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 w/ 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 w/ 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

Treatment

1. Children
   1. Reduce via slow steady pressure applied to prolapsed segment
   2. Prevent constipation
   3. Refer for evaluation of underlying condition (CF, pelvic floor weakness, diarrhea)
2. Adults
   1. Reduction
      1. Thumbs over luminal surfaces medially and fingers grasp outer walls laterally
         1. Apply continuous pressure first w/ thumbs followed by internal rolling of fingers
         2. After reduction perform digital rectal exam to evaluate for rectal mass/polyp
   2. Difficult reduction
      1. Prolonged prolapse may lead to rectal wall edema
      2. Adequate sedation and analgesia is key to successful reduction
      3. Can place granulated sugar (not synthetic sweeteners) over prolapsed rectum
         1. Wait 15min for edema to subside and re-attempt
   3. Failed reduction
      1. Obtain emergent surgical consultation
   4. Refer all pts for colonoscopy and to a surgeon for consideration of repair

Complications

1. Rare, but include bleeding and ulceration

Source

1. Tintinalli
2. Roberts