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Rectal prolapse is when the rectal walls have prolapsed to a degree where they protrude out the anus and are visible outside the body.[2] However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on if the prolapsed section is visible externally, and if the full or only partial thickness of the rectal wall is involved.[3][4]
Complete rectal prolapse, external rectal prolapse
A. full thickness external rectal prolapse, and B. mucosal prolapse. Note circumferential arrangement of folds in full thickness prolapse compared to radial folds in mucosal prolapse.[1]
Rectal prolapse may occur without any symptoms, but depending upon the nature of the prolapse there may be mucous discharge (mucus coming from the anus), rectal bleeding, degrees of fecal incontinence and obstructed defecation symptoms.[5]
Rectal prolapse is generally more common in elderly women, although it may occur at any age and in either sex. It is very rarely life-threatening, but the symptoms can be debilitating if left untreated.[5] Most external prolapse cases can be treated successfully, often with a surgical procedure. Internal prolapses are traditionally harder to treat and surgery may not be suitable for many patients.
The different kinds of rectal prolapse can be difficult to grasp, as different definitions are used and some recognize some subtypes and others do not. Essentially, rectal prolapses may be
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.[6][7]
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.[8] This infolding is perhaps best visualised as folding a sock inside out,[9] creating "a tube within a tube".[10] Another definition is "where the rectum collapses but does not exit the anus".[11] Many sources differentiate between internal rectal intussusception and mucosal prolapse, implying that the former is a full thickness prolapse of rectal wall. However, a publication by the American Society of Colon and Rectal Surgeons stated that internal rectal intussusception involved the mucosal and submucosal layers separating from the underlying muscularis mucosa layer attachments, resulting in the separated portion of rectal lining "sliding" down.[5] This may signify that authors use the terms internal rectal prolapse and internal mucosal prolapse to describe the same phenomena.
Mucosal prolapse (partial rectal mucosal prolapse)[12] refers to prolapse of the loosening of the submucosal attachments to the muscularis 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).[9] However, both internal mucosal prolapse (see below) and circumferential mucosal prolapse are described by some.[12] Others do not consider mucosal prolapse a true form of rectal prolapse.[13]
Internal mucosal prolapse (rectal internal mucosal prolapse, RIMP) refers to 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.[14] The term "mucosal hemorrhoidal prolapse" is also used.[15]
Solitary rectal ulcer syndrome (SRUS, solitary rectal ulcer, SRU) occurs with internal rectal intussusception and is part of the spectrum of rectal prolapse conditions.[5] 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.[16][17] It is classified as a chronic benign inflammatory disorder.
Rectal prolapse and internal rectal intussusception has been classified according to the size of the prolapsed section of rectum, a function of rectal mobility from the sacrum and infolding of the rectum. This classification also takes into account sphincter relaxation:[18]
Rectal internal mucosal prolapse has been graded according to the level of descent of the intussusceptum, which was predictive of symptom severity:[19]
A. Normal anatomy: (r) rectum, (a) anal canal
B. Recto-rectal intussusception
C. Recto-anal intussusception
The most widely used classification of internal rectal prolapse is according to the height on the rectal/sigmoid wall from which they originate and by whether the intussusceptum remains within the rectum or extends into the anal canal. The height of intussusception from the anal canal is usually estimated by defecography.[10]
Recto-rectal (high) intussusception (intra-rectal intussusception) is where the intussusception starts in the rectum, does not protrude into the anal canal, but stays within the rectum. (i.e. the intussusceptum originates in the rectum and does not extend into the anal canal. The intussuscipiens includes rectal lumen distal to the intussusceptum only). These are usually intussusceptions that originate in the upper rectum or lower sigmoid.[10]
Recto-anal (low) intussusception (intra-anal intussusception) is where the intussusception starts in the rectum and protrudes into the anal canal (i.e. the intussusceptum originates in the rectum, and the intussuscipiens includes part of the anal canal)
An Anatomico-Functional Classification of internal rectal intussusception has been described,[10] with the argument that other factors apart from the height of intussusception above the anal canal appear to be important to predict symptomology. The parameters of this classification are anatomic descent, diameter of intussuscepted bowel, associated rectal hyposensitivity and associated delayed colonic transit:
Patients may have associated gynecological conditions which may require multidisciplinary management.[5] History of constipation is important because some of the operations may worsen constipation. Fecal incontinence may also influence the choice of management.
Rectal prolapse may be confused easily with prolapsing hemorrhoids.[5] Mucosal prolapse also differs from prolapsing (3rd or 4th degree) hemorrhoids, where there is a segmental prolapse of the hemorrhoidal tissues at the 3,7 and 11’O clock positions.[12] Mucosal prolapse can be differentiated from a full thickness external rectal prolapse (a complete rectal prolapse) by the orientation of the folds (furrows) in the prolapsed section. In full thickness rectal prolapse, these folds run circumferential. In mucosal prolapse, these folds are radially.[9] The folds in mucosal prolapse are usually associated with internal hemorrhoids. Furthermore, in rectal prolapse, there is a sulcus present between the prolapsed bowel and the anal verge, whereas in hemorrhoidal disease there is no sulcus.[3] Prolapsed, incarcerated hemorrhoids are extremely painful, whereas as long as a rectal prolapse is not strangulated, it gives little pain and is easy to reduce.[5]
The prolapse may be obvious, or it may require straining and squatting to produce it.[5] The anus is usually patulous, (loose, open) and has reduced resting and squeeze pressures.[5] Sometimes it is necessary to observe the patient while they strain on a toilet to see the prolapse happen[20] (the perineum can be seen with a mirror or by placing an endoscope in the bowl of the toilet).[9] A phosphate enema may need to be used to induce straining.[3]
The perianal skin may be macerated (softening and whitening of skin that is kept constantly wet) and show excoriation.[9]
These may reveal congestion and edema (swelling) of the distal rectal mucosa,[20] and in 10-15% of cases there may be a solitary rectal ulcer on the anterior rectal wall.[5] Localized inflammation or ulceration can be biopsied, and may lead to a diagnosis of SRUS or colitis cystica profunda.[5] Rarely, a neoplasm (tumour) may form on the leading edge of the intussusceptum. In addition, patients are frequently elderly and therefore have increased incidence of colorectal cancer. Full length colonoscopy is usually carried out in adults prior to any surgical intervention.[5] These investigations may be used with contrast media (barium enema) which may show the associated mucosal abnormalities.[9]
This investigation is used to diagnose internal intussusception, or demonstrate a suspected external prolapse that could not be produced during the examination.[3] It is usually not necessary with obvious external rectal prolapse.[9] Defecography may demonstrate associated conditions like cystocele, vaginal vault prolapse or enterocele.[5]
Colonic transit studies may be used to rule out colonic inertia if there is a history of severe constipation.[3][5] Continent prolapse patients with slow transit constipation, and who are fit for surgery may benefit from subtotal colectomy with rectopexy.[5]
This investigation objectively documents the functional status of the sphincters. However, the clinical significance of the findings are disputed by some.[9] It may be used to assess for pelvic floor dyssenergia,[5] (anismus is a contraindication for certain surgeries, e.g. STARR), and these patients may benefit from post-operative biofeedback therapy. Decreased squeeze and resting pressures are usually the findings, and this may predate the development of the prolapse.[5] Resting tone is usually preserved in patients with mucosal prolapse.[20] In patients with reduced resting pressure, levatorplasty may be combined with prolapse repair to further improve continence.[9]
May be used to evaluate incontinence, but there is disagreement about what relevance the results may show, as rarely do they mandate a change of surgical plan.[5] There may be denervation of striated musculature on the electromyogram.[20] Increased nerve conduction periods (nerve damage), this may be significant in predicting post-operative incontinence.[5]
Rectal prolapse is a "falling down" of the rectum so that it is visible externally. The appearance is of a reddened, proboscis-like object through the anal sphincters. Patients find the condition embarrassing.[9] The symptoms can be socially debilitating without treatment,[5] but it is rarely life-threatening.[9]
The true incidence of rectal prolapse is unknown, but it is thought to be uncommon. As most sufferers are elderly, the condition is generally under-reported.[21] It may occur at any age, even in children,[22] but there is peak onset in the fourth and seventh decades.[3] Women over 50 are six times more likely to develop rectal prolapse than men. It is rare in men over 45 and in women under 20.[20] When males are affected, they tend to be young and report significant bowel function symptoms, especially obstructed defecation,[5] or have a predisposing disorder (e.g., congenital anal atresia).[9] When children are affected, they are usually under the age of 3.
35% of women with rectal prolapse have never had children,[5] suggesting that pregnancy and labour are not significant factors. Anatomical differences such as the wider pelvic outlet in females may explain the skewed gender distribution.[9]
Associated conditions, especially in younger patients include autism, developmental delay syndromes and psychiatric conditions requiring several medications.[5]
Initially, the mass may protrude through the anal canal only during defecation and straining, and spontaneously return afterwards. Later, the mass may have to be pushed back in following defecation. This may progress to a chronically prolapsed and severe condition, defined as spontaneous prolapse that is difficult to keep inside, and occurs with walking, prolonged standing,[5] coughing or sneezing (Valsalva maneuvers).[3] A chronically prolapsed rectal tissue may undergo pathological changes such as thickening, ulceration and bleeding.[5]
If the prolapse becomes trapped externally outside the anal sphincters, it may become strangulated and there is a risk of perforation.[20] This may require an urgent surgical operation if the prolapse cannot be manually reduced.[5] Applying granulated sugar on the exposed rectal tissue can reduce the edema (swelling) and facilitate this.[20]
The precise cause is unknown,[3][9][8] and has been much debated.[5] In 1912 Moschcowitz proposed that rectal prolapse was a sliding hernia through a pelvic fascial defect.[9]
This theory was based on the observation that rectal prolapse patients have a mobile and unsupported pelvic floor, and a hernia sac of peritoneum from the Pouch of Douglas and rectal wall can be seen.[5] Other adjacent structures can sometimes be seen in addition to the rectal prolapse.[5] Although a pouch of Douglas hernia, originating in the cul de sac of Douglas, may protrude from the anus (via the anterior rectal wall),[20] this is a different situation from rectal prolapse.
Shortly after the invention of defecography, In 1968 Broden and Snellman used cinedefecography to show that rectal prolapse begins as a circumferential intussusception of the rectum,[3][9] which slowly increases over time.[20] The leading edge of the intussusceptum may be located at 6–8 cm or at 15–18 cm from the anal verge.[20] This proved an older theory from the 18th century by John Hunter and Albrecht von Haller that this condition is essentially a full-thickness rectal intussusception, beginning about 3 inches above the dentate line and protruding externally.[5]
Since most patients with rectal prolapse have a long history of constipation,[9] it is thought that prolonged, excessive and repetitive straining during defecation may predispose to rectal prolapse.[3][8][20][23][24][25] Since rectal prolapse itself causes functional obstruction, more straining may result from a small prolapse, with increasing damage to the anatomy.[8] This excessive straining may be due to predisposing pelvic floor dysfunction (e.g. obstructed defecation) and anatomical factors:[9][20]
Some authors question whether these abnormalities are the cause, or secondary to the prolapse.[3] Other predisposing factors/associated conditions include:
The association with uterine prolapse (10-25%) and cystocele (35%) may suggest that there is some underlying abnormality of the pelvic floor that affects multiple pelvic organs.[3] Proximal bilateral pudendal neuropathy has been demonstrated in patients with rectal prolapse who have fecal incontinence.[5] This finding was shown to be absent in healthy subjects, and may be the cause of denervation-related atrophy of the external anal sphincter. Some authors suggest that pudendal nerve damage is the cause for pelvic floor and anal sphincter weakening, and may be the underlying cause of a spectrum of pelvic floor disorders.[5]
Sphincter function in rectal prolapse is almost always reduced.[3] This may be the result of direct sphincter injury by chronic stretching of the prolapsing rectum. Alternatively, the intussuscepting rectum may lead to chronic stimulation of the rectoanal inhibitory reflex (RAIR - contraction of the external anal sphincter in response to stool in the rectum). The RAIR was shown to be absent or blunted. Squeeze (maximum voluntary contraction) pressures may be affected as well as the resting tone. This is most likely a denervation injury to the external anal sphincter.[3]
The assumed mechanism of fecal incontinence in rectal prolapse is by the chronic stretch and trauma to the anal sphincters and the presence of a direct conduit (the intussusceptum) connecting rectum to the external environment which is not guarded by the sphincters.[5]
The assumed mechanism of obstructed defecation is by disruption to the rectum and anal canal's ability to contract and fully evacuate rectal contents. The intussusceptum itself may mechanically obstruct the rectoanal lumen, creating a blockage that straining, anismus and colonic dysmotility exacerbate.[5]
Some believe that internal rectal intussusception represents the initial form of a progressive spectrum of disorders the extreme of which is external rectal prolapse. The intermediary stages would be gradually increasing sizes of intussusception. However, internal intussusception rarely progresses to external rectal prolapse.[27] The factors that result in a patient progressing from internal intussusception to a full thickness rectal prolapse remain unknown.[5] Defecography studies demonstrated that degrees of internal intussusception are present in 40% of asymptomatic subjects, raising the possibility that it represents a normal variant in some, and may predispose patients to develop symptoms, or exacerbate other problems.[28]
Surgery is thought to be the only option to potentially cure a complete rectal prolapse.[6] For people with medical problems that make them unfit for surgery, and those who have minimal symptoms, conservative measures may be beneficial. Dietary adjustments, including increasing dietary fiber may be beneficial to reduce constipation, and thereby reduce straining.[6] A bulk forming agent (e.g. psyllium) or stool softener can also reduce constipation.[6]
Surgery is often required to prevent further damage to the anal sphincters. The goals of surgery are to restore the normal anatomy and to minimize symptoms. There is no globally agreed consensus as to which procedures are more effective,[6] and there have been over 50 different operations described.[5]
Surgical approaches in rectal prolapse can be either perineal or abdominal. A perineal approach (or trans-perineal) refers to surgical access to the rectum and sigmoid colon via incision around the anus and perineum (the area between the genitals and the anus).[29] Abdominal approach (trans-abdominal approach) involves the surgeon cutting into the abdomen and gaining surgical access to the pelvic cavity. Procedures for rectal prolapse may involve fixation of the bowel (rectopexy), or resection (a portion removed), or both.[6] Trans-anal (endo-anal) procedures are also described where access to the internal rectum is gained through the anus itself.
The abdominal approach carries a small risk of impotence in males (e.g. 1-2% in abdominal rectopexy).[9] Abdominal operations may be open or laparoscopic (keyhole surgery).[3]
Laparoscopic procedures Recovery time following laparoscopic surgery is shorter and less painful than following traditional abdominal surgery.[29] Instead of opening the pelvic cavity with a wide incision (laparotomy), a laparosc
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