Rectal Prolapse

Rectal prolapse, also known as rectal procidentia, is the protrusion of rectal tissue through the anus. The tissue may include just the mucosa or the full thickness of the rectal wall. Common risk factors include chronic straining, constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation, bowel motility disorders, and weakening of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor muscles. The diagnosis is primarily clinical. In children, rectal prolapse can be managed conservatively with hydration, fiber, stool softeners, and treatment of any predisposing conditions. In adults, the prolapse is often complete and requires surgical management.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Epidemiology

  • Bimodal incidence:
    • Adults: 30–70 years of age
    • Children: < 5 years of age
  • Distribution by sex:
    • Adults: women > men (> 80% of cases are women)
    • Children: girls = boys

Risk factors

Rectal prolapse is associated with several predisposing conditions and risk factors:

  • ↑ Intraabdominal pressure or bowel motility issues due to:
    • Chronic straining
    • Chronic constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
    • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
    • Diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea:
      • Infectious
      • Inflammatory bowel disease
      • Laxative abuse
  • Weakening of the pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor muscles associated with:
    • Multiparity
    • Vaginal delivery
    • Women
    • Prior pelvic surgery
    • Pelvic floor dysfunction:
      • Paradoxical puborectalis contraction
      • Nonrelaxing puborectalis muscle
  • Other causes:
    • Cystic fibrosis Cystic fibrosis Cystic fibrosis is an autosomal recessive disorder caused by mutations in the gene CFTR. The mutations lead to dysfunction of chloride channels, which results in hyperviscous mucus and the accumulation of secretions. Common presentations include chronic respiratory infections, failure to thrive, and pancreatic insufficiency. Cystic Fibrosis
    • Dementia
    • Stroke
    • Pelvic floor anatomic defects: 
      • Rectocele
      • Cystocele
      • Enterocele
      • Deep cul-de-sac

Classification

Rectal prolapse is the protrusion of rectal tissue through the anal orifice and is classified as follows: 

  • Complete rectal prolapse (full thickness):
    • Protrusion of all rectal layers
    • Appearance: concentric rings of rectal mucosa
  • Partial rectal prolapse (rectal mucosal prolapse): prolapse of the mucosa only
  • Occult rectal prolapse (rectal intussusception Intussusception Intussusception occurs when a part of the intestine (intussusceptum) telescopes into another part (intussuscipiens) of the intestine. The condition can cause obstruction and, if untreated, progress to bowel ischemia. Intussusception is most common in the pediatric population, but is occasionally encountered in adults. Intussusception):
    • Internal “telescoping” of the bowel on itself
    • Not a true prolapse (no tissue passes out of the anus)
    • Does not always progress to complete rectal procidentia
    • Symptoms may be similar to rectal prolapse.
Partial versus complete rectal prolapse

Partial versus complete rectal prolapse:
A partial rectal prolapse (left) is characterized by mucosal tissue protruding through the anal canal. A complete (full-thickness) rectal prolapse (right) is characterized by involvement of the full thickness of the rectal wall.

Image by Lecturio.

Clinical Presentation

  • Protrusion of rectal tissue with ↑ intraabdominal pressure, such as:
    • Straining
    • Coughing
    • Laughing
    • Valsalva
  • Protruding tissue may either:
    • Reduce spontaneously
    • Require manual reduction
  • A chronically prolapsed rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal can lead to:
    • Excoriation
    • Ulceration
    • Constant soiling
  • Mucus secreted by the exposed mucosa of the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal → maceration and irritation of the surrounding skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
  • Associated with difficulty in bowel regulation:
    • Tenesmus
    • Constipation
    • Fecal incontinence
  • May be associated with urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence or uterine prolapse
  • Rectal bleeding can occur.
  • Anal sphincter tone may be diminished.
A full thicknes rectal prolapse

A full-thickness (complete) rectal prolapse

Image: “Prolapse of rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal 01” by Dr. K.-H. Günther. License: CC BY 3.0

Diagnosis and Management

Diagnosis

  • Clinical diagnosis is based on visualization during the physical examination.
  • Defecography:
    • Images are obtained at different stages of defecation. 
    • Not needed for the diagnosis, but can be used to:
      • Distinguish the 2 types of rectal prolapse (if not clinically obvious)
      • Evaluate for any other pelvic floor Pelvic floor Soft tissue formed mainly by the pelvic diaphragm, which is composed of the two levator ani and two coccygeus muscles. The pelvic diaphragm lies just below the pelvic aperture (outlet) and separates the pelvic cavity from the perineum. It extends between the pubic bone anteriorly and the coccyx posteriorly. Vagina, Vulva, and Pelvic Floor abnormalities
  • Further testing to be considered:
    • Pelvic physiology studies:
      • To assess anal sphincter function
      • May include anal manometry, electromyography, and pudendal nerve terminal motor latency
    • Colonoscopy: to rule out any other pathology (such as malignancy)
    • Colonic transit study: to evaluate severe or lifelong constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation

Management

Conservative management:

  • Typically effective in children
  • Includes:
    • Adequate fluid and fiber intake
    • Straining avoidance
    • Stool softeners, enemas, and suppositories for constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
    • Pelvic floor exercises
    • Management of predisposing conditions

Surgical management:

  • Often needed for adults
  • 2 surgical approaches (chosen based on age and comorbidities):
    • Abdominal procedures:
      • Usually chosen for younger, healthier individuals
      • ↓ Recurrence rate
      • ↑ Morbidity
    • Perineal procedures:
      • Preferred for older or frail individuals
      • ↑ Recurrence rate
      • Fewer operative risks
  • Incarcerated rectal prolapse is a surgical emergency.

Differential Diagnosis

  • Rectosigmoid intussusception Intussusception Intussusception occurs when a part of the intestine (intussusceptum) telescopes into another part (intussuscipiens) of the intestine. The condition can cause obstruction and, if untreated, progress to bowel ischemia. Intussusception is most common in the pediatric population, but is occasionally encountered in adults. Intussusception: occurs when the distal sigmoid colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix telescopes into the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal. In adults, a large rectosigmoid intussusception Intussusception Intussusception occurs when a part of the intestine (intussusceptum) telescopes into another part (intussuscipiens) of the intestine. The condition can cause obstruction and, if untreated, progress to bowel ischemia. Intussusception is most common in the pediatric population, but is occasionally encountered in adults. Intussusception can present similarly to rectal prolapse. However, unlike with rectal prolapse, pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, distention, nausea, and vomiting are also present. Imaging provides the diagnosis and surgery provides definitive treatment.
  • Hemorrhoids Hemorrhoids Hemorrhoids are normal vascular cushions in the anal canal composed of dilated vascular tissue, smooth muscle, and connective tissue. They do not cause issues unless they are enlarged, inflamed, thrombosed, or prolapsed. Patients often present with rectal bleeding of bright red blood, or they may have pain, perianal pruritus, or a palpable mass. Hemorrhoids: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, thrombosis, and/or prolapse of the normal vascular cushions in the anal canal. Individuals may have pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, perianal pruritus, or a palpable mass and often present with bright-red rectal bleeding. External hemorrhoids are associated with perianal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, but internal hemorrhoids are usually painless. The diagnosis is made based on the physical exam and/or anoscopy. Surgical methods are reserved for more severe hemorrhoids or if unresponsive to conservative measures.
  • Proctitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the rectal mucosa. Etiologies include inflammatory bowel disease, infection, and radiation. Individuals may notice anorectal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, tenesmus, rectal bleeding, and/or mucus. The diagnosis is made with proctoscopy and cultures should be taken to evaluate for infectious causes. Management can include antibiotics, topical steroids, and anti-inflammatory medications, depending on the cause.

References

  1. Varma, M. G., & Steele, S. R. (2020). Overview of rectal procidentia (rectal prolapse). UpToDate. Retrieved September 16, 2021, from https://www.uptodate.com/contents/overview-of-rectal-procidentia-rectal-prolapse
  2. Varma, M. G., & Steele, S. R. (2021). Surgical approach to rectal procidentia (rectal prolapse). UpToDate. Retrieved September 16, 2021, from https://www.uptodate.com/contents/surgical-approach-to-rectal-procidentia-rectal-prolapse
  3. Ansari, P. (2021). Rectal prolapse and procidentia. MSD Manual Profession Version. Retrieved September 16, 2021, from https://www.msdmanuals.com/professional/gastrointestinal-disorders/anorectal-disorders/rectal-prolapse-and-procidentia
  4. Segal, J., McKeown, D. G., and Tavarez, M. M. (2021). Rectal prolapse. StatPearls. Retrieved September 16, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK532308/
  5. Rakinic, J., and Poritz, L. S. (2020). Rectal prolapse. Medscape. Retrieved September 16, 2021, from https://emedicine.medscape.com/article/2026460-overview

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