Classification
Complete prolapse
- Full thickness prolapse of rectum through anus
- Contains two layer of rectal wall
- Has intervening peritoneal sac
- Occurs in older adults
- Female to male ratio is approximately 6:1
- Associated with weak pelvic and anal musculature
- Sigmoid and rectum often floppy and redundant
Incomplete or mucosal prolapse
- Prolapse limited to mucosa
- Occurs in both children and adults
- Often associated with excessive straining, constipation and
haemorrhoids
- In children occasionally seen in cystic fibrosis
Concealed prolapse
- Internal intussusception of upper into lower rectum
- Prolapse does not emerge through anus
Clinical features
- Rectal prolapse occurs in the extremes of life
- Prolapse in children usually noted by parents
- Needs to be differentiated from
- Colonic intussusception
- Juvenile rectal polyp
- In adults usually presents with prolapsing anal mass
Picture provided by Mr Ralph Austin, Broomfield
Hospital Chelmsford, UK
- Usually occurs after defaecation
- May reduce spontaneously or be reduced manually
- Bleeding, mucus discharge or incontinence may be troublesome
- Examination usually shows poor anal tone
- Prolapse may be visible on straining
- Most prolapses that are longer than 5 cm are complete
- Differential diagnosis in adult
- Large haemorrhoids
- Prolapsing rectal tumours
- Prolapsing anal polyp
- Abnormal perineal descent
Management
Complete prolapse
- Many patients too frail for surgery
- Should be given bulk laxatives and carers taught how to reduce the
prolapse
- Urgent treatment required if prolapse is irreducible or ischaemic
- If fit for surgery can be performed via perineal or abdominal
approach
- Perineal options include:
- Perineal sutures (Thiersh procedure)
- Delorme's procedure
- Perineal rectopexy
- Abdominal or sacral options include:
- Abdominal rectopexy
- Anterior resection rectopexy
- Abdominal procedures may be performed laparoscopically
Incomplete prolapse
- In children improvement often seen with dietary advice and treatment
of constipation
- Surgery is rarely required
- In adults management similar to that of haemorrhoids
- Includes injection sclerotherapy, mucosal banding or formal
haemorrhoidectomy
- Occasionally anal sphincter repair is required
Bibliography
Madiba T E, Baig M K, Wexner S D. Surgical management
of rectal prolapse. Arch Surg 2005; 140: 201-208.
Melton G B, Kwaan M R. Rectal prolapse. Surg Clin
North Am 2013; 93: 187-198
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