Rectal prolapse

Background

• Circumferential protrusion of part or all layers of the rectum through the anal canal

Risk factors

• Extremes of age
• Chronic constipation

Types

1. Prolapse involving the rectal mucosa only
   • Rarely protrudes more than 2 to 3 cm beyond the anal verge
   • Anal edges appear everted
   • Radially directed folds
   • No sulcus between extruded mucosa and anus
   • Frequently associated with 3rd and 4th degree hemorrhoids
2. Prolapse involving all layers of the rectum
   • May protrude up to 15cm
   • Anus appears normal
   • Prolapse appears as red, ball-like mass with concentric folds
   • Sulcus may be palpated between the extruded bowel and anus
3. Intussusception of upper rectum into and through the lower rectum

Clinical Features

• Irritation to mucosa caused by recurrent prolapse results in mucous discharge and bleeding
• Anal sphincter weakness may result in fecal incontinence
• In children, parents often mistake prolapsed mucosa for hemorrhoids

Differential Diagnosis

Anorectal Disorders

• Anal fissure
• Anal fistula
• Anal malignancy
• Anal tags
• Anorectal abscess
• Coccydynia
• Colorectal malignancy
• Condyloma acuminata
• Constipation
• Crohn's disease
• Cryptitis
• GC/Chlamydia
• Fecal impaction
• Hemorrhoids
  • Internal hemorrhoid
  • External hemorrhoid
• Levator ani syndrome
• Pedunculated polyp
• Pilonidal cyst
• Proctalgia fugax
• Proctitis
• Pruritus ani
  • Enterobius (pinworms)
• Rectal foreign body
• Rectal prolapse
• Syphilitic fissure

Non-GI Look-a-Likes

• Prostatitis

Management

Children

• Reduce via slow steady pressure applied to prolapsed segment
• Prevent constipation
• Refer for evaluation of underlying condition (CF, pelvic floor weakness, diarrhea)

Adults

• Reduction
  • Thumbs over luminal surfaces medially and fingers grasp outer walls laterally
    • Apply continuous pressure first with thumbs followed by internal rolling of fingers
    • After reduction perform digital rectal exam to evaluate for rectal mass/polyp
• Difficult reduction
  • Prolonged prolapse may lead to rectal wall edema
  • Adequate sedation and analgesia is key to successful reduction
  • Can place granulated sugar (not synthetic sweeteners) over prolapsed rectum
    • Wait 15min for edema to subside and re-attempt
• Failed reduction
  • Obtain emergent surgical consultation

Disposition

• Refer all patients for colonoscopy and to a surgeon for consideration of repair

Complications

• Rare, but include bleeding and ulceration

See Also

• Anorectal Disorders

References

1. Tintinalli
2. Roberts