RECTAL PROLAPSE !!!!!!!!!-1.pptx hdhdbdh

OUTLINE
Introduction
Epidemiology
Risk Factors
Types
Causes
Clinical Presentation
Diagnosis
Management
Complication
References
2

INTRODUCTION
Rectal Prolapse is a condition that occurs when the
rectum protrudes and slips or slides out of the anus.
It is commonly caused by the dysfunction or weakening
of the muscles that hold the rectum in place.
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Introduction
In Rectal prolapse, the protrusion of mucus membranes and submucosa of
rectum typically extends 1-4 cm outside the anal opening.
It usually begins with rectal intussusception. This is a condition where one
part of the rectum telescopes into another part.
This telescoping process leads to subsequent protrusion of the rectal tissue
through the anus.

The Rectum
The rectum is the distal 12-15 cm of the large intestine
between the sigmoid colon and the anal canal.
It primarily serves as a reservoir for faecal material
The mucosa is the inner lining of the intestinal tract.
The dentate line is the junction of the ectoderm and endoderm
in the anal canal.
At the end of the rectum is the anal sphincter.
It is supported by the puborectalis sling of levator ani.

It is uncommon, with a prevalence of about 0.25% in adults.
It is estimated that the annual incidence of rectal prolapse was found to be 2.5 per
100,000 population
It is more common in women than men. The male-to-female ratio is 1:6
Pediatric patients usually are affected when younger than 3 years, with the peak
incidence in the first year of life.
EPIDEMIOLOGY

RISK FACTORS
Age ( > 40 years)
Gender ( Female > Male)
Multiparity
Vaginal Delivery
Previous pelvic surgery
Chronic constipation
Chronic diarrhea
7

TYPES OF RECTAL PROLAPSE
Rectal prolapse may be grouped into two;
Partial thickness or mucosal prolapse
Full thickness prolapse
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Mucosal Prolapse
This involves protrusion of only the rectal mucosa (not the entire wall) from the
anus.
It generally occurs when the connective tissue attachments of the rectal mucosa are
loosened and stretched, thus allowing the tissue to prolapse through the anus.
It mostly occurs in children and managed conservatively.
9

Complete Prolapse
This is also known as full thickness rectal prolapse
In this, the entire thickness of the the rectal wall is extruded.
It mainly occurs in adults.
It is frequently associated with symptoms of fecal incontinence.
Presence of full thickening can impact bowel control and may require surgical
intervention for optimal management.
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Mucosal Prolapse
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Complete Prolapse

CAUSES
Children
 Chronic Diarrhea
 Weight loss , leading to decrease of fat in the ischiorectal fossae
 Fibrocystic disease (connective tissue disorder)
 Maldevelopment of pelvis
Adults
 Torn perenium in females
 Straining due to obstruction of urethra in males.
 Atony of sphincter
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CLINICAL PRESENTATION
 Abdominal pain and discomfort
 Bleeding from the anus
 Mucous discharge from the anus
 Faecal Incontinence or reduced ability to control the bowels.
 Protrusion of the rectum through the anus that may reduce spontaneously or require
manual reduction
 Leakage of liquefied faeces, particularly following a bowel motion
 The feeling of constipation or that the rectum is never completely emptied after passing a
motion
13

DIAGNOSIS
History Taking
Physical Examination
 Visual inspection of anus
 Digital rectal exam, using gloved finger
Colonsocopy : This test examines the inside of your large intestine with a flexible scope.
Defecography: This is an imaging study of your muscles when you poop, using an X-ray
or MRI.
14

Diagnosis
 Electromyography: This test determines if nerve damage is the reason why the anal
sphincters are not working properly. It also examines muscle coordination.
 Barium enema (Lower GI series): A chalky liquid containing barium is placed in your
rectum. A series of video X-rays of your lower gastrointestinal tract.
 Manometry : Involves measure of pressure within rectum and anal canal.
15

Differential Diagnosis
Hemorrhoids
There are some similarities, in that, there is bleeding and tissue protrusion in both rectal
prolapse and hemorrhoids.
Differences
 Rectal prolapse involves an entire segment of the bowel located higher up within the body
while hemorrhoids only involve the inner layer of the bowel near the anal opening.
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Differences
 The prolapsed mucus membrane in rectal prolapse appears pink in color and mucus
membranes have smooth, shiny appearance extending outside anal opening whiles
prolapsed internal hemorrhoids are often plum colored or bluish in hue and may have
trifoliate shape resembling cluster of grapes.
17
A = Rectal Prolapse
B = Hemorrhoids

MANAGEMENT
Goals of therapy
 To relieve pain and to stop bleeding
 Restore normal bowel function
 To prevent complications
 To improve patient’s quality of life
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Management
Surgical Management
Non- surgical management
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Non-Surgical Management
This is mostly done in children or when a patient refuses surgery.
 Management includes treating underlying causes.
 The buttocks can also be firmly strapped together with tape between bowel
movements to facilitate spontaneous resolution of prolapse.
 In small or mild prolapse recently occuring, the prolapsed rectum can be pushed back
by applying pressure with hand.
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Non-Surgical Management
 Manual anal support during defecation
 Perineal exercises
 Electrical stimulation
 Submucosal injection of phenol in almond oil
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Non- Surgical Management - Medications
Stool softeners
 Docusate Sodium ( 50-300mg PO OD or divided doses)
 Liquid paraffin, oral, Adults; 10-30 ml at night
 Mineral oil ( 15-45 mL/day PO, single or divided dose)
22

Medications
Osmotic Laxative
 Lactulose (15-30 mL (10-20 g) PO once daily, dose adjusted according to stools
passed)
 Polyethylene glycol ( ~1 heap spoon of oral powder in 120-240 mL of beverage
per day)
 Glycerine suppositories.
 Analgesics for pain management.
23

Surgical Management
This is the treatment of choice.
There are two main procedures;
Abdominal Procedures
Perineal Procedures
The choice of surgical procedure depends on the age, overall health and surgical
considerations.
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Abdominal Procedures
This is the procedure of choice for the young and fit individuals due to their potential for
improving continence and having lower recurrence rates.
It is not suitable for the elderly or infirmed patients.
Procedure includes:
Abdominal Rectopexy
Laparascopic Rectopexy
Resection Rectopexy
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Abdominal Rectopexy
Rectopexy refers to the fixation of the rectum in the pelvis with nonabsorbable suture or
mesh. Suturing the rectum to the sacral promontory aims to prevent the telescoping of the
redundant bowel.
 Suture Rectopexy:
Suture rectopexy is when the rectum is surgically fixed to sacrum using sutures. It reduces
the risk of foreign body reactions but has a slightly higher recurrence rate.
26

Abdominal Rectopexy
Anterior Mesh Rectopexy
With this procedure, a synthetic mesh is placed around the rectum and fixed to the sacrum. It
provides strong support but carries a risk of infection and constipation.
Posterior Mesh Rectopexy
The rectum is mobilized and attached to the sacrum while preserving autonomic nerves. The
mesh is positioned posteriorly between rectum and sacrum. This procedure lowers the risk of
constipation compared to anterior mesh rectopexy.
27

Laparoscopic Rectopexy
A minimally invasive approach (laparoscopic or robotic), where a mesh is placed
ventrally to reinforce the rectovaginal or rectovesical septum.
Advantages of this procedure are lower risk of constipation, less nerve damage, and
good long-term outcomes.
28

Resection Rectopexy
This procedure combines rectopexy with resection of a redundant segment of the
sigmoid colon to reduce constipation.
It involves removing the sigmoid colon and fixing the rectum to the sacrum.
It is recommended for patients with chronic constipation and redundant bowel loops.
29

Perineal Procedure
This procedure is well tolerated by the elderly, frail/unfit patients.
It is less likely to improve continence
It includes;
 Delorme's mucosectomy
 Thiersch & Encirclement
 Atemeier Rectosigmoidectomy
30

Delorme's Mucosectomy
This is a procedure where the prolapse mucosa is excised and rectal wall,
plicated or folded to reduce prolapse.
It is typically performed for short segment ( 1 to 3cm ) rectal prolapse
31

Thiersch Repair
In this procedure, the circumferential suture is placed around the rectum to tighten and
secure it.
The anal canal is tightened by passing a silver/nylon/silicone rubber in perineal space
32

Atemeier Rectosigmoidectomy
In this procedure, the prolapsed portion of the rectum is exorcised/resected and
remaining part of rectum is sutured/ stapled closed.
It is typically for rectal prolapse that are more extensive (> 3cm ).
33

Selecting Surgical Procedure
Symptomatic full- thickness prolapse?
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Is patient a candidate for abdominal procedure?
Yes No
Does Patient have preexisting constipation? Is rectal prolapse < 3-4 cm?
Yes No Yes No
Transabdominal Transabdominal
rectopexy with rectopexy without
sigmoid resection sigmoid resection
Delorme Altemeier

ANTIBIOTIC
The Standard Treatment Guidelines (STG) Ghana, 7th Edition (2017) provides recommendations for antibiotic use in surgical
prophylaxis and post-surgical infections, including procedures like rectal prolapse surgery. Below are the relevant guidelines:
1. Surgical Antibiotic Prophylaxis (STG Ghana 2017) For colorectal surgeries (including rectal prolapse repair), the following
antibiotics are recommended:
1) First-Line Prophylaxis (Single Dose Preoperatively)- Ceftriaxone 1g IV+Metronidazole 500mg IV (given 30–60 mins before
incision) OR - Amoxicillin-Clavulanate 1.2g IV (alternative if ceftriaxone unavailable) Alternative (Penicillin Allergy)-
Gentamicin 5mg/kg IV+Metronidazole 500mg IV
2) Postoperative Antibiotics (If Infection is Suspected) If there is contamination (e.g., bowel perforation, fecal spillage) or signs of
infection, a 5–7 day course may be given: - Ceftriaxone 1g IV once daily+Metronidazole 500mg IV/PO 8-hourly OR -
Amoxicillin-Clavulanate 1.2g IV 8-hourly (switch to oral when possible)

COMPLICATIONS
 Risk of damage to the rectum , such as ulcerations
 Recurring prolapse
 Strangulation of the rectum – the blood supply is reduced
 Death and decay (gangrene) of the strangulated section of the rectum.
35

COUNSELLING POINTS
1) Avoid in Rectal Prolapse
Chronic stimulant laxatives (can worsen pelvic floor
dysfunction).
Excessive enemas(may weaken rectal tone over time).
2) Non-Pharmacological Measures
High-fiber diet (whole grains, fruits, vegetables).
Adequate hydration (2–3L water/day).
Regular exercise (improves colonic motility).

REFERENCES
1. Bordeianou L, Paquette I, Johnson E, et al. Clinical Practice Guidelines for the
Treatment of Rectal Prolapse. Dis Colon Rectum 2017; 60:1121.
2. Emile SH, Elbanna H, Youssef M, et al. Laparoscopic ventral mesh rectopexy vs
Delorme's operation in management of complete rectal prolapse: a prospective
randomized study. Colorectal Dis 2017; 19:50.
3. American society of Colon and Rectal Surgeons, Clinical Practice guidelines for the
treatment of rectal Prolapse (2017).
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