Rectal prolapse
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Rectal Prolapse
Rectal prolapse is the protrusion of the rectal wall through the anal orifice. It ranges from partial mucosal descent to complete full-thickness extrusion of the rectal wall.
Classification
| Type | Description |
|---|---|
| Mucosal prolapse | Only the mucosa protrudes; muscularis propria remains in place |
| Full-thickness (complete) prolapse | All layers of the rectal wall protrude through the anus |
| Internal rectal prolapse (intussusception) | Rectum telescopes internally without external protrusion; a precursor to full-thickness prolapse |
Etiology & Predisposing Factors
- Children: Typically mucosal, associated with malnutrition, cystic fibrosis, chronic diarrhea, or straining
- Adults: More common in older women (though men are also affected); associated with:
- Chronic straining / constipation
- Multiparity and pelvic floor laxity
- Neurological conditions (e.g., cauda equina lesions, multiple sclerosis)
- Redundant sigmoid colon / deep pouch of Douglas
- Pudendal neuropathy
- Prior pelvic surgery
Clinical Features
- Visible red mass protruding from the anus, especially on straining or defecation
- Mucus or blood-stained discharge
- Fecal incontinence (common, due to sphincter stretch and pudendal nerve injury)
- Constipation or obstructed defecation
- Perineal heaviness or discomfort
- In advanced cases: ulceration, edema, or incarceration of prolapsed tissue
Diagnosis
Clinical examination is usually sufficient:
- Inspect at rest and during straining (squatting position or sitting on a commode is ideal)
- Digital rectal exam: assess sphincter tone (often reduced)
- Differentiate from prolapsing hemorrhoids (see below)
Differentiating full-thickness prolapse from prolapsing hemorrhoids:
| Feature | Full-thickness Prolapse | Prolapsing Hemorrhoids |
|---|---|---|
| Mucosal folds | Concentric (circular) | Radial |
| Sulcus between mass and anal skin | Absent | Present |
| Consistency | Cylinder of bowel wall | Discrete cushions |
| Incontinence | Common | Less common |
Further investigations (selected cases):
- Defecating proctogram / MRI defecography: identifies internal prolapse, enterocele, associated pelvic floor disorders
- Colonoscopy: if concern for coincident colorectal pathology
- Anorectal manometry: pre-operative baseline for sphincter function
- EMG / pudendal nerve terminal motor latency: assess degree of neuropathy
Management
Children
Conservative management is preferred (Bailey & Love's, p. 1418):
- Treat underlying cause (nutritional supplementation, treat diarrhea, cystic fibrosis management)
- Manual reduction after each episode
- Strapping the buttocks between episodes
- Most resolve spontaneously with growth
Adults — Full-Thickness Prolapse
Surgery is almost always necessary for full-thickness rectal prolapse (Bailey & Love's, p. 1418).
Surgical approaches fall into two categories:
1. Perineal Approaches
Preferred for elderly/high-risk patients with significant comorbidities:
| Procedure | Description |
|---|---|
| Delorme's procedure | Mucosal sleeve resection + plication of muscularis propria; lower morbidity |
| Altemeier's procedure (perineal rectosigmoidectomy) | Full-thickness resection of prolapsed bowel via perineum; useful for large/incarcerated prolapse |
| Thiersch wire / Encirclement | Subcutaneous suture/wire around anus to reduce outlet; largely historical |
2. Abdominal Approaches
Generally preferred in fit patients — lower recurrence rates:
| Procedure | Description |
|---|---|
| Resection rectopexy | Rectum mobilized, sigmoid resected, rectum fixed to sacrum; addresses constipation |
| Suture rectopexy (Wells / posterior mesh rectopexy) | Rectum fixed to sacrum without resection; lower risk but may worsen constipation |
| Ventral mesh rectopexy (D'Hoore) | Laparoscopic; mesh fixed anteriorly; gaining popularity, especially for associated pelvic organ prolapse |
| Laparoscopic approaches | Now preferred over open; equivalent recurrence rates with faster recovery |
Complications
- Incarceration / strangulation: surgical emergency requiring urgent reduction or operative intervention
- Ulceration and bleeding: from repeated trauma to exposed mucosa
- Fecal incontinence: may persist even after successful repair (due to irreversible sphincter/nerve damage)
- Recurrence: higher after perineal procedures (~20–30%) vs. abdominal procedures (~5–10%)
- Constipation: may worsen after rectopexy without sigmoid resection
Prognosis
- In children, the prognosis is excellent with conservative management
- In adults, surgical repair reliably prevents recurrence; however, continence may not fully recover post-operatively, especially when pudendal neuropathy is established
- Pelvic floor physiotherapy is an important adjunct pre- and post-operatively
Primary reference: Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 1418–1419
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