Rectal Prolapse Flashcards
What is a rectal prolapse?
Protrusion of mucosal or full-thickness layer of rectal tissue out of the anus.
Epidemiology
Uncommon
2.5 per 100000
Mainly affecting older females
Two main types
Partial thickness where the rectal mucosa protrudes out of the anus
Full thicknes where the rectal wall protrudes out of the anus
Internal intussusception is prolapse of the rectum into the distal rectum or anal canal, but there is no protrusion.
Pathophysiology of full prolapse.
Theorised to be a form of sliding hernia through a defect of the fascia in the pelvic region.
Chronic straining from constipation, chronic cough or multiparity might contribute.
Pathophysiology of partial prolapse
Loosening and stretching of connective tissue that attaches to the rectal mucosa to the remained of the rectal wall.
This can happen in conjunction with long standing haemorrhoidal disease.
Risk factors
Increasing age
Female
Multiparity
Straining
Anorexia
Previous traumatic vaginal delivery
Clinical features
Rectal mucus discharge
Faecal incontinence
PR bleed
Visible ulceration
Specific features of full prolapse
Will begin internally and can initially present with a sensation of rectal fullness, tenesmus or repeated defecation.
Examinatino findings
Prolapse may not always be evident
Ask the patient to strain to see if there is any evidence.
DRE should be performed and the anal sphincter should be assessed for any weakness.
What investigation should be done for a suspected internal prolapse?
Defecating proctography and examination under anaesthesia (EUA)
Conservative management
More common in those unfit for surgery or minimal symptoms, or in children (most resolve spontaneously in children).
Dietary fibre and fluid intake to increase
Minor mucosal prolapses may be banded in clinic.
There are two surgical approaches, which?
Perineal approach
Abdominal approach
Explain perineal approach.
Delormes operation = prolapsed lining of the rectal mucosa is removed, underlying muscle is reinforced with plicated sutures.
Altemeier’s operation = resection of the redundant prolapsed bowel to restore the original anatomy.
Explain abdominal approach
Usually done laparoscopically, but can also be done robotically or open.
Rectopexy where the rectum is mobilised and fixed onto the sacral prominence via sutures or mesh.
Which surgical approach is preferred?
In older patients the perineal procedure is preferred because it is considered safer.
