Rectal Prolapse or procidentia is defined as a protrusion of the rectum beyond the anus. Complete or full-thickness rectal prolapse is the protrusion of all of the rectal wall through the anal canal if the rectal wall has prolapsed but does not protrude through the anus, it is called an occult (internal) rectal prolapse or a rectal intussusception [rx]. Full-thickness rectal prolapse should be distinguished from mucosal prolapse in which there is protrusion of only the rectal or anal mucosa [rx].
Rectal prolapse refers specifically to the prolapse of some or all of the rectal mucosa through the external anal sphincter. In pediatric populations aged between infancy and age 4, rectal prolapse is usually a self-limiting condition, responding to conservative management. The highest incidence of rectal prolapse has been noted in the first year of life.[rx] However, children presenting after age 4 usually have a chronic condition predisposing them to have developed rectal prolapse.[rx] In some cases, the prolapse may persist indefinitely, requiring surgical intervention.[rx]
Types of Rectal Prolapse
- External (complete) rectal prolapse – (rectal procidentia, full-thickness rectal prolapse, external rectal prolapse) is a full-thickness, circumferential, true intussusception of the rectal wall which protrudes from the anus and is visible externally.
- Internal rectal intussusception – (occult rectal prolapse, internal procidentia) can be defined as a funnel-shaped infolding of the upper rectal (or lower sigmoid) wall that can occur during defecation.[rx] This infolding is perhaps best visualized as folding a sock inside out,[rx] creating “a tube within a tube”.[rx] Another definition is “where the rectum collapses but does not exit the anus”.[rx]
- Rectal prolapse (procidentia)It is a full-thickness – circumferential intussusception of the entire rectal wall through the anal canal resulting in part of the rectum remaining intermittently or occasionally permanently distal to the anus. The latter condition is known as third-degree prolapse and the former state as a second degree.
- Internal intussusception – It is an invagination of part or the entire rectum into itself without any external component, also known as 1° rectal prolapse.
- Mucosal prolapse (partial rectal mucosal prolapse) – refers to the prolapse of the loosening of the submucosal attachments to the muscular propria of the distal rectummucosal layer of the rectal wall. Most sources define mucosal prolapse as an external, segmental prolapse which is easily confused with prolapsed (3rd or 4th degree) hemorrhoids (piles). However, both internal mucosal prolapse (see below) and circumferential mucosal prolapse are described by some.[rx] Others do not consider mucosal prolapse a true form of rectal prolapse.[rx]
- Internal mucosal prolapse (rectal internal mucosal prolapse, RIMP) – refers to the prolapse of the mucosal layer of the rectal wall which does not protrude externally. There is some controversy surrounding this condition as to its relationship with hemorrhoidal disease, or whether it is a separate entity.[rx] The term “mucosal hemorrhoidal prolapse” is also used.[rx]
- Solitary rectal ulcer syndrome (SRUS, solitary rectal ulcer, SRU) – occurs with internal rectal intussusception and is part of the spectrum of rectal prolapse conditions.[rx] It describes ulceration of the rectal lining caused by repeated frictional damage as the internal intussusception is forced into the anal canal during straining. SRUS can be considered a consequence of internal intussusception, which can be demonstrated in 94% of cases.
- Mucosal prolapse syndrome (MPS) – is recognized by some. It includes solitary rectal ulcer syndrome, rectal prolapse, proctitis cystica profunda, and inflammatory polyps. It is classified as a chronic benign inflammatory disorder.
There are three types of rectal prolapse:
- Full-thickness – The full thickness of the wall of the rectum sticks out through the anus. This is the most common type of rectal prolapse. There can be a partial or complete protrusion.
- Mucosal – Only the lining of the anus (known as the mucosa) sticks out through the anus.
- Internal – The rectum folds in on itself but does not stick out through the anus.
Patients were considered to be constipated if they had two or fewer bowel actions per week or strained for more than 25% of the time spent defecating. Incontinence of feces was graded according to Park’s classification [rx] into: –
- Grade 4 = Incontinence for solid stool.
- Grade 3 = Incontinence for liquid and flatus.
- Grade 2 = Incontinence for flatus only.
- Grade 1 = Normal.
Rectal prolapse and internal rectal intussusception have been classified according to the size of the prolapsed section of the rectum, a function of rectal mobility from the sacrum and infolding of the rectum. This classification also takes into account sphincter relaxation:
- Grade I – nonrelaxation of the sphincter mechanism (anismus)
- Grade II – mild intussusception
- Grade III – moderate intussusception
- Grade IV – severe intussusception
- Grade V – rectal prolapse
Rectal internal mucosal prolapse has been graded according to the level of descent of the intussusceptum, which was predictive of symptom severity:[rx]
- First-degree prolapse – is detectable below the anorectal ring on straining
- Second degree – when it reached the dentate line
- Third-degree – when it reached the anal verge
Pathogenesis of Rectal Prolapse
Etiologic factors: 1) congenital, 2) acquired.
- At the beginning of the century Moschcowitz (rx) described the anatomical basis for a rectal prolapse as a deficient pelvic floor through which the rectum herniates. This theory was that a redundant sigmoid colon lying within the deep pelvic sac, together with the resulting acute rectosigmoid junction, caused the patient to strain excessively to evacuate. Thus, the hypothesis continued, the eventual prolapse was the result of herniation through the weakened pelvic floor.
- A latter concept suggested that rectal prolapse was actually a circumferential 2° or 3° intussusception (rx). Complete circumferential intussusception usually starts 6–8 cm from the anal verge but can continue through the anal canal (rx).
Predisposing and associated anatomical and functional factors:
- Anatomical factors include female sex, redundant rectosigmoid, a deep pouch of Douglas, patulous anus (weak internal sphincter), diastasis of levator ani muscle (defects in the pelvic floor), lack of fixation of the rectum to the sacrum. Functional factors include poor bowel habits (chronic constipation), neurologic disease including congenital anomaly, cauda equina lesion, spinal cord injury, and senility.
- The majority of patients are women (rx) and peak occurrence is in the sixth decade of life. Rectal prolapse is relatively uncommon in men; moreover, they usually present when they are less than 50 years of age.
Causes of Rectal Prolapse
A variety of things can cause the condition, including:
- The long-term history of diarrhea or constipation
- The long-term history of having to strain when you poop
- Old age, which weakens muscles and ligaments in the rectal area
- Previous injury to the anal or hip area
- Nerve damage that affects your muscles’ ability to tighten and loosen.
- The long-term history of straining during bowel movements
- Older age – Muscles and ligaments in the rectum and anus naturally weaken with age. Other nearby structures in the pelvis area also loosen with age, which adds to the general weakness in that area of the body.
- Weakening of the anal sphincter – This is the specific muscle that controls the release of stool from the rectum.
- Earlier injury to the anal or pelvic areas
- Damage to nerves – If the nerves that control the ability of the rectum and anus muscles to contract (shrink) are damaged, rectal prolapse can result. Nerve damage can be caused by pregnancy, difficult vaginal childbirth, anal sphincter paralysis, spinal injury, back injury/back surgery and/or other surgeries of the pelvic area.
- Other diseases, conditions and infections – Rectal prolapse can be a consequence of diabetes, cystic fibrosis, chronic obstructive pulmonary disease, hysterectomy, and infections in the intestines caused by parasites – such as pinworms and whipworms – and diseases resulting from poor nutrition or from difficulty digesting foods.
Since rectal prolapse itself causes functional obstruction, more straining may result from a small prolapse, with increasing damage to the anatomy. This excessive straining may be due to predisposing pelvic floor dysfunction (e.g. obstructed defecation) and anatomical factors
- Abnormally low descent of the peritoneum covering the anterior rectal wall
- poor posterior rectal fixation, resulting in loss of posterior fixation of the rectum to the sacral curve[rx]
- loss of the normal horizontal position of the rectum with lengthening (redundant rectosigmoid)[rx][rx] and downward displacement of the sigmoid and rectum
- long rectal mesentery[rx]
- a deep cul-de-sac
- levator diastasis
- a patulous, weak anal sphincter
Some authors question whether these abnormalities are the cause, or secondary to the prolapse. Other predisposing factors/associated conditions include:
- pregnancy[rx] (although 35% of women who develop rectal prolapse are nulliparous)[rx] (have never given birth)
- previous surgery[rx] (30-50% of females with the condition underwent previous gynecological surgery)[rx]
- pelvic neuropathies and neurological disease[rx]
- high gastrointestinal helminth loads (e.g. Whipworm)
- cystic fibrosis
Symptoms of Rectal Prolapse
Additional symptoms of rectal prolapse can include
- Feeling a bulge outside your anus
- Seeing a red mass outside your anal opening
- Pain in the anus or rectum
- Bleeding from the rectum
- Leaking blood, poop, or mucus from the anus
- history of a protruding mass.[rx]
- degrees of fecal incontinence, (50-80% of patients) which may simply present as a mucous discharge.[rx]
- constipation (20-50% of patients) also described as tenesmus (a sensation of incomplete evacuation of stool) and obstructed defecation.[rx]
- a feeling of bearing down.[rx]
- rectal bleeding[rx]
- diarrhea and erratic bowel habits.
Diagnosis of Rectal Prolapse
Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get rectal prolapse; not having risk factors doesn’t mean that you will not get cancer. Talk to your doctor if you think you may be at risk for rectal prolapse
Having a family history of colon or rectal prolapse in a first-degree relative (parent, sibling, or child).
Having a personal history of rectal prolapse of the colon, rectum, or ovary.
Having a personal history of high-risk adenomas (colorectal polyps that are 1 centimeter or larger in size or that have cells that look abnormal under a microscope).
Having inherited changes in certain genes that increase the risk of familial adenomatous polyposis (FAP) or Lynch syndrome (hereditary nonpolyposis colorectal cancer).
Having a personal history of chronic ulcerative colitis or Crohn disease for 8 years or more.
Having three or more alcoholic drinks per day.
Older age is the main risk factor for most rectal prolapse. The chance of getting rectal prolapse increases as you get older.
Tests that examine the rectum and colon are used to detect (find) and diagnose rectal cancer
Tests used to diagnose rectal prolapse include the following:
Physical exam and history – An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
Digital rectal exam (DRE) – An exam of the rectum. The doctor or nurse inserts a lubricated, gloved finger into the lower part of the rectum to feel for lumps or anything else that seems unusual. In women, the vagina may also be examined.
- Anal electromyography (EMG) – This test determines if nerve damage is the reason why the anal sphincters are not working properly. It also examines the coordination between the rectum and anal muscles.
- Anal manometry – This test studies the strength of the anal sphincter muscles. A short, thin tube, inserted up into the anus and rectum, is used to measure the sphincter tightness.
- Anal ultrasound – This test helps evaluate the shape and structure of the anal sphincter muscles and surrounding tissue. In this test, a small probe is inserted up into the anus and rectum to take images of the sphincters.
- Pudendal nerve terminal motor latency test – This test measures the function of the pudendal nerves, which are involved in bowel control.
- Proctography (also called defecography) – This test is done in the radiology department. In this test, an X-ray video is taken that shows how well the rectum is functioning. The video shows how much stool the rectum can hold, how well the rectum holds the stool, and how well the rectum releases the stool.
- Colonoscopy – A procedure to look inside the rectum and colon for polyps (small pieces of bulging tissue), abnormal areas, or cancer. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
- Biopsy – The removal of cells or tissues so they can be viewed under a microscope to check for signs of rectal prolapse. Tumor tissue that is removed during the biopsy may be checked to see if the patient is likely to have the gene mutation that causes HNPCC. This may help to plan treatment. The following tests may be used:
- Reverse transcription-polymerase chain reaction (RT–PCR) test – A laboratory test in which the amount of a genetic substance called mRNA made by a specific gene is measured. An enzyme called reverse transcriptase is used to convert a specific piece of RNA into a matching piece of DNA, which can be amplified (made in large numbers) by another enzyme called DNA polymerase. The amplified DNA copies help tell whether a specific mRNA is being made by a gene. RT–PCR can be used to check the activation of certain genes that may indicate the presence of rectal prolapse cells. This test may be used to look for certain changes in a gene or chromosome, which may help diagnose rectal prolapse.
- Immunohistochemistry – A laboratory test that uses antibodies to check for certain antigens (markers) in a sample of a patient’s tissue. The antibodies are usually linked to an enzyme or a fluorescent dye. After the antibodies bind to a specific antigen in the tissue sample, the enzyme or dye is activated, and the antigen can then be seen under a microscope. This type of test is used to help diagnose cancer and to help tell one type of cancer from another type of cancer.
- Carcinoembryonic antigen (CEA) assay – A test that measures the level of CEA in the blood. CEA is released into the bloodstream from both rectal prolapse and normal cells. When found in higher than normal amounts, it can be a sign of rectal prolapse or other conditions.
- Anorectal manometry – measures and assesses the anal sphincter (internal and external) and rectal pressure and its function. This method is used to evaluate patients with fecal incontinence and constipation. It can directly measure the luminal pressure, including the high-pressure zone, resting pressure, squeezing pressure, rectal sensation/compliance, and the anorectal inhibitory reflex.[rx]
- Defecating proctography/Defecography – A study using X-ray imaging to evaluate anatomic defects of the anorectal region and function of the puborectalis muscle. A contrast filled paste gets initially introduced to the rectum, and the patient is instructed to defecate in a series of stages (relaxation, contraction, tensing of the abdomen, and evacuation).[rx]
- Balloon capacity and compliance test – Evaluates the function of the rectum using a device (plastic catheter with a latex balloon attached), which is inserted into the rectum and gradually filled with warm water. During this process, the volume and pressure are measured.[rx]
- Balloon evacuation study – This test is similar to the balloon capacity and compliance test in which a catheter with a small balloon gets inserted into the rectum and filled with water. Different volumes of water get loaded inside the balloon, and the patient is instructed to evacuate the balloon. This procedure is done to evaluate the opening of the anal canal and to assess the relaxation of the pelvic floor.[rx]
- Pudendal nerve terminal motor latency – A probe designed to stimulate and record nerve activity is placed on the physician’s gloved finger, which is then inserted into the rectum to measure pudendal nerve activity (latency to contraction of the anal sphincter muscle). The pudendal nerve innervates the anal sphincter muscles; therefore, this test can be used to assess any injury to that nerve.
- Electromyography – A test to measure the ability of the puborectalis muscle and sphincter muscles to relax properly. An electrode is placed inside the rectum, and the activity of these muscles gets evaluated throughout a series of stages (relaxation, contraction, and evacuation).[rx]
- Endoanal Ultrasonography – The use of ultrasound imaging to examine rectal lesions, defects, or injuries to the surrounding tissues.[rx]
- Suction rectal biopsy – Gold standard for the diagnosis of Hirschsprung disease. A biopsy is taken two cm above the dentate line, and the absence of ganglion cells on histology confirms the diagnosis. Hypertrophic nerve fibers may be present in addition to this finding.[rx]
- Contrast enema – Used as one of the diagnostic methods for Hirschsprung disease. Useful for localization of the aganglionic segment by looking for a narrowed rectum. Diagnostic confirmation is via a rectal biopsy.[rx]
Treatment of Rectal Prolapse
- Activity – Typically, the child is encouraged to walk around as soon as possible.
- Diet – Patients are started on liquids after their surgery then advanced to a general diet.
- Antibiotics – To help prevent or treat an infection caused by bacteria.
- Anti-nausea medicine – To control vomiting (throwing up).
- Pain medicine – Pain medicine can include acetaminophen (Tylenol®), ibuprofen (Motrin®), or narcotics. These medicines can be given by vein or by mouth.
- Stool softeners – Polyethylene glycol (Miralax), Docusate (Colace) or senna are among the medications used to avoid straining after surgery.
- Management of rectal prolapse is surgical; over 100 different procedures have been described. The existence of so many surgical options is an attestation to the lack of uniform success associated with any one single procedure. Since no procedure is a panacea, the operation selected should be matched to the physiologic condition of the patient.
- Transabdominal repairs involve rectal fixation, rectal resection or a combination of resection and fixation. Attachment of the rectum to the sacrum can be performed using foreign material or sutures although the lateral rectal attachments can be achieved to the sacral periosteum without foreign material.
- The primary advantages of a transabdominal procedure are the lower recurrence rates and the associated improvements in incontinence as well as the preservation of a rectal reservoir. Disadvantages are that they are a more invasive procedures and do have an associated risk of postoperative sexual dysfunction in males.
Anterior rectopexy (Ripstein procedure)
Posterior sling rectopexy (Wells procedure)
- After posterior rectal mobilization and fixation of a mesh to the sacral hollow, the mesh is wrapped around the lateral aspects while the anterior rectal wall is left free to prevent stricture.
- Results: Recurrence rates for anterior and posterior rectopexy are similar. However, the rate of stricture and therefore postoperative constipation may be lower after posterior than after anterior rectopexy.
Anterior resection without fixation
- After anterior resection – the rectum becomes secondarily scarred and therefore adherent to the sacrum.
- Advantages – removal of the redundant colon may prevent volvulus and torsion and may ameliorate some bowel complaints, especially constipation.
- Disadvantages – Risk for anastomotic leak.
- Results – Recurrence rate 9% (rx). Deterioration of continence has been reported in 10–20% (rx) of patients.
Resection with sacral fixation
- Fixation of the distal rectal segment to the sacrum with redundant sigmoid extirpation.
- Results: Initial reports stated recurrence rates of 2–9% (rx–rx). Bowel control is more likely to be improved when compared to other methods. The procedure is comparable to rectopexy with respect to operative morbidity but postoperative constipation is less likely (rx). Division of the lateral ligaments decreases recurrence rates but increases the incidence of postoperative constipation.
- Perhaps the simplest abdominal approach is rectopexy. The rectum is mobilized distally down to the levator ani muscles. The mesentery of the rectum and the muscular are secured to the sacral fascia or bone.
- Results: Recurrence rates are reported in 2–5% (rx, rx). However, a redundant sigmoid colon may at least theoretically cause the onset of or exacerbate preexisting constipation.
- Sutured rectopexy, mesh rectopexy, and anterior resection or resection rectopexy are all technically feasible laparoscopic approaches. So far controlled trials have not been performed and long-term recurrence data are not yet available. Small series suggest that morbidity and short term recurrence rates are similar to these reported by laparotomy.
- Perineal procedures are associated with a higher recurrence rate than abdominal procedures. In addition, postoperative incontinence may be exacerbated (rx). However, the benefits are related to avoiding a laparotomy and include very low morbidity and negligible disability. These operations can be done under general, regional or occasionally local anesthesia.
Altemeier operation (perineal proctosigmoidectomy)
Perineal resection of the full thickness of the prolapsed segment with coloanal anastomosis.
- These operations are no longer used as they fail to eliminate the prolapse or to improve incontinence. Moreover high rates of infection, implant extrusion and stenosis with associated prolapse incarceration have been noted.
The most common types of surgery
- Through the abdomen – This type of surgery can be done either with a large incision or using laparoscopy — this process uses small cuts and a camera attached to an instrument so the surgeon can see what needs to be done and if there are any additional issues that need to be fixed.
- Rectal repair – This approach may be used if you are older or have other medical problems. This type of surgery can involve the inner lining of the rectum or the portion of the rectum extending out of the anus.
- Altemeier procedure – In this procedure — also called a perineal proctosigmoidectomy — the portion of the rectum extending out of the anus is cut off (amputated) and the two ends are sewn back together. The remaining structures that help support the rectum are stitched back together in an attempt to provide better support.
- Delorme procedure – In this procedure, only the inner lining of the fallen rectum is removed. The outer layer is then folded and stitched and the cut edges of the inner lining are stitched together so that rectum is now inside the anal canal.
- Laparoscopic rectal prolapse surgery – Also done through the abdomen, this procedure uses several smaller incisions. The surgeon inserts special surgical tools and a tiny camera through the abdominal incisions to repair the rectal prolapse. An emerging robotic approach uses a robot to perform the operation.
- Rectal prolapse repair through the area around the anus (perineal rectosigmoidectomy) – During the more commonly performed form of this procedure (Altemeier procedure), the surgeon pulls the rectum through the anus, removes a portion of the rectum and sigmoid and attaches the remaining rectum to the large intestine (colon). This repair is typically reserved for those who are not candidates for open or laparoscopic repair
Home Care (“What do I need to do once my child goes home?”)
- Diet – Your child may eat a normal diet after surgery. Avoid constipating foods such as dairy products, rice and bananas.
- Activity – Your child should avoid strenuous activity and heavy lifting for the first 1-2 weeks after laparoscopic surgery, 4-6 weeks after open surgery.
- Wound care – Surgical incisions should be kept clean and dry for a few days after surgery. Most of the time, the stitches used in children are absorbable and do not require removal. Your surgeon will give you specific guidance regarding wound care, including when your child can shower or bathe.
- Medicines – Medicines for pain such as acetaminophen (Tylenol®l) or ibuprofen (Motrin® or Advil®) or something stronger like a narcotic may be needed to help with pain for a few days after surgery. Stool softeners and laxatives are needed to help regular stooling after surgery, especially if narcotics are still needed for pain.
- What to call the doctor for – Call your doctor for worsening belly pain, fever, vomiting, diarrhea, problems with urination, or if the wounds are red or draining fluid.
- Follow-up care – Your child should follow up with his or her surgeon 2-3 weeks after surgery to ensure proper post-operative healing.
Long-Term Outcomes (“Are there future conditions to worry about?”)
- The long-term prognosis for children with rectal prolapse is good. More than 90 percent of children who experience rectal prolapse between nine months and three years of age will respond to medical treatment and will not require surgery.
- Children who develop rectal prolapse after the age of four are more likely to have underlying neurologic or muscular defects of the pelvis. These children are less likely to respond to medical treatments and should be seen early for surgical intervention.
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