Rectal prolapse

1. Rectal prolapse
Dr. Diwan Shrestha
MS resident
IOM, TUTH

2. Introduction
• disorder characterized by a full-thickness intussusception of the
rectal wall, which protrudes externally through the anus
• Complete rectal prolapse
 All layers of rectum prolapse
through the anal canal
• Partial or mucosal prolapse
 Only the mucosal layer prolapse
• Internal prolapse
 Rectum descends towards but does not pass through the anal canal

3. Anatomy of rectum
• 12 - 15 cm long
• Begins from rectosigmoid junction
• Ends at anorectal junction
• follows the curve of the sacrum in the true pelvis
• posterior surface is almost completely extraperitoneal
• possesses three curves known as the valves of Houston
• middle valve folds to the left
• proximal and distal valves fold to the right

4. Anatomy of rectum
• Upper 1/3rd – anterior & lateral surface
covered by peritoneum
• Middle 1/3rd - anterior peritoneal
covering only
• the lower 1/3 – no peritoneal covering
• Lower rectum separated from
other organs by fascial condensation
 Anterior – fascia of Denonvillier
 Posterior – fascia of Waldeyer

5. Anatomy of rectum
• Arterial supply
 Superior rectal artery : branch of IMA
 Middle rectal artery : branch of anterior
division of internal iliac
 Inferior rectal artery : terminal branch of
internal pudendal artery
• Venous drainage
 Corresponds to arteries
• Lymphatic drainage
 Upper 2/3rd – paraaortic node
 Lower 1/3rd – internal iliac node

6. Pelvic floor
• consists of the pubococcygeus, iliococcygeus, and puborectalis
• Pelvic diaphragm resides between the sacrum, obturator fascia,
ischial spines, and pubis
 forms a strong floor that supports the pelvic organs
 with the external anal sphincter, regulates defecation
• Puborectalis a strong, U-shaped sling of striated muscle course
around the rectum just above the level of the anal sphincters
 Relaxation of the puborectalis straightens the anorectal angle and permits
descent of feces
 contraction produces the opposite effect

7. Etiology
Two competing theories of rectal prolapse :
1. Alexis Moschcowitz in 1912
 caused by a sliding herniation of the pouch of Douglas through the pelvic floor
fascia into the anterior aspect of the rectum
2. Broden & Snellman in 1968
 a full-thickness rectal intussusception starting approx 3 inches above the
dentate line and extending beyond the anal verge

8. Etiology
• anatomic abnormalities
 diastasis of the levator ani
 abnormally deep cul-de-sac
 a redundant sigmoid colon
 a patulous anal sphincter
 loss or attenuation of the rectal sacral attachments
• Chronic constipation with straining
• Multiparity
 Nulliparity (35%)
• Pudendal nerve damage
 Obstetric injury
 Diabetes

9. Epidemiology
• Bimodal incidence
o One peak occurs in children within the first 3 years of life
o the second peak occurs after the seventh decade
• Rectal prolapse associated with children
o Equal in both sexes
o often associated with a diarrheal illness
o typically not a recurring problem and can be self-limited
• In the elderly
o rectal prolapse is more common in women (80% to 90%)
o prevalence increases with age
• Rectal prolapse may affect institutionalized patients
 neurologic or psychiatric comorbidities (15%)

10. Clinical presentation
• Protuberance or bulge from the anus
• mucus discharge
• Rectal bleeding
• Fecal incontinence
• Feeling of incomplete evacuation
• Chronic constipation
• Rectal pain in early prolapse
 less in patients with long-standing prolapse
 Uncomfortable sensation of sitting on a mass within anal canal
• Urinary incontinence (35%)

11. Clinical presentation
• Some patients experience rectal incarceration or even strangulation
 a large, painful, immobile rectal mass
• Patients with internal intussusception
 obstructed defecation
 severe abdominal pain

12. Rectal prolapse Hemorrhoid
Tissue folds Circumferential Radial
Sulcus between prolapse
& rectum
circumferential none
Abnormality on palpation Double rectal wall hemorrhoidal plexus
Resting & squeeze
pressure
decreased normal
Easily reducible &
painless
Extreme pain & can be
accompanied by fever

13. Evaluation
• On standing or Valsalva
 Visualisation of prolapse
• DRE
 Lax anal sphincter
 Diminished squeeze efforts
• Proctosigmoidoscopy
 Erythematous, edematous rectal mucosa
 Solitary rectal ulcer in mid rectum
• Anal manometry
 Normal resting and squeeze values are 40 to 80 mm Hg

14. Evaluation
• Pudendal nerve terminal motor latency test
 Values between 1.8 and 2.2 milliseconds normal
• Dynamic MRI
 Redundant, prolapsing rectosigmoid
• Triple contrast cinedefecography
 Delineate complex floor abnormalities
• Defecography
 Evaluates anatomic abnormalities, such as rectocele, enterocele, and vaginal
vault prolapse

15. Defecography grading system of
intussuseption
Grade Description
N Rectum remains fixed to sacrum, sphincter relaxes &
rectum empties
1 Nonrelaxation of puborectalis
2 Mild intussuseption or mobility from sacrum
3 Moderate intussuseption
4 Severe intussuseption
5 Prolapse
R Rectocele

16. Treatment
Acute condition ( non complicated )
• Reduction – immediate management
 Continuous, steady pressure
 Applying table salt or sugar to the mucosa reduce swelling of incarcerated
rectum
 Elastic compression wrapping
 Hyaluronidase injection into the prolapsed rectum

17. Treatment
In infants & young children
• Digital repositioning
 Parents are taught to replace the protusion
 Any underlying causes addressed
• Submucosal injections
 If digital repositioning fails after 6 weeks trial, 5% phenol in almond oil injected
under GA
• Surgery
 Child placed in prone jack knife position
 Rectum sutured to sacrum

18. Surgical treatment
• More than 100 different surgical procedures
• Goal
 Elimination of rectal prolapse
 Restoration of continence
• Choice of procedure based on
 Patient age
 Comorbidities
 Operative risk
 Associated anatomic abnormalities
 Prior rectal or colonic surgery

19. Surgical treatment
• Can be :
1. Transabdominal
2. Perineal
1. Transabdominal approach : open or laparoscopic
a. Ripstein procedure
b. Well‘s procedure
c. Resection +/- rectopexy
d. Suture / mesh rectopexy

20. Transabdominal approach
• Advantages :
 Low recurrence rates
 Resection rectopexy improve the bowel habit of patients having
preoperative constipation
• Disadvantage :
 High morbidity
 Evacuation difficulties may occur after suture or mesh rectopexy
• Reserved for younger patients who can tolerate GA

21. Ripstein procedure
• Mobilization of rectum on both sides and
posteriorly down to the levator ani muscle
plate
• 5-cm band of rectangular mesh placed
around its anterior aspect at the level of the
peritoneal reflection
• both sides of the mesh sutured to presacral
fascia
• Recurrence rate : 2.5% to 5%
• Complication :
 Constipation
 large bowel obstruction
 erosion of the mesh through the bowel
 ureteric injury or fibrosis
 small bowel obstruction
 rectovaginal fistula

22. Well‘s procedure
• Mobilisation of rectum
• Mesh kept in posterior aspect of rectal
fascia proper
• Fixed to presacral fascia
• Recurrence rate : 3 – 5%
• Advantage : low constipation rate

23. Resection rectopexy
• Frykman and Goldberg
procedure
 sigmoid colon and rectum
mobilized to the level of the
levators
 Resection of the redundant
sigmoid colon
 Anastomosis is completed
 Rectopexy sutures are placed
• Recurrence : 2-5%
• Complication :
 obstruction
 anastomotic leak

24. 2. Perineal approach can be :
a. Altmeier procedure
 Perineal rectosigmoidectomy
b. Delorme procedure
 Mucosal sleeve resection
c. Thiersch procedure
 Anal encirclement

25. Perineal approach
• Advantages :
 Can be done under regional anesthesia
 Low morbidity
 Shorter hospital stay
• Disadvantages :
 High recurrence rate

26. Altmeier procedure
• Redundant rectum extenalised
• Full thickness circumferential
rectal incision 1-2 cm proximal
to dentate line
• Vascular supply ligated
• Redundant rectum & sigmoid
colon resected
• Coloanal anastomosis either
handsewn or stapled

27. Altmeier procedure
• Recurrence : 12-24%
• Complication
 Bleeding from suture line
 Pelvic abscess
 Fecal incontinence

28. Delorme procedure• Rectal prolapse delivered
through anus
• Circumferential incision 2 cm
above dentate line through
mucosa & submucosal layer
• Mucosal sleeve stripped from
muscularis & plication done
using longitudinal suture
• Resection of excess stripped
mucosa
• Mucosal coloanal anastomosis
Recurrence : 12-31%

29. Thiersch procedure
• 2 small incisions made lateral
to external anal sphincter
• Submucosal tunnel created
around anus
• Wire inserted & advanced
around anal canal & tightened
• Can be done under LA
• Recurrence > 30%

30. Thiersch procedure
• Materials used :
 Silver wire
 Stainless steel wire
 Nonabsorbable mesh
 Nylon suture
 Polypropylene
• Complications :
 Erosion of wire into sphincter
 Anovaginal fistula
 Fecal impaction
 Incarcerated rectal prolapse

31. Laparoscopic mesh rectopexy
• A periumbilical port is put in
place, followed by two
additional ports in the lower
abdomen (one in each
quadrant)

32. Laparoscopic mesh rectopexy
• mobilization of the rectum
• the nonabsorbable mesh is
rolled up and inserted through
a port
• The mesh is tacked to the
sacrum with a laparoscopic
stapler, and the lateral edges
of wrapped mesh are secured
to the rectal wall with sutures

33. Algorithm for management of rectal prolapse

36. Recurrent prolapse
• Can occur after either perineal or abdominal procedure
 Overall recurrence – 15%
 Abdominal procedure – up to 10%
 Perineal procedure – up to 20%

37. Recurrent prolapse
• 2 types
 Mucosal prolapse
 Full thickness prolapse
• Early recurrence
 Occur within first year after surgery
 likely the result of a specific technical failure
 incomplete mobilization of the rectum
 inadequate fixation of the rectum to the sacrum
 incomplete resection of a redundant sigmoid
 vigorous physical activity

38. Recurrent prolapse
• Late recurrence
 recurs beyond 1 year of surgery
 results from persistence of the underlying pathophysiology
 disordered defecation
 abnormal intestinal motility
 straining
• Currently,no standardized strategy for recurrent rectal prolapse

39. Recurrent prolapse
• Some authorities advocate an abdominal procedure for the second
operation, regardless of the initial operation (1)
• Some studies suggest that unless the previous anastomosis can be
resected in the second procedure, repeat resectional procedures
should be avoided(2)
• Perineal rectosigmoidectomies are an exception to this broad rule:
they can be safely repeated as long as the recurrent prolapse
contains the previous anastomosis.
• Subtotal colectomy should be considered in patients with slow
transit constipation without sphincter weakness
1. Hool GA et al, Surgical treatment of recurrent complete rectal prolapse. Dis Colon Rectum 1997
2. Fengler SA,, et al. Management of recurrent rectal prolapse. Dis Colon Rectum 1997

40. Rectal prolapse with solitary rectal ulcer
syndrome (SRUS)
• 80% of patients with SRUS have an associated rectal prolapse
• SRUS, a clinical condition characterised by rectal bleeding, copious
mucus discharge, anorectal pain & difficult evacuation
• Typically affect young female with an average age of 25 years
• The cause of SRUS unclear, but speculation centers on chronic
ischemia

41. Rectal prolapse with solitary rectal ulcer
syndrome
• gross pathologic features of SRUS can range from a typical crater-
like ulcer with a fibrinous central depression to a polypoid lesion
 always located on the anterior aspect of the rectum, 4 to 12 cm from the anal
verge
• The rectal ulcer is usually found on proctoscopy or flexible
sigmoidoscopy
• Defecography, radiologic procedure of choice
 reveals the underlying disorder

42. Rectal prolapse with solitary rectal ulcer
syndrome
• Symptomatic SRUS associated with asymptomatic prolapse
 a trial of nonoperative therapy including pelvic floor retraining , dietary management,
short-term use of topical antiinflammatory medications containing mesalamine
 if such therapy fails, surgical intervention considered
• In cases of symptomatic prolapse associated with asymptomatic
SRUS
 healing of the ulcer can be demonstrated in one third of patients undergoing operation
for the prolapse
 Abdominal repairs resulted in a cure rate of 80% in patients with SRUS and full-
thickness rectal prolapse
• Rarely, symptoms of severe bleeding, pain, and spasm may require a
temporary diverting sigmoid colostomy

43. References
1. Sabiston textbook of surgery, 20th Edition
2. Shackelford's Surgery of the Alimentary Tract, 8th Edition
3. Fischer‘s Mastery of Surgery, 7th Edition