Rectal Prolapse

Overview

Epidemiology

• Bimodal incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency:
  • Adults: 30–70 years of age
  • Children: < 5 years of age
• Distribution by sex Sex The totality of characteristics of reproductive structure, functions, phenotype, and genotype, differentiating the male from the female organism. Gender Dysphoria:
  • 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 Motility The motor activity of the gastrointestinal tract. Gastrointestinal 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 The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and 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 Laxative Agents that produce a soft formed stool, and relax and loosen the bowels, typically used over a protracted period, to relieve constipation. Hypokalemia 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: Anatomy muscles associated with:
  • Multiparity
  • Vaginal delivery
  • Women
  • Prior pelvic surgery
  • 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: Anatomy dysfunction:
    • Paradoxical puborectalis Puborectalis Vagina, Vulva, and Pelvic Floor: Anatomy contraction
    • Nonrelaxing puborectalis Puborectalis Vagina, Vulva, and Pelvic Floor: Anatomy muscle
• Other causes:
  • Cystic Cystic Fibrocystic Change fibrosis Fibrosis Any pathological condition where fibrous connective tissue invades any organ, usually as a consequence of inflammation or other injury. Bronchiolitis Obliterans
  • Dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders
  • Stroke
  • 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: Anatomy anatomic defects:
    • Rectocele Rectocele Herniation of the rectum into the vagina. Pelvic Organ Prolapse
    • Cystocele Cystocele A hernia-like condition in which the weakened pelvic muscles cause the urinary bladder to drop from its normal position. Fallen urinary bladder is more common in females with the bladder dropping into the vagina and less common in males with the bladder dropping into the scrotum. Pelvic Organ Prolapse
    • Enterocele Enterocele Pelvic Organ Prolapse
    • 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 Procidentia Pelvic Organ Prolapse
  • Symptoms may be similar to rectal prolapse.

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: Anatomy can lead to:
  • Excoriation Excoriation Mastitis
  • Ulceration Ulceration Corneal Abrasions, Erosion, and Ulcers
  • 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: Anatomy → 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. Skin: Structure and Functions
• Associated with difficulty in bowel regulation:
  • Tenesmus
  • 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
  • Fecal incontinence Fecal incontinence Failure of voluntary control of the anal sphincters, with involuntary passage of feces and flatus. Pediatric Constipation
• 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 Uterine prolapse Downward displacement of the uterus. It is classified in various degrees: in the first degree the uterine cervix is within the vaginal orifice; in the second degree the cervix is outside the orifice; in the third degree the entire uterus is outside the orifice. Pelvic Organ Prolapse
• Rectal bleeding can occur.
• Anal sphincter tone may be diminished.

Diagnosis and Management

Diagnosis

• Clinical diagnosis is based on visualization during the physical examination.
• Defecography:
  • Images are obtained at different stages of defecation Defecation The normal process of elimination of fecal material from the rectum. Gastrointestinal Motility. 
  • 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: Anatomy abnormalities
• Further testing to be considered:
  • Pelvic physiology studies:
    • To assess anal sphincter function
    • May include anal manometry Manometry Measurement of the pressure or tension of liquids or gases with a manometer. Achalasia, electromyography Electromyography Recording of the changes in electric potential of muscle by means of surface or needle electrodes. Becker Muscular Dystrophy, and pudendal nerve Pudendal nerve A nerve which originates in the sacral spinal cord (s2 to s4) and innervates the perineum, the external genitalia, the external anal sphincter and the external urethral sphincter. It has three major branches: the perineal nerve, inferior anal nerves, and the dorsal nerve of penis or clitoris. Gluteal Region: Anatomy terminal motor Motor Neurons which send impulses peripherally to activate muscles or secretory cells. Nervous System: Histology latency
  • Colonoscopy Colonoscopy Endoscopic examination, therapy or surgery of the luminal surface of the colon. Colorectal Cancer Screening: to rule out any other pathology (such as malignancy Malignancy Hemothorax)
  • 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 Suppositories Medicated dosage forms that are designed to be inserted into the rectal, vaginal, or urethral orifice of the body for absorption. Generally, the active ingredients are packaged in dosage forms containing fatty bases such as cocoa butter, hydrogenated oil, or glycerogelatin that are solid at room temperature but melt or dissolve at body temperature. Large Bowel Obstruction 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 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: Anatomy exercises
  • Management of predisposing conditions

Surgical management:

• Often needed for adults
• 2 surgical approaches (chosen based on age and comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus):
  • Abdominal procedures:
    • Usually chosen for younger, healthier individuals
    • ↓ Recurrence rate
    • ↑ Morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status
  • Perineal procedures:
    • Preferred for older or frail individuals
    • ↑ Recurrence rate
    • Fewer operative risks
• Incarcerated rectal prolapse is a surgical emergency Surgical Emergency Acute Abdomen.

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 Sigmoid A segment of the colon between the rectum and the descending colon. Volvulus 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: Anatomy 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: Anatomy. 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 An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, distention, nausea Nausea An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses. Antiemetics, and vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia 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 Thrombosis Formation and development of a thrombus or blood clot in the blood vessel. Epidemic Typhus, and/or prolapse of the normal vascular cushions in the anal canal. Individuals may have pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, perianal pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema), or a palpable mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast and often present with bright-red rectal bleeding. External 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 are associated with perianal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, but internal 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 are usually painless. The diagnosis is made based on the physical exam and/or anoscopy Anoscopy Anal Fissure. Surgical methods are reserved for more severe 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 or if unresponsive to conservative measures.
• Proctitis Proctitis Inflammation of the mucous membrane of the rectum, the distal end of the large intestine. Chronic Granulomatous Disease: 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 Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma. Individuals may notice anorectal pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, 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 Steroids A group of polycyclic compounds closely related biochemically to terpenes. They include cholesterol, numerous hormones, precursors of certain vitamins, bile acids, alcohols (sterols), and certain natural drugs and poisons. Steroids have a common nucleus, a fused, reduced 17-carbon atom ring system, cyclopentanoperhydrophenanthrene. Most steroids also have two methyl groups and an aliphatic side-chain attached to the nucleus. Benign Liver Tumors, and anti-inflammatory medications, depending on the cause.