History

Fact Explanation
Presence of a mass protruding through the anus. Initially, the mass protrudes from the anus only after a bowel movement and retracts after the patient stands up. With time, the mass protrudes even with straining, sneezing or coughing. This may progress to the mass being constantly protruded from the anus throughout the day. Rectal prolapse is an intussusception that begins at the rectosigmoid junction, with the intussusception pulling the rectosigmoid area away from its moorings. Repeated straining results in the rectum pulling away more and more distally. This leads to the fixed point becoming lower and lower, and the intussusception, on subsequent straining, is seen to begin just above the new fixed point. When it reaches a point of stronger fascial attachment in the area below the peritoneal reflection, and also in the region of the lateral neurovascular stalks, the process comes to a temporary halt. Eventually, with repeated straining this barrier is overcome, and the bowel continues to protrude until the final stage is reached and the first observed point of protrusion becomes the mucocutaneous junction [1].
Complete inability in reducing the mass. It occurs due to incarceration of the prolapsed rectum which may result following a long history of prolapse [2].
Pain. The incarcerated prolapsed rectum could become strangulated. This would lead to bowel ischemia, resulting in pain [2].
Rectal bleeding. It occurs due to ulceration of the prolapsed rectal mucosa. It is the combination of rectal prolapse and a high voiding pressure, caused in most cases by overactivity of the external anal sphincter during voiding, that leads to mucosal ulceration [3].
fecal incontinence. Rectal prolapse causes the ligamentous attachments of the rectum and presacral fascia to become attenuated and there is often a redundant sigmoid colon. As a result of descent of the prolapse, external anal sphincter and muscles of the pelvic floor become lax. Chronic straining associated with the prolapse may cause pudental neuropathy resulting in a motor deficiency to the sphincter muscles and sensory loss to the anorectum. These factors together would result in fecal incontinence [4].
Constipation. It is attributed to difficult evacuation. Also, slow transit constipation may develop secondary to impaired rectal evacuation [4].
References
  1. THEUERKAUF FJ JR, BEAHRS OH, HILL JR. Rectal prolapse. Causation and surgical treatment. Ann Surg [online] 1970 Jun, 171(6):819-835 [viewed 16 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1396889
  2. GOLDSTEIN SCOTT, MAXWELL PINCKNEY. Rectal Prolapse. Clinics in Colon and Rectal Surgery [online] December, 24(01):039-045 [viewed 16 October 2014] Available from: doi:10.1055/s-0031-1272822
  3. WOMACK N R, WILLIAMS N S, HOLMFIELD J H, MORRISON J F. Pressure and prolapse--the cause of solitary rectal ulceration.. Gut [online] 1987 October, 28(10):1228-1233 [viewed 16 October 2014] Available from: doi:10.1136/gut.28.10.1228
  4. KAIRALUOMA MV, KELLOKUMPU IH. Epidemiologic Aspects of Complete Rectal Prolapse. Scandinavian Journal of Surgery [online] 2005 September, 94(3): 207-210 [viewed 17 October 2014] Available from: doi:10.1177/145749690509400306

Examination

Fact Explanation
Protruding rectal mucosa. Rectal prolapse is an intussusception that begins at the rectosigmoid junction, with the intussusception pulling the rectosigmoid area away from its moorings. Repeated straining results in the rectum pulling away more and more distally. This leads to the fixed point becoming lower and lower, and the intussusception, on subsequent straining, is seen to begin just above the new fixed point. When it reaches a point of stronger fascial attachment in the area below the peritoneal reflection, and also in the region of the lateral neurovascular stalks, the process comes to a temporary halt. Eventually, with repeated straining this barrier is overcome, and the bowel continues to protrude until the final stage is reached and the first observed point of protrusion becomes the mucocutaneous junction [1].
Thick concentric mucosal ring. Complete rectal prolapse is recognised by its concentric mucosal rings, whereas mucosal prolapse has radial folds [2].
Rectal ulcer. It is the combination of rectal prolapse and a high voiding pressure, caused in most cases by overactivity of the external anal sphincter during voiding, that leads to mucosal ulceration [3].
Reduced anal sphincter tone. As a result of descent of the prolapse, external anal sphincter and muscles of the pelvic floor become lax. Chronic straining associated with the prolapse may cause pudental neuropathy resulting in a motor deficiency to the sphincter muscles [4].
References
  1. THEUERKAUF FJ JR, BEAHRS OH, HILL JR. Rectal prolapse. Causation and surgical treatment. Ann Surg [online] 1970 Jun, 171(6):819-835 [viewed 16 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1396889
  2. ANDREWS NJ, JONES DJ. ABC of colorectal diseases. Rectal prolapse and associated conditions. BMJ [online] 1992 Jul 25, 305(6847):243-246 [viewed 17 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1882675
  3. WOMACK N R, WILLIAMS N S, HOLMFIELD J H, MORRISON J F. Pressure and prolapse--the cause of solitary rectal ulceration.. Gut [online] 1987 October, 28(10):1228-1233 [viewed 16 October 2014] Available from: doi:10.1136/gut.28.10.1228
  4. KAIRALUOMA MV, KELLOKUMPU IH. Epidemiologic Aspects of Complete Rectal Prolapse. Scandinavian Journal of Surgery [online] 2005 September, 94(3): 207-210 [viewed 17 October 2014] Available from: doi:10.1177/145749690509400306

Differential Diagnoses

Fact Explanation
Hemorrhoids. It also presents with a mass protruding out from the anus, but the most common manifestation of hemorrhoids is painless rectal bleeding associated with bowel movement, described by patients as blood drips into toilet bowl. The blood is typically bright red [1].
Intussusception. It also presents with a mass at the anal canal if the head of the intussusception protrudes out, but bowel obstruction is its predominant feature [2].
Proctitis. It also presents with anorectal pain or discomfort, rectal bleeding and constipation, but a lump protruding at the anus is not a symptom [3].
References
  1. LOHSIRIWAT VARUT. Hemorrhoids: From basic pathophysiology to clinical management. WJG [online] 2012 December [viewed 17 October 2014] Available from: doi:10.3748/wjg.v18.i17.2009
  2. AZAR T, BERGER DL. Adult intussusception. Ann Surg [online] 1997 Aug, 226(2):134-138 [viewed 17 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1190946
  3. HAMLYN E, TAYLOR C. Sexually transmitted proctitis. Postgraduate Medical Journal [online] 2006 November, 82(973):733-736 [viewed 17 October 2014] Available from: doi:10.1136/pmj.2006.048488

Investigations - for Diagnosis

Fact Explanation
Video defecography. A standard caulking gun is used to instill 200 ml of barium paste into the rectum. The patient sits on a radiolucent commode, and defecation is recorded with cineradiography or fluoroscopy with video recording. Defecography is performed to confirm the diagnosis (since it can distinguish rectal prolapse from mucosal prolapse) as well as evaluate for sigmoidorectal intussusception, puborectalis function, and perineal descent [1].
Rigid proctosigmoidoscopy. It is performed to assess for additional lesions, especially solitary rectal ulcers which commonly occur in this condition [2]. These may require biopsy to differentiate them from rectal neoplasms or inflammatory bowel disease [1].
Barium enema. It allows for evaluation of the entire colon which should be done to assess for other abnormalities prior to performing surgery [1].
Anal sphincter manometry. It is used to assess for sphincter dysfunction which is found in variable amounts in patients with rectal prolapse [1].
References
  1. HAMMOND K, BECK DE, MARGOLIN DA, WHITLOW CB, TIMMCKE AE, HICKS TC. Rectal Prolapse: A 10-Year Experience Ochsner J [online] 2007, 7(1):24-32 [viewed 18 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096348
  2. WOMACK N R, WILLIAMS N S, HOLMFIELD J H, MORRISON J F. Pressure and prolapse--the cause of solitary rectal ulceration.. Gut [online] 1987 October, 28(10):1228-1233 [viewed 16 October 2014] Available from: doi:10.1136/gut.28.10.1228

Investigations - Fitness for Management

Fact Explanation
Complete blood count. Low hemoglobin levels would indicate anemia , while low platelets indicate a thrombocytopenia [1]. Anemia would impair surgical site healing and thrombocytopenia would interfere with the coagulation process.
Electrocardiogram. Previous myocardial infarctions (eg: pathological Q waves) identified on the ECG implies an increased risk of developing a postoperative cardiac complication and longer postoperative ventilation [2].
Serum electrolyte levels. Abnormalities in serum electrolytes (hyperkalemia, hypernatremia, etc) indicate renal insufficiency and would predict an increased rate of postoperative complications [2].
References
  1. TEFFERI AYALEW, HANSON CURTIS A., INWARDS DAVID J.. How to Interpret and Pursue an Abnormal Complete Blood Cell Count in Adults. Mayo Clinic Proceedings [online] 2005 July, 80(7):923-936 [viewed 20 October 2014] Available from: doi:10.4065/80.7.923
  2. WOLTERS U., WOLF T., STUTZER H., SCHRODER T.. ASA classification and perioperative variables as predictors of postoperative outcome. British Journal of Anaesthesia [online] 1996 August, 77(2):217-222 [viewed 20 October 2014] Available from: doi:10.1093/bja/77.2.217

Investigations - Screening/Staging

Fact Explanation
Sweat chloride test. It is used to diagnose cystic fibrosis, a common complication of which is rectal prolapse, especially in the pediatric population [1].
Stool examination and culture. A lot of cases of rectal prolapse have been attributed to acute diarrheal disease and intestinal parasitic infestation [1].
Colonoscopy. It is used to evaluate the colon for lesions [2]. Presence of other colonic lesions should be addressed simultaneously. The presence of such lesions may also affect the choice of the procedure to be performed to correct the rectal prolapse.
Colonic transit marker study. After the patient ingests a capsule containing 24 radiopaque rings, a plain abdominal radiograph is obtained within 24 hours of ingestion and again at one, three and five days later. Normal patients should have no more than four rings remaining at five days. At seven days, no rings should remain. Abnormal results would point towards either slow transit constipation of pelvic outlet obstruction, both of which occur in this condition [3].
Pudendal nerve terminal motor latency. It is lengthened in patients with rectal prolapse, suggesting that nerve stretch contributes to sphincter dysfunction [3].
References
  1. ZEMPSKY WILLIAM T.. The Cause of Rectal Prolapse in Children. Arch Pediatr Adolesc Med [online] 1988 March [viewed 18 October 2014] Available from: doi:10.1001/archpedi.1988.02150030112034
  2. LIEBERMAN DAVID A., WEISS DAVID G., BOND JOHN H., AHNEN DENNIS J., GAREWAL HARINDER, HARFORD WILLIAM V., PROVENZALE DAWN, SONTAG STEVE, SCHNELL TOM, DURBIN THEODORE E., NELSON DOUG B., EWING STEVE L., TRIADAFILOPOULOS GEORGE, RAMIREZ FRANCISCO C., LEE JOHN G., COLLINS JUDITH F., FENNERTY M. BRIAN, JOHNSTON TIINA K., CORLESS CHRISTOPHER L., MCQUAID KENNETH R., SAMPLINER RICHARD E., MORALES THOMAS G., FASS RONNIE, SMITH ROBERT, MAHESHWARI YOGESH, CHEJFEC GREGORIO. Use of Colonoscopy to Screen Asymptomatic Adults for Colorectal Cancer. N Engl J Med [online] 2000 July, 343(3):162-168 [viewed 18 October 2014] Available from: doi:10.1056/NEJM200007203430301
  3. HAMMOND K, BECK DE, MARGOLIN DA, WHITLOW CB, TIMMCKE AE, HICKS TC. Rectal Prolapse: A 10-Year Experience Ochsner J [online] 2007, 7(1):24-32 [viewed 18 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096348

Management - General Measures

Fact Explanation
Manual reduction. A prolapsed rectum can be reduced by applying gentle digital pressure. This conservative management is useful especially in children in whom it is mostly a self limiting disorder [1]. Sedation or a field block with local anesthetic can be used to aid the procedure.
High-fiber diet, use of stool softeners and bulking agents in cases of constipation. This resolves constipation and minimizes straining at defecation, which is a common precipitating factor for rectal prolapse [1].
Antibiotic (cefixime) and antiparasitic (furazolidone) treatment in cases of diarrhea caused by bacteria and parasitic infestation, respectively. A lot of cases of rectal prolapse have been attributed to acute diarrheal disease and intestinal parasitic infestation [2].
Education regarding proper bowel habits. Patients should be educated on avoidance of chronic straining at bowel movements since it is a precipitating factor of rectal prolapse [3].
Weight reduction. Obesity is a risk factor for rectal prolapse [4].
Antibiotic therapy in the case of postoperative signs of infection. Rectal fixation utilizing synthetic materials has been known to be associated with postoperative infection [4]. Infection occurs most commonly from the skin organisms.
Postoperative intravenous volume repletion in the case of hypovolemia. Tearing of the presacral venous plexus when performing abdominal surgical approaches would lead to presacral hemorrhage [5]. This can lead to torrential bleeding.
References
  1. ANTAO B., BRADLEY V., ROBERTS J. P., SHAWIS R.. Management of Rectal Prolapse in Children. Diseases of the Colon & Rectum [online] 2005 August, 48(8):1620-1625 [viewed 18 October 2014] Available from: doi:10.1007/s10350-005-0074-0
  2. ZEMPSKY WILLIAM T.. The Cause of Rectal Prolapse in Children. Arch Pediatr Adolesc Med [online] 1988 March [viewed 18 October 2014] Available from: doi:10.1001/archpedi.1988.02150030112034
  3. HAMMOND K, BECK DE, MARGOLIN DA, WHITLOW CB, TIMMCKE AE, HICKS TC. Rectal Prolapse: A 10-Year Experience Ochsner J [online] 2007, 7(1):24-32 [viewed 18 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096348
  4. GOLDSTEIN SCOTT, MAXWELL PINCKNEY. Rectal Prolapse. Clinics in Colon and Rectal Surgery [online] December, 24(01):039-045 [viewed 19 October 2014] Available from: doi:10.1055/s-0031-1272822
  5. THEUERKAUF FJ JR, BEAHRS OH, HILL JR. Rectal prolapse. Causation and surgical treatment. Ann Surg [online] 1970 Jun, 171(6):819-835 [viewed 16 October 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1396889

Management - Specific Treatments

Fact Explanation
Abdominal surgical procedures: suture rectopexy. It involves mobilization of the rectum from the sacrum to the level of the anorectal junction posteriorly. After a complete rectal mobilization is performed, a posterior rectopexy is performed by direct suture fixation to the upper sacrum. The abdominal approach is best suited to young healthy patients with significant constipation and sigmoid redundancy and incontinence [1].
Abdominal surgical procedures: suture rectopexy in conjunction with a sigmoid resection. By removing the redundant sigmoid colon, constipation will improve. This would result in reduced straining, thereby helping prevent recurrent prolapse [1].
Perineal surgical procedures: Perineal rectosigmoidectomy. Perineal rectosigmoidectomy aims to resect the redundant bowel via the perineum and anchor the lower rectum to the sacrum through fibrosis in the hope of preventing future prolapse. The perineal approach is less invasive than open approaches, can be done under regional anesthesia and is associated with shorter hospital stays. It is ideal for the elderly or patients with significant comorbidities [2].
Perineal surgical procedures: Delorme’s procedure. In the Delorme’s procedure the mucosa is stripped and the muscle layer plicated and placed as a buttress above the pelvic floor. Since it is also a perineal approach it is less invasive than open approaches, can be done under regional anesthesia and is associated with shorter hospital stays. It is ideal for the elderly or patients with significant comorbidities [2].
Postoperative intravenous fluid management while receiving nothing by mouth during the initial period. It is given until gut dysfunction improves [3]. Enteral feeding is commenced earlier following perineal procedures.
Postoperative epidural local anaesthesia It provides optimal postoperative analgesia while allowing early mobilisation [3].
References
  1. GOLDSTEIN SCOTT, MAXWELL PINCKNEY. Rectal Prolapse. Clinics in Colon and Rectal Surgery [online] December, 24(01):039-045 [viewed 19 October 2014] Available from: doi:10.1055/s-0031-1272822
  2. TOU S, BROWN SR, MALIK AI, NELSON RL. Surgery for complete rectal prolapse in adults. Cochrane Database of Systematic Reviews [online] 2008 December, issue 4 [viewed 19 October 2014] Available from: doi:10.1002/14651858.CD001758.pub2
  3. FEARON K.C.H., LJUNGQVIST O., VON MEYENFELDT M., REVHAUG A., DEJONG C.H.C., LASSEN K., NYGREN J., HAUSEL J., SOOP M., ANDERSEN J., KEHLET H.. Enhanced recovery after surgery: A consensus review of clinical care for patients undergoing colonic resection. Clinical Nutrition [online] 2005 June, 24(3):466-477 [viewed 26 October 2014] Available from: doi:10.1016/j.clnu.2005.02.002