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Rectal prolapse
This document describes a case of rectal prolapse in a 15-year-old male patient who reported a mass coming out of his anus for the past 4 years. On examination, the doctor observed a pinkish mass coming out of the anus during straining that was soft and reducible. Rectal prolapse was included in the differential diagnosis along with large rectal polyp and hemorrhoids. The document proceeds to provide details on the types, causes, symptoms, evaluation, and management of rectal prolapse, including non-surgical and surgical treatment options such as perineal and abdominal procedures. Complications of treatment are also discussed.
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Rectal prolapse
- 1. Approach to Pt. WithSomething Coming out of Anus DR. HASSAN MAHMUD PGR TEACHING SURGERY UNIT A.B.S.T.H
- 2. History Usama 15year Male Student Kotla Gujrat Opd 15-03-16
- 3. Presenting Complaint Somethingcoming out of anus- 4years Bleeding PR on & off- 4years
- 4. HOPI Pt. wasalright 4 years back when he noticed something coming out of anus. It was initially small but gradually increased in size. It is including whole circumference of anus. It always comes out during defecation or straining. It is associated with bleeding per rectum. It is of bright red color & comes after defecation. There is no associated bruises on skin or Hx of gum bleed. No Hx of constipation, diarrhea, jaundice. He has Hx of sodomy.
- 5. Cont. No pastmedical or surgical Hx No family Hx No personal Hx No drug Hx
- 6. Impression Rectal Prolapse Large rectal polyp Hemorrhoids
- 7. Examination A younghealthy boy, well oriented, lying comfortably on bed Vitals: Pulse: 82/min Temp: 98 degree F B.P: 110/70 mmHg R.R: 24/min
- 8. Examination A pinkishmass coming out of anus during straining, covering anus circumferentially, soft in consistency, non tender, no bleeding spots, having concentric rings and grooves around its wall, reduced manually.
- 9. Cont. GIT: Normal CVS: Normal CNS: Normal Resp: Normal Genitourinary: Normal
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- 12. Rectal Prolapse DR. HASSAN MAHMUD PGRTEACHING SURGERY UNIT A.B.S.T.H
- 13. Outline Introduction Types Etiology Pathophysiology Clinical Features Evaluation Examination Investigations Non surgical Management Surgical Management Complication
- 14. Introduction Rectal Prolapse iscircumferential descent of rectum (bowel) through the anal canal. Common in infants, children & elderly Common in females (6:1)
- 15. Types Partial orRectal mucosal prolapse: • Protusion of the rectoanal mucosa & submucosa Complete prolapse or Procidentia • Include mucosa, submucosa & muscles Internal prolapse or intussusception: •Occult rectoanal intussusception • Prolapse does not protude from the anus •Not always pathologic/symptomatic • Occurs in 50% of defograms
- 16. Mucosal vs FullRectal Prolapse
- 17. Mucosal vs FullRectal Prolapse
- 18. Difference Between Rectal Prolapseand Hemorrhoids Rectal Prolapse Hemorroids Tissue Folds Circumferential Radial Abnormality on Palpation Double Rectal Wall Hemorrhoidal Plexus Resting and Squeeze Pressures Decreased Normal
- 19. Difference Between Rectal Prolapseand Hemorrhoids
- 20. Etiology Extreme ofage Children: first three years (male=female) ● Cystic fibrosis, malnutrition, diarrhea, severe cough, parasites Constipation (component of colonic dysmotility) Weakening/malfunctioning of pelvic floor/sphincters Anismus – spastic pelvic floor Pudendal neuropathy (obstetric injuries, aging) Sphincter dysfunction (trauma, aging) Decreased sacral curvature Multipara female Diarrhea, cough, malnutrition Decreased ischiorectal fossa fat Mental illness (depression, autism)
- 21. Pathophysiology Rectum passesthrough opening in pelvic floor funnel Intussusception occurs much like what happened with hiatal hernia • Lateral & rectosigmoid attachments relax • Mesorectum lengthens •Anal sphincters stretch • Rectal prolapse
- 23. Pathophysiology Associated pelvicanatomic abnormalities ● Deep anterior cul de sac ● Redundant sigmoid colon ● Patulous anal sphincter ● Loss of posterior rectal fixation
- 24. Clinical Features MucusDischarge Rectal Bleeding Soilage Feeling of incomplete evacuation Diarrhea, constipation, Fecal Incontinence Itching
- 25. Clinical Features Constipationis associated with prolapse in 30%-70% of pts Chronic straining, sensation of anorectal blockage, need of digital evacation 60% have coexisting incontinence ● Stretching of anal sphincters ● Impaired rectal compliance 20-35% have associated urinary incontinence
- 26. Evaluation Ask patientto produce the prolapse If not obvious ● straining in sitting position (toilet) ● phosphate enema or glycerine suppositories (children) to induce strain Look for associate vaginal prolapse (15-30%)
- 27. Examination Concentric ringsand grooves Perianal skin excoriation and maceration Chronic prolapse ● Inflamed, edematous and irregular surface ● Biopsies to rule out neoplasia Digital examination ● Sphincter pressures
- 28. Investigations Colonoscopy orbarium enema ● Exclude tumor ● Biopsy of ulcers and mass lesions Defecography • Megarectum, incontinence, nonrelaxing puborectalis, abnormal perineal descent, rectocele, mucosal prolapse N Normal rectal fixation & sphincter relaxation 1 Nonrelaxed puborectalis 2 Mild intussusception 3 Moderate intussesception 4 Severe intussesception 5 Prolapse R Rectocele
- 29. Investigations Anal manometrycan help assess sphincters ● Longstanding prolapse may damage internal sphincter EMG for patients with history of severe straining Pudendal nerve latency study Pudendal nerve terminal motor latency (1.8-2.2msec)
- 30. Non operative management Treat constipation ● Fiber supplements ● Stool softeners Reduce incarcerated rectal prolapse ● Table sugar
- 31. Surgical Treatment PertialRectal prolapse Improve nutrition, correct constipation Submucosal injection of 10ml of 5% phenol in almond oil, tetracycline, hypertonic saline Thiresch wiring Goodsall,s operation(excision of prolapsed mucosa at three different places) Stapled transanal rectal resection surgery(STARR)
- 32. Surgical Treatment Complete RectalProlapse Perineal procedures ● Resection, reefing, and encirclement Abdominal procedures ● Fixation, colon resection or combination of both
- 33. Choosing Type ofSurgery/ Perineal High-risk or eldery patients Advantages ● Low morbidity and pain ● Low mortality Disadvantages ● Higher recurrence rate ● Risks coloanal leak
- 34. Choosing Type ofSurgery/ Abdominal Overall better results than perineal approaches Full mobilization of the rectum, sacral fixation with or without resection Younger patients
- 35. Choosing Type ofSurgery Perineal ● Recurrence (20%) ● Constipation rate unchanged ● Persistent incontinence worse rate due to removal of rectal resevoir ● Correction of associated abnormalities (rectoceole, sphincter) ● No pelvic dissection – preserves sexual function Abdominal ● Recurrence low (<10%) ● ↑ constipation 50% ● Higher M & M esp. with anastomosis ● Mesh placement – stricture, migration, erosion, infection
- 36. Perineal Procedures PerinealProctosigmoidectomy – Altemeir Mucosal Sleeve Resection - Delorme Anal Encirclement - Thiersch Wire Technique Perineal suspension/fixation - Wyatt
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- 42. Perineal Procedures - Advocates Pts suffer mainly from incontinence, constipation and decreased quality of life Pts are not mainly threatened from recurrence Surgery should be verified in priority to its effect on post op QOL rather than recurrence
- 43. Abdominal Procedures Anteriorrectopexy or Ripstein procedure ● Anterior wrapping of the rectum and fixation to sacrum Posterior rectopexy - Wells procedure ● Synthetic mesh ● Sutures alone Sigmoid colectomy with sutured rectopexy ● Low recurrence ● Low morbidity ● Improves constipation
- 44. Materials used forMesh Rectopexy Natural • Fascia Lata Non-absorbable Synthetic • Nylon • Polypropylene • Marlex • Polyvinyl Alcohol • Polytef Absorbable Synthetic • Polyglactin • Polyglycolic Acid
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- 48. Laparoscopic Rectopexy Largelyreplacing open abdominal procedures Ease of performing rectopexy and colon resection simultaneously with shorter hospital stay Morbidity and mortality no different than open controls Recurrence rate lower but not statistically significant
- 49. Laparoscopic Rectopexy Idealapproach Laproscopic posterior mesh rectopexy Posterior as well as anterior mobilisation of rectum done, mesh placed in presacral region and sutured to rectal wall and presacral fascia Laproscopic sigmoid resection and rectopexy Done in rectal prolapse with constipation, excess redundant sigmoid colon with kinking
- 50. Complications Injury tohypogastric nerve causing impotence Bladder dysfunction Bleeding from sacral venous plexus Injury to rectum & colon causing fistula Constipation after rectopexy Recurrence Infection
- 51. Recurrence Can happenafter either perineal or abdominal procedure ● Overall 15% recurrence rate (range is 0-60%) ● Abdominal operations – up to 10% ● Perineal operations – up to 20%
- 52. Recurrence 2 typesof recurrence ● Mucosal ● Full thickness Early recurrence ● Occurs within first year ● Likely the result of a specific technical failure Non-early(late) recurrence ● Generally occurs 18-24 months postoperatively
- 53. Recurrence - Etiology Surgical factors ● Inadequate mobilization of rectum ● Inadequate fixation of the rectum to the sacrum ● Incomplete resection of a redundant rectosigmoid Nonsurgical factors: ● Vigorous physical activity or childbirth – disruption of pexy ● Continued constipation with persistent straining Pathophysiologic factors: ● Disordered defecation ● Intestinal dysmotility
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