Rectal prolapse involves the descending of the rectum through the anal canal. It can involve the inner mucosa alone (mucosal prolapse), or all layers of the rectal wall (full-thickness prolapse). Mucosal prolapse is more common in children, presents as less than 4cm of protrusion, and can be treated with injections or surgery. Full-thickness prolapse presents as a protrusion over 4cm, involves the entire rectal wall, and is more common in elderly females. Surgical treatment depends on the degree of prolapse but involves approaches to fixate and support the rectum.

1. Rectal Prolapse
Sunil Kumar Daha

2. Anatomy of Rectum
approximately 12–18 cm in length and is conveniently divided into
three equal parts:
 the upper third  mobile and has a peritoneal coat
 the middle third  peritoneum covers only the anterior and part of
the lateral surfaces;
 the lowest third  lies deep in the pelvis surrounded by fatty
mesorectum

4. Blood supply
 Superior rectal artery
-the direct continuous of
inferior mesenteric artery
 Middle rectal artery
-a branch of internal iliac
artery
 Inferior rectal artery
-branch of internal
pudendal artery

5. Rectal Prolapse
Circumferential descend of rectum through anal canal
Classified as:
a) Mucosal prolapse
b) Full-thickness prolapse

6. Mucosal Prolapse
The mucous membrane and submucosa of the rectum protrude outside
the anus for approximately 1–4 cm.
On palpation of prolapsed mucosa between the finger and thumb it
is composed of double layer of mucous membrane

7. Etiology
• In infant: Undeveloped sacral curve, Reduced resting anal tone
• Children:
• Attack of Diarrhoea
• Loss of weight loss of fat in ischiorectal fossa,
• Others fibrocystic disease, neurological causes, mal development of pelvis
• Adult:
1. Torn perineum
2. Straining from urethral obstruction
3. Atony of sphincter

9. • Partial prolapse may follow an operation for fistula in ano where large
portion of muscle has been divided
• Prolapsed mucous membrane is pink

10. Treatment
•In infants and young children
–Digital repositioning
• parents are taught to replace the protrusion, and any
underlying causes are addressed.
–Submucosal injections
• If digital repositioning fails after 6 weeks
• injections of 5% phenol in almond oil under GA
aseptic inflammation
the mucous membrane becomes tethered to the muscle
coat.

11. Contd...
•Surgery
• Occasionally
• Prone jack-knife position,
• rectum is sutured to the sacrum.

12. Adults
• Local treatments
– Submucosal injections of phenol in almond oil
– Application of rubber bands
• Excision of the prolapsed mucosa
– Unilateral can be excised
– Circumferential endoluminal stapling

13. Complete Prolapse
• all layers of the rectal wall involved
• usually associated with a weak pelvic floor and is as much as 10-15 cm.
• Less common
• more common in elderly people.
• Common in female (6:1)
• Fecal incontinence (approx.50% of adults)

14. Mucosal prolapse Full thickness prolapse
Protrusion of mucosa and submucosa
outside of the anus
Protrusion of the all layer of the rectum
Protrusion length < 4 cm > 4cm (as much as 10-15 cm)
Palpation between finger and
thumb
No more than double layer mucous
membrane
Much thicker, consist of double thickness of
entire wall
Common in children Common in adult (M:F=1:6)
More common Less common

15. Features of full thickness prolapse
> 5 cm prolapse contains anteriorly between its
layers a pouch of peritoneum.
 When large, the peritoneal pouch contains small
intestine which returns to the general peritoneal
cavity with a characteristic gurgle when the
prolapse is reduced.
The anal sphincter is patulous and gapes widely on
straining to allow the rectum to prolapse.

16. Clinical Features
• Something coming out per rectum during
defecation
• May even on standing ,walking or coughing
• Red
• Fecal incontinence (75%)
• May reduce spontaneously or required
digital reduction

17. Differential diagnosis
• Ileocecal intussusetion (in children)
• Rectosigmoid intussucetion (in adults)

18. Contd…….
Child with intussusception is usually sick, while the child with prolapse is
well,
To distinguish, pass finger between the prolapsed bowel and the anal
sphincter. This is possible with intussusception,
but
in rectal prolapse, the protruding mucosa is continuous with the
perianal skin, and the finger will not pass this junction

19. Treatment
• Surgery is required
• Perineal approach
• Abdominal approach

20. Indications
• Abdominal rectopexy lower rate of recurrence
• But in case of elderly and very frail patient perineal operation
• Abdominal procedure risks damage to the pelvic autonomic nerves,
• resulting in possible sexual dysfunction
• Perineal approach
• usually preferred in young men.

21. Perineal Approach
• Most commonly used
1.Thiersch operation
• Aimed to place a steel wire or, more commonly, a silastic or
nylon suture around the anal canal
• Become obsolete.
–Suture would often break or
–Cause chronic perineal sepsis, or
–Both
–Anal stenosis so created would produce severe functional
problems.

22. 2.Delorme’s operation
•Prolapsed mucosa is removed circumferentially over its length.
•Underlying muscle plicated with a series of sutures in such a way that
when these are tied, the rectal muscle is concertinated towards anal canal
•Anal mucosa sutured circumferentially to rectal mucosa remaining at
the tip of the prolapse.
•Prolapse is reduced, and a ring of muscle is created above the anal canal,
which prevents recurrence.

24. 3. Altemeier’s procedure
•Excision of the prolapsed rectum and associated sigmoid colon from
below
•Construction of a coloanal anastomosis.

25. Abdominal approach
• Principle to replace and hold the rectum in its proper position
• Recommended in patients with complete prolapse who are otherwise
in good health
• Many operative procedures
• Well’s operation
• Ripstein’s operation

26. • Well’s opertion
• Rectum is fixed firmly to the sacrum by inserting a sheet of polypropylene
mesh between them
• Ripstein’s operation
• Hitching up the rectosigmoid junction by a Teflon sling to the front of the
sacrum
• sutured rectopexy
• Suture the mobilised rectum to the sacrum using 4-6 interrupted non-
absorbable sutures

27. • Abdominal rectopexy
• Complication
• severe constipation combine with resection of the sigmoid
colon (Goldberg)known as resection rectopexy
• Approximately 50% of adult patients with a complete rectal prolapse
are incontinent, and rectopexy cures only about one third.

29. Summary

30. References
• Bailey and Love’s Short Practice of Surgery; 26th Edition
• SRB’s manual of surgery; 5th edition

31. Answer this ?
1. How will you distinguish:
Hemorrhoids vs Rectal Prolapse
Intussusception vs Rectal Prolapse
Partial vs complete rectal prolapse
2. Stepwise management of rectal prolapse
The end