Lecture notes for medical students

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2. Format

3. Format
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10.Prevention

4. Introduction & History.

5. Introduction & History.
• Rectal prolapse occurs when a mucosal or
full-thickness layer of rectal tissue protrudes
through the anal orifice.
• Three different clinical entities are often
combined under the umbrella term rectal
prolapse:
1. Full-thickness rectal prolapse
2. Mucosal prolapse
3. Internal prolapse (internal intussusception)

6. Introduction & History.
• Full-thickness rectal is defined as protrusion of
the full thickness of the rectal wall through the
anus; it is the most commonly recognized type.
• Mucosal prolapse, in contrast, is defined as
protrusion of only the rectal mucosa (not the entire
wall) from the anus.
• Internal intussusception may be a full-thickness
or a partial rectal wall disorder,
• Today we shall focus on full-thickness rectal
prolapse, which will be referred to as rectal
prolapse.

9. Relevant Anatomy

10. Relevant Anatomy
Common anatomic features-
• Patulous or weak anal sphincter
• Levator diastasis,
• deep anterior Douglas cul-de-sac,
• poor posterior rectal fixation with a long
rectal mesentery,
• Redundant rectosigmoid.
Whether these anatomic features are the cause
or result of the prolapsing rectum is not
known.

11. Relevant Anatomy
Common anatomic features in children-
• vertical orientation of the rectum,
• the mobility of the sigmoid colon,
• the relative weakness of the pelvic floor
muscle
• mucosa that is poorly fixed to submucosa
• Redundant rectal mucosa..

12. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative
• Iatrogenic
• Psychosomatic

13. Associated conditions-
• chronic straining with
defecation and
constipation.
• Pregnancy
• Previous surgery
• Diarrhea
• Benign prostatic
hypertrophy
• Chronic obstructive
pulmonary disease
(COPD)
•
• Cystic fibrosis
• Pertussis (ie,
whooping cough)
• Pelvic floor
dysfunction
• Parasitic infections –
Amebiasis,
schistosomiasis
• Disordered defecation
(eg, stool withholding)
• Neurologic disorders -

14. Associated conditions-
• Neurologic disorders - Previous lower
backor pelvic trauma/lumbar disk disease,
cauda equina syndrome, spinal tumors,
multiple sclerosis

15. Pathophysiology

16. Pathophysiology
• The pathophysiology of rectal prolapse is not
completely understood or agreed upon.
• The first theory postulates that rectal prolapse is a
sliding hernia through a defect in the pelvic fascia.
• The second theory holds that rectal prolapse starts
as a circumferential internal intussusception of the
rectum beginning 6-8 cm proximal to the anal
verge.
• Often, prolapse begins with an internal prolapse of
the anterior rectal wall and progresses to full
prolapse.

17. Clinical Features

18. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

19. Demography

20. Demography
• The annual incidence 2.5 per 100,000
• peak incidences are observed in the fourth
and seventh decades of life.
• Pediatric patients usually are affected when
younger than 3 years with the peak
incidence in the first year of life.
• The incidence of prolapsed rectum in
children with cystic fibrosis approaches
20%.

21. Demography
• In the adult population, the male-to-female
ratio is 1:6.
• pediatric population: equal

22. Symptoms

23. Symptoms
• Mass protruding through the anus
• Pain
• Some 10-25% of patients also have uterine
or bladder prolapse,
• and 35% may have an associated cystocele.
• Constipation occurs in 15-65% of cases.
• There may also be rectal bleeding.
• fecal incontinence

24. Symptoms
• mass protruding through the anus
• Initially only after a bowel movement and
usually retracts when the patient stands up.
• As the disease process progresses, the mass
protrudes more often, especially with
straining and Valsalva maneuvers such as
sneezing or coughing.
• Finally, the rectum prolapses with daily
activities such as walking and may progress
to continual prolapse.

25. Symptoms
• As the disease progresses, the rectum no
longer spontaneously retracts, and patients
may have to replace it manually.
• may then progress to a point where the
rectum prolapses immediately after being
replaced and is continuously prolapsed.
• Rarely, the rectum becomes incarcerated,
and patients cannot replace the rectum.

26. Signs

27. Signs
• Protruding rectal mucosa
• Thick concentric mucosal ring
• Sulcus noted between anal canal and rectum
• Solitary rectal ulcer (10-25%)
• Decreased anal sphincter tone
• The patient is asked to sit on a toilet and
strain, after which the rectum should
prolapse.
• phosphate enema glycerin suppository

28. Signs
• The protruding mass should show
concentric rings of mucosa.
• Mucosal prolapse typically exhibits radial
folds instead of concentric rings.

29. Prognosis

30. Prognosis
• The prognosis generally is good with
appropriate treatment.
• Spontaneous resolution usually occurs in
children.

31. Complications

32. Complications
Uncommon
• incarceration and strangulation (rare).
• Bleeding
• Ulceration
• Incontinence

33. Investigations

34. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histology

35. Investigations
• Laboratory Studies
– sweat chloride test for pediatric patients; as
many as 11% of children with rectal prolapse
have cystic fibrosis.

36. Diagnostic Studies

37. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

38. Diagnostic Studies
Imaging Studies
• Rigid proctosigmoidoscopy- solitary rectal
ulcers.
• Colonoscopy
• Barium enema
• Video defecography
– internal prolapse or to distinguish rectal
prolapse from mucosal prolapse
– intussusception of proximal colon
– pelvic outlet obstruction.

39. Diagnostic Studies
Other Tests
• Anal-rectal manometry
• The Sitz marker study
• Pudendal nerve terminal motor latency

40. Differential Diagnosis

41. Differential Diagnosis
• Hemorrhoids
• Intussusception
• Proctitis
• Rectal polyps
• Evaluate pediatric patients for cystic
fibrosis

42. Management

43. Management
• In adult patients, treatment of rectal
prolapse is essentially surgical;
• Children, however, can usually be treated
nonsurgically.

44. Non Operative Therapy

45. Non Operative Therapy
• Reduce with gentle digital pressure
sedation,
• Field block with local anesthetic
• Sprinkling the prolapse with either salt or
sugar to decrease the edema.
• Manage constipation and diarrhea

46. Emergency Surgery

47. Emergency Surgery
• If the prolapse cannot be reduced and the
viability of the bowel is in question
• Rupture of the rectum

48. Operative Therapy
•

49. Operative Therapy
• Surgical treatments can be divided into two
categories-
1. Abdominal procedures
2. Perineal procedures.
• The abdominal procedures have a lower
recurrence rate but a higher morbidity.
• Older, debilitated patients -perineal
procedures
• Younger, healthier patients -abdominal
procedures.

50. Operative Therapy
Abdominal procedures
• Anterior resection
• Ripstein procedure Marlex rectopexy-
Marlex mesh or an Ivalon sponge.
• Suture rectopexy
• Laparoscopic surgical rectopexy
• Frykman-Goldberg procedure- resection
with rectopexy

51. Operative Therapy
Perineal procedures
• Anal encirclement Thiersch wire
• Delorme mucosal sleeve resection
• Altemeier perineal rectosigmoidectomy
• Hemorrhoidectomy-Mucosal prolapse
• Perineal stapled prolapse resection

52. Minimally invasive Therapy
• A laparoscopic approach to rectal prolapse
repair

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