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

Differential Diagnosis

Anorectal Disorders

Treatment

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

References

  1. Tintinalli
  2. Roberts