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RECTAL PROLAPSE: CAUSES, SYMPTOMS AND TREATMENT OPTIONS
- 2. OBJECTIVES • Anatomy • Definition • Classification • Risk factors • Diagnosis and evaluation • Differential diagnosis • Complication • Treatment • Complications of surgery
- 3. SURGICAL ANATOMY OF THE RECTUM • Begins at the rectosigmoid junction and ends at the anorectal junction • Approximately 12-18 cm in length • Houston’s valves • Anatomical relations
- 4. THE PROTRUSION OF MUCOSA AND SUBMUCOSA OF THE RECTUM OR ENTIRE RECTAL WALL THROUGH THE ANUS Partial thickness prolapse Full-thickness prolapse
- 5. PARTIAL THICKNESS PROLAPSE (MUCOSAL PROLAPSE) • The mucus membrane and submucosa of the rectum protrude outside the anus for approximately 1-4cm. • The commonest type of rectal prolapse.
- 6. CONTINUE… Etiology In infants • The direct downward course of the rectum, due to the as-yet undeveloped sacral curve. In children • It commences after an attack of diarrhea, or from loss of weight and consequent loss of fat in the ischiorectal fossa. • It may also be associated with cystic fibrosis, neurological disorders, Hirschsprung's disease, rectal polyps and maldevelopment of the pelvis.
- 7. CONTINUE… In adults • Often associated with third-degree hemorrhoids, when it is referred as mucohaemorrhoidal prolapse. • In the female, a torn perineum, and in the male straining from urethral obstruction, predispose to mucosal prolapse. • In old age, both types is associated with weakness of the sphincter mechanism. • Partial prolapse may follow an operation for fistula-in-ano.
- 8. FULL-THICKNESS PROLAPSE • A circumferential, full-thickness protrusion of the rectum through the anus. • Complete rectal prolapse (synonym: procidentia) is less common than mucosal variety. • consists of all layers of the rectal wall and is usually associated with a weak pelvic floor and/or chronic straining. • More than 4 cm and commonly as much as 10-15 cm in length.
- 9. CONTINUE… • Uncommon in children but may occur as a result of malnutrition. • In adult can occur at any age, but more common in the elderly and sometimes in patient with anorexia nervosa. • Women are affected six times more than men, and commonly associated with other pelvic organ prolapse. • It becomes more prevalent with age in women and peaks at the 70th decade of life. • In men prevalence is unrelated to age
- 10. RISK FACTORS • Advanced age • Multiparous females • Chronic constipation • Weakened pelvic floor • Chronic diarrhea • Female sex (Male-to-female ration=1:6)
- 11. DIAGNOSIS AND EVALUATION Symptoms include: • Tenesmus • pain • A sensation of tissue protruding from the anus • And a sensation of incomplete evacuation Mucus discharge and leakage may accompany the protrusion. Patients also present with a myriad of functional complaints, from incontinence (In approximately 50% of adults) and diarrhea to constipation and outlet obstruction.
- 12. CONTINUE… Partial prolapse • It is distinguished from full-thickness prolapse by palpation. Full-thickness prolapse • On palpation, the prolapse feels much thicker than mucosal prolapse. • Any prolapse over 5 cm will contain anteriorly, between its layers a pouch of peritoneum. • When large, may contain small intestine or bladder. • Examination most often reveals concentric rings of rectal tissue with a patulous anal canal.
- 13. CONTINUE… The colon should be evaluated by: • Colonoscopy • Air contrast barium enema • Or CT colonography to exclude neoplasms or diverticular disease. Cardiopulmonary condition should be thoroughly evaluated.
- 14. DIFFERENTIAL DIAGNOSIS • They can be distinguished by the concentric, circumferential mucosal folds seen in true prolapse compared with radial pattern of folds seen in mucosal prolapse or hemorrhoid. • Intussusception • Proctitis • polyps
- 15. COMPLICATION Complication of the rectal prolapse include: • Rectal ulceration • Bleeding • Incontinence and even incarceration with strangulation of the rectum
- 16. TREATMENT OF PARTIAL PROLAPSE In infants and young children • Digital repositioning • Submucosal injection and banding If digital repositioning fails after 6-week trial, injection of 5% phenol in almond oil or rubber band ligation under general anesthetic.
- 17. CONTINUE… In adults • Local treatments • Excision of the prolapsed mucosa If unilateral, the redundant mucosa is excised or, if circumferential, an endoluminal stapling technique or internal Delorme’s procedure can be used
- 18. TREATMENT OF FULL THICKNESS PROLAPSE • Full-thickness rectal prolapse requires surgery. • More than 100 different procedures. • Operations can be categorized as either; abdominal or perineal • abdominal rectopexy has a lower rate of recurrence (<10%), but for elderly and very frail patients, perineal operation is usually safer. • Perineal approach may be preferred in young men.
- 19. PERINEAL APPROACH Thiersch operation • In this procedure a steel wire, or silastic or nylon tape, is placed around the anus. • Has become largely obsolete owing to problems with chronic perineal sepsis, anal stenosis and obstructed defecation.
- 21. CONTINUE... Delorme’s operation • Rectal mucosa is stripped circumferentially from the rectum over the length of prolapse. • The underlying muscles is plicated with a series of suture, so that the rectal muscle concertinaed towards the anal canal. • The excess rectal mucosa is excised and a mucosal anastomosis performed. • Reduce the prolapse as a plicated ring of muscle above the anal canal. • Preferred in patients with short segment full rectal prolapse. • Recurrence rate are high, in the region of 30% over 5 years.
- 23. CONTINUE... Altemier’s procedure • Full-thickness resection of the prolapsed rectum. • Colorectal continuity is restored by anastomosis. • Procedure of choice in patient presenting with incarcerated and strangulated prolapse. • A good alternative perineal approach to the Delorme’s operation, particularly following recurrence. • Often complicated by poor bowel control. • Recurrence range from 0-20%.
- 24. CONTINUE... Advantages of perineal approach • Minimal post operative pain • Early mobility and low levels of morbidity. Given the higher recurrence rate when compared with the abdominal operation. Best reserved for patients at high risk of complications when undergoing a major operation.
- 25. ABDOMINAL APPROACH • To fix the rectum in its normal anatomic position. • Many variations have been described, including inserting a sheet of a polypropylene mesh between rectum and the sacrum, hitching up the rectosigmoid junction with a Teflon sling to the front of the sacrum, or simply suturing the mobilised rectum to the sacrum, so called “sutured rectopexy”. • Currently, most performed laparoscopically, reducing operative trauma, limiting the hospitalization time and broadening its indication for high risk patients.
- 26. CONTINUE ... • Some surgeons recommend this procedure with resection of sigmoid colon, so called ‘resection rectopexy’. • Recently, a laparoscopic anterior mesh rectopexy has gained favour.
- 27. RIPSTEIN RECTOPEXY AND WELL’S RECTOPEXY
- 28. SUTURED RECTOPEXY • Suturing the mobilized rectum to the sacrum • Using 4-6 interrupted non absorbable sutures
- 31. COMPLICATIONS OF SURGERY • Damage to nearby structures, such as nerves and organs • Prolapse recurrence • Bleeding • Bowel obstruction • Fistula • Development of new or worsened constipation • Infection • Sexual dysfunction
- 32. REFERENCES 1. Baily and Love’s short practice of surgery 27th edition 2. Shwatrzs-Principles-of-Surgery-2019