Up ] Abdominal incisions ] Groin hernias ] Other hernias ] Peritonitis ] Appendicitis ] Ovarian cysts ] Oesophageal perforation ] Perforated peptic ulcer ] Diverticular disease ] Upper GI haemorrhage ] Lower GI haemorrhage ] Small bowel obstruction ] Large bowel obstruction ] Sigmoid and caecal volvulus ] Pseudo-obstruction ] Enterocutaneous fistulae ] Mesenteric ischaemia ] Acute pancreatitis ] Pyogenic liver abscess ] Amoebic liver abscess ] Hydatid disease ] Gynecological pain ] GORD ] Achalasia ] Oesophageal carcinoma ] Peptic ulcer disease ] Gastric carcinoma ] Hepatocellular carcinoma ] Pancreatic cancer ] Chronic pancreatitis ] Colonic polyps ] Colorectal carcinoma ] Liver metastases ] Anal carcinoma ] Inflammatory bowel disease ] Anal fissure ] Haemorrhoids ] Perianal sepsis ] Pilonidal sinus ] [ Rectal prolapse ] Jaundice ] Gall stones ] Portal hypertension ] Ascites ] Stomas ] Abdominal pain ] Abdominal masses ]

Rectal prolapse

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

Complete rectal prolapse

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

Eu K W, Seow-Choen F.  Functional problems in adult rectal prolapse and controversies in surgical treatment.  Br J Surg 1997;  84:  904-911.

Tobin S A,  Scott I H.  Delorme's operation for rectal prolapse.  Br J Surg 1994;  81:  1681-1684.

 
 

Copyright 1997- 2013 Surgical-tutor.org.uk