Rectal Prolapse - Called as Guda bhramsha in Ayurveda.

1. RECTAL PROLAPSE
Done by, Under the guidance of,
Dr ANISHA S ASHRAF Dr Gopikrishna B J
FINAL YEAR PG SCHOLAR PROFESSOR & HOD
DEPT OF SHALYA TANTRA,SDMCAHH

2. DEFINITION
 Protrusion of the rectal mucosa or full thickness of rectum
through the anus is known as rectal prolapse.
 Circumferential descent of rectum through the anal canal

3. ETIOLOGY
 Sliding herniation of pouch of douglas through pelvic
floor fascia into the anterior aspect of rectum
 Procidentia is a full thickness rectal intussusception
starting approximately 7.5 cm above the dentate line
which is extending beyond the anal verge.
 Commonly seen in infants, children and elderly
 Common in females 6:1

4. TYPES
 Partial
 Complete
 Hidden/ concealed
PARTIAL RECTAL PROLAPSE

5. HIDDEN/CONCEALED PROLAPSE
 Internal intussusception of
the sigmoid into the rectum
or part of the rectum distally
 Do not come out of the anal
orifice
 Only mucosa and submucosa
separates from muscularis layer
and descends
 May be associated with SRUS

6. PARTIAL PROLAPSE
 Only mucosa and submucosa comes out
 Length is not more than
3.75 cm
 Commonest type
 When the prolapsed mucosa is palpated between the finger and
thumb, it is evident that it is composed of no more than a double
layer of mucous membrane

7. IN INFANTS
 Sacral curve of rectum is
not developed
 Direct downward course
 Diminished tone of anal
musculature

8. IN CHILDREN
 Faulty bowel habit
 Straining – diarrheal attacks,
whooping cough
 Malnutrition – loss of para-rectal
fat
 Habitual constipation
 Associated with
 Fibrocystic disease,
 Neurological causes
 Mal development of the pelvis.

9. IN ADULTS
 Some loss of sphincter tone
 May be associated with 3rd degree
haemorrhoids
 In female torn perineum - common
in multipara
 Excessive straining in – BPH,
Urethral strictures
 Excessive cough – Bronchitis
 Post operative cases – injury to
sphincter muscles

10. CLINICAL FEATURES
 History of mass per
anum
 Observed in squatting
position
 Pink in color and
circumferential
(Haemorrhoids are not
circumferential and plum
or blue color)

11. MANAGEMENT
Conservative:
 Treat malnutrition
 Digital reposition: By index finger
after lubricating
 Appropriate bowel movements
(Avoid constipation) – use of stool
softeners and bulking agents rather
than stimulant
 Avoid straining and adaptation of
defecatory habit

12. SUBMUCOUS INJECTION
 5% Phenol with Almond oil under GA – 10
ml in one sitting
 Only after digital reposition fails – 6 weeks
 Apex is injected circularly then reach
submucosa
 Similarly base of the prolapse is injected
 Sterile inflammation – fibrosis – fixed to
muscular coat
 Ethanolamine oleate can also be used

13.  Alternatively 30 ml of tetracycline or oxytetracycline
or hypertonic saline injection can also be used
 Initial injection is supported by Thiersch wiring –
chromic catgut -(in 3 weeks)

14. APPLICATION OF BARRON BANDS
 Special rubber bands tied on the bases
 Endoscopically

15. OPERATIVE TREATMENT
Thiersch’s operation:
 When conservative measures fail
 To patients of any age group
 Can be repeated if recurs
 In children with rectal prolapse, temporary wiring along
with Goodsall’s ligature or injection sclerotherapy using
thick catgut are often advocated

16. CONT...
 2 midline small incisions one in front and one
behind
 ½ inch away
 A long curved needle is passed from posterior
incision emerging through anterior incision
 A piece of silver wire or stainless steel wire
20G is threaded through eye of the needle
 Polypropylene, Nylon can also be
used

17. THIERSCH’S OPERATION CONT...
 Needle is taken out
 Reinsert needle from posterior opening
 Now taking out from other half through
anterior incision with other end of wire
 Index finger (Little finger in children)
should be inserted to anal cavity
 Assistant should twist the two ends of
wire and make tight
 Twisted ends are cut short

18. THIERSCH’S OPERATION CONT...
 Anterior and posterior incisions are closed with
stitches
 Gives mechanical support and chemical support by
fibrous deposition around anal canal
 Wire can be removed after 3-12 months if required
 In children stitches should be removed to prevent
stenosis (Strong chromic catgut can be used)
 Complication – wound – discharging sinus –
Perianal sepsis; Anal stenosis; Breakdown of wire;
fecal impaction; high recurrence;

19. EXCISION OF PROLAPSED MUCOSA
 Endoluminal stapling technique
 When a part of circumference is
involved
 Base – ligated by Goodsall’s
ligature
 Transfixed twice and tightened
 Redundant mucosa is excised
 If required cut margins are sutured
interruptedly
 Can be adopted when associated
with 3rd degree haemorrhoids

20. STAPLED TRANSANAL RECTAL RESECTION
SURGERY (STARR)
STARR – Exposure of the prolapse. b Traction sutures. c Opening of the prolapse. d
Progressive stapling. e Control of hemostasis f Final appearance of the staple line

21. COMPLETE PROLAPSE (PROCIDENTIA)
 Prolapse of all layers of rectal wall
 It is descending sliding hernia
 Always more than 3.75 cm usually
10-15 cm
 Contains pouch of peritoneum
anteriorly (If large may contain
coils of intestine)
 Rare in children, common in
elderly, women
 Due to weakened levator ani and
supporting pelvic tissues

22. CLINICAL FEATURES
 Complete descent of rectum as mass per anum
circumferentially - red in colour.
 Mass usually reducible and painless. Incarcerated or
infected rectal prolapse is painful.
 May be associated with the uterine prolapse (uterine
procidentia) in females.
 Faecal incontinence (75%) is very common – due to
disruption of the anal sphincter and prolapsed rectal
mucosal discharge.
 Bleeding – because of the congestion.
 Sepsis, discharge, fever, anaemia.
 P/R examination shows lax sphincter.

23. DIFFERENTIAL DIAGNOSIS
 Large 3rd degree haemorrhoids
 Large polypoid tumor
 Prolapse of sigmoid colon
 Intussusception
 Proctitis

24. ANORECTAL PHYSIOLOGICAL INVESTIGATION
1. ANORECTAL MANOMETRY:
 Normal resting pressure 40-80 mmHg – Function of internal
anal sphincter
 Squeeze pressure – maximum voluntary contraction minus
resting pressure. It is 40-80 mmHg above resting pressure.
Reflects function of external anal sphincter
 Measured by placing water filled balloons attached to catheters
and transducers placed in the anal canal

25. 2. NERVE CONDUCTION STUDIES
 To know about function of Pudendal nerve and
branches:
Pudendal nerve latency study:
 Specialized transducer attached to a glove like
device is to be worn on the finger through which
digital rectal examination is done
 Electrode in the finger is directed over the right and
left levator ani complex to measure pudendal nerve
terminal motor latency (PNTML)
 Normal : 1.8–2.2 msec.
 Prolonged in pudendal nerve damage

26. 3. DEFECOGRAPHY
 Increased mobility of rectum from sacral fixation point
 Fluoroscopic and spot filming in lateral projection after
instilling radio-opaque material into the rectum
 Done in sitting posture over a radiolucent commode

27. 3. DEFECOGRAPHY CONT...
 For complex pelvic floor problems: Cinedefecography,
triple contrast cinedefecography, dynamic MRI
defecography, colpocystodefecography
 Preprolapse in defecography: Rectum is funnel shaped;
lack of fixation to sacrum; excessive rectosigmoid
mobility; Ring pocket formation; Intussusception
 Rectal prolapse in defecography: Redundant sigmoid
colon, wide deep pouch of Douglas

28. DEFECOGRAPHIC GRADING OF RECTAL
PROLAPSE
N— normal rectal fixation and
sphincter relaxation and rectal
emptying
1—nonrelaxed puborectalis
2—mild intussusception
3—moderate intussusception
4—severe intussusception
5—prolapse
R—rectocele

29. SIGMOIDOSCOPY
 To detect the tumor in the intussuscepted prolapsed rectum –
Occasional

30. AIM OF MANAGEMENT
 To control the prolapse; to restore continence; to prevent
constipation
 Should avoid abdominal repair in young males – may injure
pelvic nerves – impotency
 Delorme’s operation is better option in young with complete
prolapse
 Anal encircling surgeries using synthetic wires/mesh/suture
materials are limited to extremely ill patients and elderly
who will not withstand perineal proctectomy

31. MANAGEMENT
 PERINEAL PROCEDURES
 Delorme’s procedure
 Altemeier’s procedure
 Thiersch wiring
 ABDOMINAL PROCEDURES
 Wells operation – posterior rectopexy
 Ripstein sling operation – anterior rectopexy
 Mesh rectopexy
 Lahaut’s operation

32. FIXATION OPERATIONS
1. IVALON SPONGE WRAP OPERATION
(WELLS’)
 Abdominal approach
 Rectum is fully mobilized posteriorly
 Rectangular sheet Ivalon sponge (Polyvinyl
alcohol ) – sutured to the presacral fascia and
periosteum of sacrum
 Mobilized rectum is drawn up
 Ivalon sponge is wrapped over and sutured
 Anterior surface is uncovered
 Ivalon sponge will initiate fibrosis and fixes
rectum
 Chances of infection and fistula formation are
high

33. 2. RECTOPEXY (LOCKHARDT MUMMERY
OPERATION)
 Abdominal approach, rectum mobilization
 A curved incision about 2 inches in length is made
midway between the anus and tip of coccyx
 Incision is deepened
 Fibers of external sphincter and anococcygeal
ligament ligaments are cut
 Further fascia of Waldeyer is incised transversely
 Rectum is stripped off to 3rd sacral vertebra
 Resulting cavity is packed with long strips of guaze
of polyvinyl alcohol sponge
 This is attached to fascia in front of the sacrum by 3
or 4 sutures

34. MESH RECTOPEXY
 Instead of Polyvinyl sponge, a marlex
mesh is kept behind the rectum
 Sutured behind to sacrum then to the
posterior and lateral surfaces
 Laparoscopic methods are popular –
procedure of choice
 Constipation is one of the
complications
 Some resect sigmoid colon with this
procedure – Goldberg operation

35. LAPAROSCOPIC POSTERIOR MESH
RECTOPEXY (LPMR)
 Ideal and good
 Prior bowel preparation is needed
 Head down, low lithotomy position
 Ports are placed
 Sigmoid colon is held by left side port
 Surgeon dissects from right side

36.  Peritoneum on the right of the rectum is opened from
sacral promontory downwards to reach presacral
avascular plane
 Injury to autonomic nerves, ureters should be avoided
 Dissection is extended down for adequate mobilization
 Lateral ligaments are either divided or left alone
 Anterior mobilization along with Denonvillier’s fascia
5 cm below the peritoneal reflection

37.  10 x 6 cm polypropylene mesh is placed in the
presacral space deep to rectum then fixed to
presacral fascia along with sacrum and sacral
promontory
 Mesh is sutured to rectal wall also on both
sides using interrupted polypropylene sutures
 Only partial wrapping of mesh is done and
peritoneum is closed using vicryl

38. 3. RECTAL SLING OPERATION (RIPSTEIN)
 Abdominal approach
 Rectum is mobilized down to the tip of
the coccyx
 Rectum is freed from sacrum
 Rectum is pulled up taut
 5 cm band of Teflon is placed around
the rectum
 Free ends of band are sutured to
Presacral fascia and periosteum of the
sacrum 5 cm below the promontory of
the sacrum
 Sling should be loose enough to allow
one finger to pass between the Rectum
and the sacrum

40. 4. PERINEAL APPROACH – DELORME’S
OPERATION
 Mucosal sleeve resection and plication
 Prior bowel preparation
 Under Spinal anaesthesia in lithotomy position
 Collapsed rectum is pulled down as far as possible with Babcock’s
forceps
 1 in 2,00,000 adrenaline solution is injected into the submucosal
plane of the rectum to cause haemostasis
 Longitudinal incision – with sharp scissor and cautery dissection

41.  Mucosa is stripped off from the deeper muscular layer from 1
cm below the anal margin to the apex of the prolapsed rectum
 Series of chromic catgut sutures are placed to imbricate the
underlying muscle – plication – by using vicryl 2-0 –
interrupted suturing – all around – 12-15 stiches are needed
 After this rectal muscles are pulled up towards the anal canal
 Anal canal mucosa is sutured with rectal mucosa interrupted
vicryl sutures
 Easy in elderly; relapse rates are high; does not correct defect

42. 5. LAHAUT’S OPERATION
 The whole of rectum and sigmoid colon are mobilized
 Held up
 Stitched with the rectus sheath
 Not popular nowadays

43. 6. GOLIGHER’S OPERATION
 Rectum is entirely mobilised up to anorectal
ring
 Posterior muscular layer is fixed to pre-
sacral fascia using interrupted
polypropylene sutures

44. DEVADHAR RECTAL PLICATION
 Abdominal approach
 Junction between thicker lower part
and thinner upper part of the
intussusception is identified
 A purse string suture using silk is
placed in front and laterally
 Further 3-4 interrupted submucosal
Lambert sutures are placed to create
reverse intussusception

45. RESECTION OPERATIONS
1.ANTERIOR RESECTION OF
RECTUM:
 In lithotomy- trendelenberg position
 A guaze piece is inserted into the anus
 Long right paramedian incision from
umbilicus to 2 cm below the pubic
crest
 Inferior mesenteric artery is ligated
 Splenic flexure and descending colon
are mobilized
 Rectum is pulled forward
 Separated from sacral promontory and
presacral fascia as far down as the tip
of the coccyx and pelvic floor muscle

46.  Anteriorly seminal vesicles are pulled forward by using
St. Mark’s retractor and dissection is done in between
vesicles and rectum
 Denonvillier’s fascia is incised transversely till pelvic
floor
 In female dissection is carried out between rectum and
vagina
 Lateral ligaments are dissected
 Ligation of superior rectal arteries and veins

47.  The proximal line of resection should be at convenient
point at rectosigmoid junction or redundant sigmoid colon
is also resected
 The anastomosis can be done to the anus by suturing or
stapling
 Anastomosis is checked digitally or sigmoidoscopically
 Some fluid is placed in pelvis and air is blown from
sigmoidoscope if no bubbles means anastomosis is
satisfactory

48.  The peritoneum is sutured to the
pelvic colon well above the line of
anastomosis
 A drain is placed in left iliac fossa
into pre-sacral space
 Abdomen is closed in layers
 Drain is usually removed after 48
hours

49. 2. PERINEAL RECTOSIGMOIDECTOMY –
ALTEMEIER’S PROCEDURE
 In Trendelenburg position or prone jack knife position
 Circular incision is made from the outer layer of the
prolapse 2 cm proximal to the dentate line
 Anteriorly as the incision is deepened peritoneal cavity
is opened
 Excision of the prolapsed rectum and associated
sigmoid colon from below, and construction of a
coloanal anastomosis.

50. PERINEAL RECTOSIGMOIDECTOMY

51. SACRAL PROCEDURES
 In jack-knife position
 Incision is made over coccyx and para-sacral
area
 Accessing pre-sacral and post-rectal space
 Rectum is mobilized and shortened by
imbricating sutures
 Foreign material is placed in pre-sacral area
 None of these procedures has stood the test of
time and become particularly popular

52. COMPLICATIONS OF RECTAL PROLAPSE
 Proctitis
 Ulceration
 Rarely bleeding
 Gangrene of the rectum
 Rarely anemia, sepsis and fever
 Rupture with evisceration

53. COMPLICATIONS OF SURGERY
 Injury to hypogastric nerve causing impotence
 Bladder dysfunction
 Bleeding from sacral venous plexus
 Injury to rectum and colon causing faecal fistula
 Constipation
 Recurrence of prolapse
 Improper correction of continence occurs in 50%
cases
 Infection—proctitis/pelvic abscess, etc.

54. GUDA BHRAMSHA
 प्रवाहणातिसाराभ्ाां तिर्गच्छति र्ुदां बतहिः |
रूक्षदुबगलदेहस्य िां र्ुदभ्रांशमातदशेि् ||६१|| su.ni. 13/63
 The condition in which, the rectum protrudes
due to the aggravation of Vayu in a weak and
dry patient due to straining during defecation as
in dysentery.
 In Charaka Samhita it has been described as
complication Virechana Ativyapada
 In Astanga Hridaya, It has been named as Guda
Nisarana

55. CHIKITSA
 र्ुदभ्रांशे र्ुदां स्विन्नां स्नेहाभ्क्तां प्रवेशयेि् |
कारयेद्गोफणाबन्धां मध्यस्वच्छद्रेण चमगणा ||६१||
तवतिर्गमार्थं वायोश्च िेदयेच्च मुहुरमुगहुरिः |
क्षीरे महत्पञ्चमूलां मूतिकाां चान्त्रवतजिगिाम् ||६२||
पक्त्वा िस्विि् पचेत्तैलां वािघ्नौिधसांयुिम् |
र्ुदभ्रांशतमदां क
ृ च्छ
रां पािाभ्ङ्गाि् प्रसाधयेि् ||६३||
su.chi.20

56.  The protruded part should be lubricated with
Sneha and fomented then gently reintroduced
manually
 The region of anus should then be bandaged in
the manner of Gophana Bandha with an
opening (Lying immediately below the anus), so
not to interfere with emission of Vayu
 The affected part should then be constantly
fomented
 Changeryadi Ghritapana

57. Mushikadi Taila:
 A quantity of milk, Mahapanchamula, and the flesh of the
mouse, devoid of its intestines should be first boiled
together along with Taila and Vataghna Dravyas
 Thus oil prepared by this method is used internally as well
as externally to treat the difficult cases of Gudabhramsa

58. KSHARA KARMA IN GUDA BHRAMSHA

61. BEFORE KSHARA
KARMA
AFTER KSHARA
KARMA (squatting
position)
AFTER KSHARA
KARMA (Lithotomy
position)

62. CONCLUSION
 Kshara application induces aseptic fibrosis of the anal
mucosa and adheres it properly.
 During the wound healing process it causes cicatrisation
and strengthens the anorectal ring.
 There will be no mass per rectum observed after Kshara
application.