3. Introduction
● Rectal prolapse occurs when a mucosal or full-thickness layer of rectal
tissue protrudes through the anal orifice.
● Rectal prolapse is a distressing condition that is usually associated with
bowel dysfunction
● There are two types of rectal prolapse
○ Type I (false procidentia, partial, or mucosal prolapse)
○ Type II (true procidentia, or complete prolapse)
● Treatment of these two entities differs.
4. ● Type I, (false procidentia, partial, or
mucosal prolapse)
○ Protrusion of the mucosa &
submucosa
○ Usually less than 2 cm long.
○ Produces radial folds at the
junction with the anal skin
○ Mostly children < 5 years
○ Slightly high male : female
5. ● Type II (true procidentia, or complete
prolapse)
○ involves full thickness extrusion
of the rectal wall
○ concentric folds in the prolapsed
mucosa (stacked coins)
○ mainly in adults
○ F:M – 4:1
○ The age of maximum incidence
in females is the fifth decade,
and in males the third
6. ● Intussusception or Internal Prolapse of the rectum is an occult (or internal)
prolapse that occurs when the rectum descends toward but does not pass
through the anal canal.
● A partial (mucosal) prolapse occurs when all layers of the rectum are not
involved and only the mucosal layer prolapses
● A complete rectal prolapse (procidentia) occurs when all layers of the rectum
prolapse through the anal canal
16. • The roughly 80° anorectal flexure
is an important mechanism for
fecal continence
• maintained during the resting
state by the
• contraction of the puborectalis
muscle,
• and by its active contraction
during peristaltic contractions
if defecation is not to occur.
18. Epidemiology
● The incidence of rectal prolapse is bimodal, although patients of
any age can be affected.
○ One peak occurs in children within the first 5 years of life
○ Second peak occurs after the seventh decade.
● Prolapse in children is typically not a recurring problem and can
be self-limiting.
● In the elderly, rectal prolapse is more common in women (>75%),
and the prevalence of this abnormality increases with age.
19. Epidemiology
● Many of these elderly women have concurrent pelvic organ
prolapse, defecatory disorders, and may be multiparous.
● Rectal prolapse may also effect institutionalized patients who
have neurologic or psychiatric comorbidities (15%). It is possible
that chronic constipation and straining to defecate may be a
contributing factor in this group of patients.
● The exact cause of rectal prolapse is still unclear
20. Predisposing Conditions – children
● The finding of rectal prolapse should be considered as a symptom of an
underlying condition that predisposes to rectal prolapse.
○ Increased intra-abdominal pressure
○ Diarrheal disease (acute or chronic)
○ Cystic fibrosis
○ Malnutrition
○ Pelvic floor weakness
○ Atony of the anal sphincters
○ Sexual abuse
● Generally, although the following factors may be found in association with
mucosal prolapse, most affected children are healthy with no obvious
cause for the disease except perhaps excessive straining during
defaecation.
22. Pathogenesis - Adults
The exact cause of rectal prolapse is still unclear.
1. Alexis Moschcowitz proposed that a rectal prolapse was caused by a
sliding herniation of the pouch of Douglas through the pelvic floor
fascia into the anterior aspect of the rectum.
2. With the advent of defecography in 1968, however, Broden and
Snellman were able to show that procidentia is basically a full-thickness
rectal intussusception starting approximately 6-8cm above the dentate
line and extending beyond the anal verge
23. 3. Abnormal bowel habits: The frequent straining during defaecation weakens the
pelvic muscles. sphincters and attachments of the rectum to the sacrum
4. Impaired voluntary sphincter contraction and pelvic floor atony due to pelvic
floor nerve damage from childbirth or chronic prolonged straining
5. Pudendal neuropathy may be responsible for pelvic floor and anal sphincter
weakening
6. A wide pelvic inlet and redundant, nonfixed rectosigmoid are commonly found.
7. Vaginal prolapse and enteroceles are commonly seen in studies of patients
with long-standing rectal prolapse (50%).
Pathogenesis - Adults
24. ● Patients with prolapse are frequently found to have specific anatomic
characteristics.
○ Diastasis of the levator ani
○ abnormally deep cul-de-sac
○ redundant sigmoid colon
○ patulous anal sphincter
○ loss of the rectal sacral attachments
Pathogenesis - Adults
26. Clinical Presentation
Children
● The bowel comes down and projects at the anus during defaecation.
● There may be a slight discharge of mucus and blood.
● As a general rule, prolapse is painless, but it can be associated with mild
discomfort
● A DRE may reveal decreased or absent anal tone initially, but normal
tone returns within a few minutes to hours.
In patients with a predisposing neurologic condition, such as
myelomeningocele, the decreased sphincter tone may persist.
27. Clinical Presentation
Adults
● Early stages of the disease
rectum prolapses only at
defaecation.
● Painless prolapse descends
with increasing frequency and
on any increase in intra-
abdominal pressure.
● Prolapse greater than 5cm is
nearly always complete
● Tenesmus
● Bleeding
● Mucus discharge
● Constipation
● Fecal incontinence
● Sensation of incomplete evacuation
● Rectal prolapse can be as a surgical
emergency. (ulceration, hemorrhage)
28. Clinical Presentation
Adults
● The prolapse is demonstrated when the patient strains while
squatting or lying in the left lateral position
○ The concentric rings of the rectum protruding through the anus are the hallmark of
rectal prolapse.
● Atony of the sphincters is confirmed by
○ the patient's impaired ability to contract them voluntarily
○ the relative lack of discomfort when 2, 3, or even 4 fingers are inserted
into the anus
● On palpation it is found to be thick. Mucosal prolapse on the other
hand thin on palpation
29. Complications of Prolapse
● Ulceration
● Haemorrhage
● Irreducibility and gangrene
● Spontaneous rupture with evisceration
30. Investigations
● Rectal prolapse is mainly a clinical diagnosis
● Investigations done to rule out other diseases
● Colonsocopy
● Colonic transit study
● Defecography
● CT Scan or dynamic MRI
● The anal sphincter (anal physiology testing)
○ Manometry
○ Electromyography (EMG)
○ Pudendal nerve terminal motor latency (PNTML)
31.
32.
33. Differential diagnosis
Children
● Intussusception (Ileocecal – Meckel’s diverticulum is the most common lead point)
○ typically appears ill
○ intermittent severe abdominal pain
○ examiner's finger can be passed between the apex of the
prolapsed bowel and the anal sphincter
○ In contrast, in rectal prolapse, the protruding mucosa is
continuous with the perianal skin
● Prolapsing rectal polyp
● Rectal hemorrhoids
34.
35. Differential diagnosis
Adults
● Hemorrhoids
● Solitary rectal ulcer
● Large polypoid neoplasm of rectum or sigmoid
● Rectosigmoid intussusception
● Prolapsing polypoid mass
● Rectocele
● Enterocele
● Hypertrophied anal papillae
38. Management
Children - Conservative
● Most patients respond to non-operative measures
● The majority recover spontaneously even without treatment.
● Directed toward diagnosing and treating the predisposing condition (eg,
constipation, cystic fibrosis, parasitic infection).
● Manual reduction
● If left untreated, increase risk of bleeding, ulceration, congestion and
becomes more difficult to reduce
39.
40. Management
Children - Operative measures
Operation is performed only if non-operative measures fail.
1. Temporary Thiersch operation
A stitch of stout chromic catgut is used
Self-curing of the prolapse takes place by the time the catgut is absorbed
2. Submucous injection of sclerosing agents:
5 % phenol in almond oil or absolute alcohol
This causes sclerosis which fixes the mucosa to the muscle wall. Success rate of 68 to 86%
3. Linear cauterization of the anal mucosa:
It fixes the mucosato the muscle by causing sclerosis betweenthe mucosa and muscle wall
41. Management
Adults - Aims of treatment
● Control prolapse and prevent recurrence
● Restore normal bowel function
○ Restore continence
○ Prevent constipation/ impaired evacuation
● The choice of operation is determined by the patient’s age, comorbidities,
operative risk, and associated anatomic abnormalities
42. Surgical approach
Which way is the best way?
● Perineal or abdominal?
● Open or Laparoscopic or Robotic?
● How should the rectum be mobilized ?
● Resection of redundant sigmoid colon?
● How should the rectum be fixed?
● Prosthetic / Biological mesh?
43. • 1959 – Charles
Wells
– ‘ I have traced in
the literature between
30 and 50 operations
for prolapse of the
rectum and would
like to add still one
more’
44. Candidates for Abdominal / Perineal Surgery
● Patients who are candidates (physically fit) for an abdominal procedure
should have an abdominal rather than a perineal repair.
● This is because recurrence rates after an abdominal repair are generally
lower than after a perineal repair.
● In general, the perineal procedures are better tolerated than abdominal
procedures because they can be performed without general anesthesia
and result in fewer complications and less pain
46. Abdominal procedures
● Proper transabdominal repair involves
○ Rectal mobilization
■ anterior vs posterior
○ Sigmoid resection (when indicated)
○ Fixation of the rectum to the sacral promontory (rectopexy).
■ suture vs mesh
● Surgical approach
○ open, laparoscopic, or robotic
47. Abdominal procedures - Rectal mobilization
● The first step of any abdominal procedure is to mobilize the rectum.
The task is to free the rectum with an intact mesorectum all around up to the level of the levators
● The approaches to rectal mobilization include:
○ Posterior mobilization:
■ Mobilize the rectum posteriorlyfrom the pelvic floor to the tip of the coccyx,
preserving the lateral stalks.
■ The hypogastric nerves are preserved at the level of the sacral promontory
○ Anterior mobilization:
■ In women, mobilize the rectum anteriorly to the level of the mid to upper third of
the vagina.
■ In men, mobilize the rectum anteriorly for a few centimeters to allow for
straightening of the rectum and additional scarring.
48. Abdominal procedures - Rectopexy
● A rectopexy is performed by affixing the pararectal tissue to the presacral
fascia/sacral periosteum in the sacral promontory using nonabsorbable
sutures or mesh.
● Rectopexy has been shown to reduce recurrences when compared with
non-rectopexy.
In a small randomized trial of 63 patients, suture and mesh rectopexy resulted in similar rates of morbidity and
mortality, postoperative incontinence, constipation, and recurrence .
(Novel JR, Osborne MJ. Prospective randomized trial of Ivalon sponge vs sutured rectopexy for full thickness rectal prolapse)
49. ● Suture rectopexy — the general steps include:
○ Select a point approximately 1 to 4 cm below the sacral
promontory for the inferiormost aspect of suture fixation.
○ Place two to three nonabsorbable sutures in the presacral
fascia/sacral periosteum approximately 1 cm apart in a
horizontal mattress fashion.
○ To avoid accidental ligation of the blood supply, kinking of the
bowel, or damage to the underlying nerves, sutures should be
placed only on one side of the rectal mesentery.
50. Anterior resection with
rectopexy, or the Frykman-
Goldberg procedure, for rectal
prolapse.
A, After full mobilization by
sharp dissection, the tissues
lateral to the rectal wall are
swept away laterally.
B, Resection of the redundant
sigmoid colon.
C, Anastomosis is completed,
and rectopexy sutures are
placed.
51. Copyrightsapply
Mesh rectopexy — Mesh rectopexy requires affixing a piece of
mesh to the sacrum with sutures or tacks and affixing the rectum to
the mesh with sutures
Ripstein 's Operation
• The mobile rectum is fixed to
the sacral promontory with an
encircling sling of Marlex,
Teflon or polypropylene
mesh.
• Constipation and partial
obstruction due to a tight
sling and/or angulation of the
redundant sigmoid may
occur.
52. Copyrightsapply
Well’s Procedure
• An encircling sling / mesh is
sutured to the mesorectum
and presacral fascia.
• The sponge causes intense
fibrosis which fixes the rectum
to the sacrum thereby
preventing its prolapse
53. Copyrightsapply
Typically performed laparoscopically
The rectum is not mobilized to avoid damage of the autonomic
nerves, a possible cause of constipation after rectopexy,
the anterior wall of the rectum is sutured to a mesh that is
affixed to the sacral promontory
55. Abdominal procedures - Sigmoid resection
● If the sigmoid colon is redundant in a patient with preexisting
constipation and a rectal procidentia, a sigmoid resection is
typically performed with the rectopexy
56. Complications
● Injury to the sympathetic and parasympathetic nerves from
mobilization of the rectum
● Presacral bleeding
● Strictures
● Pelvic abscesses
● Small bowel obstruction
● Fistulas
● Impotence
● Erosion of the sling into the bladder
● Constipation
57. Candidates for perineal procedures
● In general, the perineal procedures are better tolerated than abdominal
procedures because they can be performed without general anesthesia
and result in fewer complications and less pain
● For technical reasons,
○ a perineal mucosal sleeve resection (Delorme procedure) are
typically performed for short-segment (1 to 3 cm) rectal prolapse;
○ a perineal rectosigmoidectomy (Altemeier procedure) is performed
for rectal procidentias that are more extensive (>3 cm)
○ Analencirclement(Thierschoperation)–temporarily
58. Perineal Procedures - Delorme
Procedure — Mucosal sleeve resection and
muscular plication of the rectal procidentia
This procedure is well suited for patients with short-segment
full-thickness prolapse
The procedure is performed by dissecting within the
submucosal layer of the rectal prolapse.
A: Injection of a dilute saline-epinephrine solution in the
submucosa.
B: Mucosa is incised using electrocautery.
C: Circumferential stripping of the mucosa.
D: Plicating sutures placed in the seromuscular layer of the
rectum. Rectal mucosa is excised.
E: Plication of the seromuscular layer.
F: Completed anastomosis just proximal to the dentate line
59. Perineal Procedures - Altemeier Perineal
Rectosigmoidectomy
A levatorplasty (ie, suture approximation of the
levator muscles) is performed anteriorly to lengthen
the anal canal and provide additional support.
recurrence rates comparable to abdominal approaches have been described with
the perineal rectosigmoidectomy with levatorplasty
(Panel A) An incision is made through the seromuscular layer
anteriorly, within 1 to 2 cm of the dentate line.
(Panel B) The incision is extended circumferentially.
(Panel C) The prolapsed rectum is everted and fully
mobilized. The peritoneal reflexion is incised.
(Panel D) The mesorectumis divided. Full-thickness,
nonabsorbable interrupted sutures are placed betweenthe
divided boweland residual cuff.
(Panel E) The anastomosis is completed.
68. Perineal Procedures - Anal encirclement (Thiersch
operation)
● First described in 1891, and has evolved into a
procedure that is generally used in the
palliative setting.
● While silver wire was the original implant, other
materials have been described such as a
monofilament nonabsorbable suture, synthetic
mesh, and braided vascular graft.
● The implant is buried in the ischioanal fat and
tied snugly
69. Perineal Procedures - Anal encirclement (Thiersch
operation)
Two longitudinal incisions are made and a Kelly clamp is used to create a submucosaltunnel around the
anus.
A meshis passed through the submucosallayer to encircle the anus.
Calibration of the meshtension is performedusing a finger inserted into the anal canal
72. Copyrightsapply
Surgical Outcome
Of the three perineal options,namely the Delorme
procedure, the perineal rectosigmoidectomy,and
the perineal rectosigmoidectomywith
levatorplasty,the perineal rectosigmoidectomy
with levatorplastyhas the longest recurrence-free
interval, the lowest overall recurrence rate, and
the best effects in relation to incontinence and
constipation
Recurrence rates comparable to abdominal
approaches have been described with the
perineal rectosigmoidectomywithlevatorplasty
73. SURGICAL DECISION MAKING
● The choice of operation facing the surgeon is whether to offer an abdominal (open or
laparoscopic) or a perineal approach.
● Patients who are candidates (physically fit) for an abdominal procedure should have an
abdominal rather than a perineal repair.
This is because recurrence rates after an abdominal repair are generally lower than after a perineal repair.
● The perineal approach is less invasive than open approaches and is associated with
shorter hospital stays.
● It is ideal for the elderly or patients with significant comorbidities.
● The perineal approach can be done under regional anesthesia.
74. SURGICAL DECISION MAKING
● The abdominal approach is best suited to young healthy patients with significant
constipation and sigmoid redundancy and incontinence.
● A randomized controlled trial of perineal proctosigmoidectomy with pelvic floor
reconstruction versus open resection rectopexy and pelvic floor reconstruction
showed no difference in recurrence rates; however, incontinence was
significantly improved in the resection rectopexy group
(Deen K I, Grant E, Billingham C, Keighley MRB. Abdominal resection rectopexy with pelvic floor repair versus perineal
rectosigmoidectomy and pelvic floor repair for full-thickness rectal prolapse. Br J Surg. 1994;81(2):302–304. [PubMed]
Surgical management of rectal prolapse. Madiba TE, Baig MK, Wexner SD Arch Surg. 2005 Jan; 140(1):63-73. [PubMed]
75. Management of Recurrent Rectal Prolapse
● Most recurrent rectal procidentias present within three years
after surgery,
● Management of recurrent rectal prolapse is guided by
○ the type of recurrence (mucosal prolapse versus full-
thickness prolapse)
○ the severity of symptoms
■ fecal impaction, small bowel, obstruction stricture,
pelvic abscess, rectal erosion, and hemorrhage.
○ the patient's operative risk profile
○ the approach of the failed repair.
76. ● For patients with asymptomatic or minimally symptomatic rectal
prolapse, initial medical management, including observation and
bowel regimen, may suffice.
● Symptomatic patients with recurrent mucosal prolapse can be treated
with longitudinal multiple rubber band ligation of the prolapsing
mucosa.
● Symptomatic patients with full-thickness rectal procidentia require a
reoperative repair with the surgical options as for primary rectal
procidentia
Management of Recurrent Rectal Prolapse
77. Solitary Rectal Ulcer Syndrome
● Clinical condition characterized by
○ Rectal bleeding, Copious mucous discharge, Anorectal pain, Difficult
evacuation
● Patients are typically young and female, with an average age of 25 years
● 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
78. ● Although identified as an ulcer, the gross pathologic features of
SRUS can range from a typical crater-like ulcer with a fibrinous
central depression to a polypoid lesion.
● Cause unclear, associated with chronic inflammation or trauma
(internal intussception or prolapse of the rectum, direct digital
trauma, or forces to evacuate hard stool)
● It is frequently although not exclusively associated with internal
intussusception or full-thickness rectal prolapse.
Solitary Rectal Ulcer Syndrome
79. Solitary Rectal Ulcer Syndrome
● The rectal ulcer is usually found on proctoscopy or flexible
sigmoidoscopy
● Histology reveals a thick layer of fibrosis obliterating the lamina
propria and a central fibrinous exudate.
● Differentiating SRUS from malignant disease, infection, or Crohn’s
disease is important but not difficult.
● The anterior location in the context of classic symptoms and
pathologic findings is conclusive.
80.
81. Conclusion
⏷ Rectal prolapse is a chronic disturbing condition, which affects women primarily, with
varying degrees of incontinence.
⏷ The precise etiology is unclear and there are numerous surgical options.
⏷ The apparent enthusiasm and ingenuity of surgeons in the quest to define the ideal
prolapse operation serve only to highlight its elusiveness
⏷ Concomitant pelvic organ prolapse can be present in up to one third of women who
present with rectal prolapse. Evaluation by a multidisciplinary team (ie, surgeon,
gynecologist, urologist) for a combined surgical repair procedure may be required
82. References
⏷ Archampong, E. Q. et al. BAJA’s Principles and Practice of Surgery in the Tropics Including
Pathology, 5th Edition.
⏷ Brunicardi, F. Charles et al. Schwartz’s Principles of Surgery, Eleventh Edition
⏷ Farquharson, Margaret. Farquharson’s Textbook of Operative GeneralSurgery, Tenth
Edition
⏷ Fischer, Josef. Fischer’s masteryof surgery / editor, 7th
Edition
⏷ Madhulika G Varma, MD, Surgical approach to rectal procidentia (rectal prolapse) (2021).
UpToDate
⏷ Madhulika G Varma , Overview of rectal procidentia (rectal prolapse) : (2021). UpToDate
⏷ LeonelA Rodriguez,MD, MS (2020) Rectalprolapse in children. UpToDate
⏷ Townsend, Courtney M. Jr., et al. Sabiston Textbook of Surgery : The Biological Basis of
Modern Surgical Practice, 20th Edition
⏷ Williams, Norman. Bailey & Love’s Short Practice of Surgery, 27th Edition
