[26] Rectal Prolapse

Question 1

What is a rectal prolapse?

Answer 1

Where a mucosal or full-thickness layer of rectal tissue protrudes out of the anus

Question 2

How common is a rectal prolapse?

Answer 2

Relatively uncommon

Question 3

Who do rectal prolapses mainly affect?

Answer 3

Women greater than 30 years of age

Question 4

What are the main types of rectal prolapse?

Answer 4

Partial thickness

Full thickness

Question 5

What is a partial thickness rectal prolapse?

Answer 5

Where the rectal mucosa protrudes out of the anus

Question 6

What is a full thickness rectal prolapse?

Answer 6

When the rectal wall protrudes out of the anus

Question 7

What are the current theories regarding the pathophysiology of a full prolapse?

Answer 7

It is a form of sliding hernia, through a defect of the fascia of the pelvic region

Question 8

What can cause a defect in the fascia of the pelvic region?

Answer 8

Chronic straining secondary to constipation
Chronic cough
Multiple vaginal deliveries

Question 9

What is the pathophysiology of partial thickness prolapses?

Answer 9

Associated with loosening and stretching of the connective tissue that attaches the rectal mucosa to the remainder of the rectal wall

Question 10

What do partial thickness prolapses often occur in conjunction with?

Answer 10

Long-standing hemorrhoidalfa disease

Question 11

What are the symptoms of a rectal prolapse?

Answer 11

Rectal mucus discharge
Faecal soiling
Bright red blood on wiping
Visible ulceration

Question 12

What is the result of full thickness prolapses beginning internally on their presentation?

Answer 12

They can present as rectal fullness, tenesmus, or repeated defecation

Question 13

How does a prolapse progress?

Answer 13

With time, the rectum begins to prolapse with defecation, then later with minimal coughing and straining, eventually becoming completely external

Question 14

Which type of prolapse is particularly prone to ulceration?

Answer 14

External prolapse

Question 15

What may be found on examination in rectal prolapse?

Answer 15

The prolapse may not always be evident, but can be identified by asking the patient to strain
Weakened sphincter on DRE

Question 16

How is a suspected internal prolapse investigated to confirm the diagnosis?

Answer 16

Defecating proctography

Examination under anaesthesia

Question 17

Who is the conservative management of rectal prolapse particularly useful in?

Answer 17

Those unfit for surgery
Those with minimal symptoms
Children

Question 18

Why is conservative management of rectal prolapse particularly useful in children?

Answer 18

As most prolapses will resolve spontaneously

Question 19

What does the initial conservative management of rectal prolapse involve?

Answer 19

Improved dietary fibre and fluid intake, to reduce constipation and the time spent straining

Question 20

What management might minor mucosal prolapses undergo in clinic?

Answer 20

Banding

Question 21

What is the limitation of banding minor mucosal prolapses?

Answer 21

Prone to recurrence

Question 22

What is the only definitive management of a rectal prolapse?

Answer 22

Surgical repair

Question 23

What are the surgical options for the management of rectal prolapse?

Answer 23

Abdominal approach

Perineal approach

Question 24

What is the decision between abdominal and perineal approach determined by in rectal prolapse surgery?

Answer 24

The patient’s age and co-morbidities

Question 25

What are the options for perineal approach to rectal prolapse surgery?

Answer 25

Delormes operation

Altmeirs operation

Question 26

What does a Delormes operation involve?

Answer 26

Part of the prolapsed lining of the rectal mucosa being removed, and the muscle of the rectum reinforced with placating stitches

Question 27

What is an Altmeirs operation?

Answer 27

Perineal excision of sigmoid colon and rectum

Question 28

What is the abdominal approach to rectal prolapse surgery called?

Answer 28

Rectopexy

Question 29

What does a rectopexy involve?

Answer 29

The rectum being mobilised and fixed onto the sacral prominence

Question 30

How do Altmeirs and Delormes operations compare to each other?

Answer 30

Altmeirs operation carries the risks associated with a resection, but is is often more effective