plication of levator ani and
puborectalis muscle is done. Urgency and
incontinence are the features because
of removal of rectum.

23. Figure: Altemeier’s
Procedure-
(a, b) Incision of rectal
wall.
(c) Division of vessel
adjacent to bowel wall.
(d) The prolapsed
segment is amputated.
Stay sutures previously
placed in distal edge of
outer cylinder are placed
in cut edge of inner
cylinder.
(e) Anastomosis of distal
aspect of remaining colon
to the short rectal stump.

24. c) Thiersch wiring: In this operation, a steel
wire or a thick silk suture is applied all
around the anus after reducing the
prolapse. The knot is tightened around
a finger. Patient with poor surgical
compliance benefit from the operation.
However, breakdown of the wire,
perianal sepsis and anal stenosis are
the complications.

25. FIGURE:
THIERSCH
WIRING

26. II. ABDOMINAL PROCEDURES
a) Wells operation (posterior rectopexy): A
laparotomy is done, rectum is pulled
upwards and is sutured to the sacrum
posteriorly with the help of a polyvinyl
alcohol sponge kept behind the sacrum.
The sponge is sutured posteriorly and
laterally to the walls of the rectum.
Dense fibrotic reaction occurs
resulting in fixation of the rectum to
the sponge.

27. FIGURE: WELLS PROCEDURE. THE SPONGE IS
ANCHORED TO THE SACRUM. WITH THE RECTUM
UNDER TENSION, THE EDGES OF THE SPONGE ARE
BROUGHT AROUND THREE QUARTERS OF THE RECTAL
CIRCUMFERENCE AND SUTURED TO THE MUSCULARIS
OF THE ANTERIOR RECTUM.

28. b) Ripstein sling operation (anterior
rectopexy): After a laparotomy, the
rectosigmoid junction is sutured to the
sacrum by using Teflon sling, below the
sacral promontory. One complication of
this operation is constipation due to
rectosigmoid angulation. Hence,
sigmoidectomy has been suggested
along with this operation.

29. FIGURE: RIPSTEIN PROCEDURE. (a) With the
rectum under tension, a piece of mesh is sutured to
the presacral fascia on one side then sutured to the
muscularis of the anterior rectum.
(b) The rectum is then secured to the presacral
fascia on the other side to form a sling.

30. c) Mesh rectopexy: Instead of polyvinyl
sponge, a marlex mesh can be kept behind
the rectum. This is sutured behind, to the
sacrum and then to the posterior and
lateral surfaces of rectum. Laparoscopic
method of fixing the mesh has become
popular. This is the procedure of choice
today. Constipation is one of the
complications of mesh rectopexy. Hence,
some resect sigmoid with this procedure
(Goldberg operation).

31. FIGURE: LAPAROSCOPIC MESH RECTOPEXY. (a) A piece
of mesh is inserted into the abdomen through a port then
stapled to the sacrum.
(b) The lateral edges of the nonabsorbable mesh are
wrapped around three quarters of the rectal circumference
and sutured to the rectal wall.

32. HOMOEOPATHIC
THERAPEUTICS
1. Podophyllum peltatum
2. Aesculus hippocastanum
3. Sulphur
4. Ferrum metallicum
5. Ruta graveolens
6. Ignatia amara
7. Muriaticum acidum
8. Nitricum acidum

33. 1. PODOPHYLLUM PELTATUM
COMMON NAME- MAY APPLE
FAMILY-BERBERIDACEAE
INDICATIONS –
➢ Prolapse of rectum before or with stool.
➢ Prolapsus ani with stool which GUSHES OUT.
➢ Constipation; clay coloured, hard, dry, difficult stool.
➢ Rumbling and shifting of flatus in ascending colon.
➢ Diarrhoea of children during the time of dentition, in hot
summer weather.
MODALITIES-
➢ Aggravation: At night, motion.
➢ Amelioration: Rubbing, hard pressure, physical exertion

34. 2. AESCULUS
HIPPOCASTANUM
COMMON NAME- HORSE CHESTNUT
FAMILY- SAPINDACEAE
INDICATIONS-
➢ Dry, aching rectum. Feels full of small sticks.
➢ Anus raw, sore. Severe pain after stool with prolapse.
➢ Burning in the anus with chills up and down the back.
➢ Constipation with severe lumbosacral backache.
MODALITIES-
➢ Aggravation: In the morning on awaking, and from any motion,
walking, from moving bowels, after eating, afternoon, standing.
➢ Amelioration: cool, open air.

35. 3. SULPHUR
COMMON NAME- BRIMSTONE; FLOWERS OF SULPHUR
THE ELEMENT
INDICATIONS-
➢ Morning diarrhoea, painless, drives him out of bed with prolapsus
recti.
➢ Redness around the anus with itching.
➢ Frequent, unsuccessful desire; hard, knotty, insufficient stool.
➢ Complaints that are continually relapsing.
➢ Nash’s trio of burners(along with Arsenic and Phosphorus).
MODALITIES-
➢ Aggravation: At rest, when standing, warmth of bed, washing,
bathing in the morning, 11 a.m., night, from alcoholic stimulants,
periodically.
➢ Amelioration: Dry, warm weather, lying on the right side, from
drawing up the affected limbs.

36. 4. FERRUM METALLICUM
COMMON NAME- IRON
Fe, AN ELEMENT
INDICATIONS-
➢ Prolapse of rectum and itching of anus at night.
➢ Stool is followed by backache and cramping pain in the rectum.
➢ Stool is dry, knotty, with ineffectual urging.
➢ With diarrhoea, there is good appetite and prolapse of rectum.
➢ Canine hunger or alternate loss of appetite with dislike for any
food.
MODALITIES-
➢ AGGRAVATION: At night, at rest especially while sitting still.
➢ AMELIORATION: Walking about slowly and in summer.

37. 5. RUTA GRAVEOLENS
COMMON NAME- RUE
FAMILY- RUTACEAE
INDICATIONS-
➢ Prolapse of rectum immediately on ATTEMPTING TO EVACUATE
THE BOWEL.
➢ Brown, watery diarrhoea early in the morning, with cough, driving
him out of bed.
➢ Itching in the anus, with sensation of a stick in the rectum.
➢ Can not eat meat; it causes eructations, pruritis.
MODALITIES-
➢ AGGRAVATION: Touch, rest, stooping, sitting, ascending, at
night, cold weather, while reading and during menses.
➢ AMELIORATION: Lying on back, rubbing, motion, scratching.

38. 6. IGNATIA AMARA
COMMON NAME- ST. IGNATIUS’ BEAN
FAMILY- LOGANIACEAE
INDICATIONS-
➢ Prolapse of anus is more when the stool is loose.
➢ There may be prolapse of anus from moderate straining, lifting or stooping.
➢ Excessive urge and desire for stool; but there is great pain in rectum which
compels the patient to refrain from going to closet.
➢ Itching and stitching pains up the rectum.
➢ Diarrhoea from fright.
➢ Pressure as of a sharp instrument from within outwards in rectum.
➢ There is utter inability to TOLERATE TOBACCO IN ANY FORM.
MODALITIES-
➢ AGGRAVATION: From tobacco, coffee, alcohol, contact, touch, motion,
strong odour, mental emotion, grief, anger, and suppressed mental
sufferings.
➢ AMELIORATION: Warmth, hard pressure, swallowing, walking.

39. 7. MURIATICUM ACIDUM
COMMON NAME- HYDROCHLORIC ACID
FORMULA- HCl
INDICATIONS-
➢ Anal itching and prolapsus ani while micturating.
➢ Tendency to involuntary evacuations while micturating.
➢ Anus is very sensitive either with or without haemorrhoids.
➢ Great debility, slides down in bed: even the lower jaw hangs
down.
➢ Patient cannot bear the thought or sight of meat.
MODALITIES-
➢ AGGRAVATION: From touch and after sleep, damp weather,
before midnight.
➢ AMELIORATION: By lying on left side and uncovering (during
fever).

40. 8. NITRICUM ACIDUM
COMMON NAME- NITRIC ACID
FORMULA- HNO3
INDICATIONS-
➢ Prolapsus ani. Rectum feels torn.
➢ Great straining but little passes.
➢ Bowels constipated with fissures in the rectum.
➢ Tearing pains during stool.
➢ Violent cutting pains after stools, lasting for hours.
➢ Hemorrhages from the bowels, profuse and bright.
➢ Loves fat and salt.
MODALITIES-
➢ AGGRAVATION: Evening and at night, after mid-night, contact,
change of temperature or weather, during sweat, on walking and
while walking.
➢ AMELIORATION: All symptoms are better while riding in a
carriage.

41. BIBLIOGRAPHY
✓MANIPAL MANUAL OF
SURGERY BY K. RAJGOPAL
SHENOY AND ANITHA
SHENOY.
✓SRB’s MANUAL OF SURGERY
BY SRIRAM BHAT M.
✓A CONCISE TEXTBOOK OF
SURGERY BY S. DAS.
✓WIKIPEDIA FROM
INTERNET.
BIBLIOGRAPHY