78. Anal and rectal prolapses

Question 1

Anal/rectal prolapse - Definition

Answer 1

Anal/rectal prolapse = eversion of the rectum through the anus

• Protrusion of mucosa + submucosa of rectum

Question 2

Incidence

Answer 2

Females more than males.

Males incidence is 0.25-0.4% over 40yrs

Question 3

Etiology:

Answer 3

50% of cases due to chronic straining with defaecation + constipation

Question 4

Pathophysiology

Answer 4

2 theories

1. Prolapse is a sliding hernia through a defect in pelvic fascia
2. Starts as circumferential int. intussusception of the rectum. With time + straining this progresses to full thickness rectal prolapse

Question 5

Classification:

Answer 5

1. Complete: full thickness (all rectal layers), protrusion of rectum through anus aka procidentia
2. Mucosal: aka partial. Often assoc with haemorrhoidal disease upon palpation only double layer felt. 1-4cm prolapse
3. Internal: when rectal wall intussusception but doesn’t protrude

Question 6

Clinical Presentation

Answer 6

Tenesmus,

Incomplete evacuation,

Mucosa discharge/bleeding

Question 7

Diagnostic Investigations

Answer 7

Complete is obvious

Barium enema

Colonoscopy

Question 8

Treatment - Abdominal ops:

Answer 8

1. Abdominal ops:
   a. Moshowitz repair – reduction of perineal hernia + closure of cul-de-sac
   b. Ripstan + walls rectopexy – fixation of rectum with sutures (mesh) or prosthetic ring (sling)

Question 9

Perineal approach:

Answer 9

2. Perineal approach:
   a. Delorme op – tightening anus with a variety of prosthetic materials
   b. Perineal rectosigmoidectomy – resecting prolapsed bowel from perineum
3. In children = partial prolapse is more common thus tx via digital repositioning or sclerotherapy