Rectum

Rectal Prolapse

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Rectal Prolapse

  • Definitions
  1. Rectal Prolapse
    1. Protrusion of all or some layers of the Rectum via the anus with straining
    2. Intussception of the bowel through the anus
  • Epidemiology
  1. Bimodal distribution: Pediatric and Elderly patients
  • Pathophysiology
  1. Weak pelvic support
  • Types
  1. Full thickness Rectal Prolapse
  2. Internal prolapse (Internal Intussusception
    1. Prolapse not visible outside the anal canal
  3. Mucosal prolapse
    1. Progression of Hemorrhoids more than a pelvic support disorder
  • Risk Factors
  1. Chronic Constipation
  2. Conditions predisposing to straining at stool (e.g. Multiple pregnancies)
  3. Increasing Age (esp. women)
  • Symptoms
  1. Mass protruding from the anus
    1. Onset often after straining to stool
  2. Associated symptoms
    1. Rectal Pain
    2. Anal Discharge
    3. Rectal Bleeding
  • Associated Conditions
  1. Pelvic Organ Prolapse (e.g. Rectocele, Cystocele)
  2. Hemorrhoids (especially with mucosal prolapse)
  • Complications
  1. Incarcerated Hernia (rare)
  2. Tissue breakdown and necrosis of incarcerated bowel
  • Management
  • Manual Reduction
  1. Contraindications
    1. Tissue necrosis
  2. Adjuncts
    1. Applying granulated sugar to rectal mucosa reduces local edema
    2. Anxiolysis (e.g. Midazolam)
    3. Analgesia (e.g. Fentanyl)
  3. Technique
    1. Avoid delays due to risks of prolonged prolapse with tissue breakdown and necrosis risk
    2. Patient lies in lateral decubitus position or prone position
    3. Apply granulated sugar or gauze soaked in sugar water over prolapsed mucosa for 10 to 20 minutes
    4. Assistant retracts the buttock cheeks
    5. Examiner applies both thumbs against the central opening, and other fingers resting against the buttocks
      1. Thumbs apply constant gentle pressure
      2. Fingers apply circumferential pressure, rotating the hands clockwise and counterclockwise
      3. Maintain over several minutes as the prolapse reduces
    6. Apply a pressure dressing against the anus to prevent a short-term recurrence
      1. First layer against the anus may be Vaseline Gauze
  • Management
  • Other Measures
  1. Surgery Indications
    1. Failed reduction
    2. Incarcerated Hernia
  2. Disposition
    1. Follow-up for evaluation for malignancy (nidus for prolapse)
  • Prevention
  1. Pelvic Floor Exercises
  2. Avoid straining at stool
    1. Follow bowel regimen to maintain soft stools
  • Resources
  1. Emedicine
    1. http://emedicine.medscape.com/article/196411
  • References
  1. Warrington (2022) Crit Dec Emerg Med 36(7): 15
  2. Cohee (2020) Am Fam Physician 101(1):24-33 [PubMed]
  3. Jones (2011) BMJ 342:c7099 [PubMed]