Khurooj-e-Maq'ad (خروجِ مقعد) - Prolapse of the Rectum

Full-thickness rectal prolapse - note the concentric (circumferential) mucosal folds, distinguishing it from hemorrhoidal prolapse

Definition

1. Mucosal prolapse - only the rectal mucosa protrudes (partial)
2. Full-thickness (complete) prolapse - all layers of the rectal wall protrude
3. Internal (occult) prolapse - intussusception occurs but the rectum does not protrude through the anus

Asbab (Causes / Etiology)

Anatomical Predisposing Factors

• Laxity of rectal attachments - loss of posterior fixation of the rectum to the sacral curve
• Deep cul-de-sac (pouch of Douglas) - abnormally low descent of the peritoneum covering the anterior rectal wall
• Lack of fixation of the rectum to the sacrum (absent or weak presacral fascia)
• Redundant (elongated) sigmoid colon - downward displacement of the sigmoid and rectum
• Weakened pelvic floor and anal sphincters - especially with age or nerve injury

Pathophysiological Mechanisms

• Rectal procidentia begins with circumferential intussusception of the rectum that progressively increases over time. The leading edge may originate 6-8 cm or 15-18 cm from the anal verge.
• Pudendal nerve damage from repeated straining weakens the external anal sphincter and pelvic floor muscles. Bilateral pudendal nerve injury is identified significantly more with full-thickness prolapse than unilateral injury.
• The condition is essentially a sliding hernia of the rectum through a deficient pelvic floor.

Predisposing Conditions & Risk Factors

Alamaat wa Nishaniyan (Clinical Presentation)

Symptoms

• Initially appears only with straining during defecation and reduces spontaneously
• Over time, protrudes with minimal effort (even walking, coughing, sneezing)
• Eventually becomes irreducible and permanently visible

• Feeling of a rectal bulge or bearing-down sensation - the most common initial complaint
• Mucous discharge - seepage of mucus onto undergarments
• Rectal bleeding - from erosion/ulceration of the exposed mucosa
• Tenesmus - sensation of incomplete evacuation
• Constipation - present in 30-67% of patients
• Fecal incontinence - in 50-70% of patients (due to chronic sphincter stretching and pudendal nerve injury)
• Rectal pressure and pain

• Urinary symptoms / urinary incontinence: 20-35% of patients
• Vaginal vault prolapse or uterine prolapse: 15-30%
• Cystocele, enterocele, rectocele

Signs on Examination

• Patulous anus with decreased sphincter tone on rectal examination
• Concentric (circumferential) mucosal folds on the prolapsed mass - this is the key distinguishing feature from hemorrhoidal prolapse (which has radial/radiating folds)
• Prolapse may need to be demonstrated by asking the patient to strain while seated on a commode, with or without enema
• Full-thickness prolapse: double-layered tube of bowel felt on palpation
• Solitary rectal ulcer may be detected on proctoscopy (present in ~12%)

Differentiation: Prolapse vs. Hemorrhoids

Usool-e-Ilaj (Principles of Treatment)

1. Islaah-e-Ghiza wa Nizam-e-Hayat (Dietary and Lifestyle Regulation)

• Address all underlying and aggravating causes first
• High-fiber diet, adequate fluid intake to prevent straining
• Treat chronic constipation (Talyin - laxation/stool softening)
• Avoid prolonged squatting or straining at defecation
• In children: parents taught digital repositioning (manual reduction) as initial measure

2. Ghair Jarahi Ilaj - Conservative / Non-surgical Treatment

• Stool-bulking agents and fiber supplementation to ease evacuation and reduce straining
• Biofeedback - useful in internal (occult) prolapse; about one-third of patients achieve symptom resolution
• Reduction of edema in incarcerated prolapse: liberal application of sugar (osmotic agent), sedation or perianal nerve block to allow manual reduction
• In children: treat underlying cystic fibrosis, constipation, or other systemic cause; most pediatric mucosal prolapse resolves with conservative management

3. Ilaj bil Dawa - Pharmacotherapy

• Submucosal injection of 5% phenol in almond oil (sclerotherapy) - for mucosal prolapse, especially in children if manual repositioning fails after 6 weeks
• Rubber band ligation (RBL) - for mucosal/mucohaemorrhoidal prolapse
• These aim to create submucosal fibrosis, fixing the mucosa to the underlying muscle

4. Ilaj bil Yad - Surgical Treatment (Definitive)

A. Transabdominal (Preferred when patient can tolerate general anaesthesia)

• Lower recurrence rates (<10% at 10 years)
• Posterior suture rectopexy - mobilization and fixation of rectum to sacrum with sutures
• Ventral mesh rectopexy - anterior mobilization, mesh attached to anterior rectum and suspended to sacrum; elevates pelvic floor (preferred in women with concomitant anterior compartment prolapse)

B. Transperineal / Perineal Approaches (for high-risk/elderly patients)

• Higher recurrence (16-30%) but lower operative risk
• Altemeier procedure (Perineal proctosigmoidectomy) - full-thickness excision of prolapsed bowel with coloanal anastomosis; also used emergently for incarcerated or gangrenous prolapse
• Delorme procedure - mucosal proctectomy (mucosal stripping with plication of the muscular wall)
• Thiersch wire / anal encirclement - narrows the anal canal mechanically; high recurrence (33-44%), used in very frail patients

Emergency Surgery

• If incarcerated prolapse cannot be reduced manually, or if rectal necrosis is present: immediate Altemeier procedure is required

Summary of Usool-e-Ilaj