Rectal prolapse

Background

Anatomy of the anus and rectum.

Internal rectal intussusception (A) vs external (complete) rectal prolapse (B).

• Circumferential protrusion of part or all layers of the rectum through the anal canal
• Complications are rare and include bleeding and ulceration

Risk factors

• Extremes of age
• Chronic constipation

Clinical Features

A. full thickness external rectal prolapse, and B. mucosal prolapse. Note circumferential arrangement of folds in full thickness prolapse compared to radial folds in mucosal prolapse.

Complete (external) rectal prolapse. Note circumferential arrangement of mucosal folds.

Most frequent complaint at the time of clinical presentation:

• Sensation of a protruding rectal mass (98.7%)
• Painful defecation (36%)
• Fecal incontinence (38.7%)
• Rectal bleeding (25.3%)
• Constipation (25.3%)
• Rectal ulcer (8%)

Patients may mistake prolapsed mucosa for hemorrhoids

Differential Diagnosis

Anorectal Disorders

• Anal fissure
• Anal fistula
• Anal malignancy
• Anal tags
• Anorectal abscess
• Colorectal malignancy
• Condyloma acuminata
• Constipation
• Crohn's disease
• Cryptitis
• GC/Chlamydia
• Hemorrhoids
  • Internal hemorrhoid
  • External hemorrhoid
• Pedunculated polyp
• Pilonidal cyst
• Proctitis
• Pruritus ani
• Rectal foreign body
• Rectal prolapse
• Syphilitic fissure

Evaluation

• Clinical diagnosis

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 15 cm
   • 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

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 incorporate a perianal block in certain cases
  • Can place granulated sugar (not synthetic sweeteners) over prolapsed rectum
    • Wait 15 min for edema to subside and re-attempt
• Failed reduction
  • Obtain emergent surgical consultation

Disposition

• Discharge
• Refer all patients for colonoscopy and surgeon for consideration of repair

See Also

• Anorectal disorders