Rectal Prolapse

Rectal Prolapse: Excerpt from The 5-Minute Pediatric Consult

Joel Friedlander, DO, MBeAndrew E. Mulberg, MD (4th Edition)

Rectal Prolapse - BASICS

Rectal Prolapse - description

3 types exist:

• Complete: Full thickness of rectum prolapses through anus (2 layers of rectum with an intervening peritoneal sac, which may contain small bowel).
• Incomplete: Prolapse limited to only 2 layers of mucosa
• Concealed: Internal intussusception of upper rectum into lower, which does not, however, emerge through anus

Rectal Prolapse - epidemiology

• Most cases occur in children <4 years of age, equal incidence in boys and girls.
• Common in developing countries, perhaps because of poor nutrition and parasitic infection; uncommon in the Western world
• It usually presents between 6 months and 3 years of age in patients with cystic fibrosis. Incidence is 20%. Presentation in such children >5 years of age is rare. Highest incidence is in the 1st year of life.
• In older children and adults, strong (6-fold) female predilection

Rectal Prolapse - risk factors

Rectal Prolapse - genetics

No known inheritance pattern aside from the association with cystic fibrosis, which is an autosomally recessive inherited disease

Rectal Prolapse - etiology

Exact etiology uncertain, but the following are usually related findings and predisposing conditions:

• Excessive straining with bowel movements from constipation and toilet training (hips and knees flexed)
• Diarrhea; may be more of a cause in tropic and subtropic countries
• Malnutrition; can cause loss of the ischiorectal fat pad
• Complete prolapse rarer in children, but when it occurs it may be related to poor fixation of rectum to sacrum and to weak pelvic and anal musculature
• Complication of past surgery, such as imperforate anus repair
• Infections: Hookworms and other parasitic infections
• Cystic fibrosis
• Ulcerative colitis
• Hirschsprung disease
• Ehlers–Danlos syndrome
• Meningomyelocele
• Pertussis
• Rectal polyp
• Pneumonia
• Anorexia
• Rectal neoplasm

Rectal Prolapse - DIAGNOSIS

Rectal Prolapse - signs & symptoms

• Protrusion of rectal layers through anus, usually found during defecation or attempted defecation
• Although the history of rectal prolapse may be evident, it is often difficult to elicit on examination, and by the time the patient is seen after a prolapse at home, it may already be spontaneously reduced. Thus, the assumption of the diagnosis may have to rest primarily on the parental history.
• Although usually benign, rectal prolapse is distressing to both the parents and the child.

Rectal Prolapse - history

• Usually 1st noted by a parent after child has defecated; may be associated with painless rectal bleeding
• Often reduces spontaneously; if not, usually easily reduced manually by parent
• Rectal prolapse may cause some discomfort during bowel movements.
• Trauma to the recurrently prolapsed mucosa may lead to ulceration and mucus discharge.
• Ask whether this patient has cystic fibrosis or symptoms of the above conditions.

Rectal Prolapse - physical exam

• Usually, prolapse is not seen on examination while the patient is at rest, unless it is irreducible (dark or bright red mass protruding from child’s anus without discomfort)
• May see poor anal tone and/or large anal orifice, especially within hours after the prolapse
• In complete rectal prolapse, concentric mucosal rings can be seen, whereas incomplete prolapse reveals radial folds. If clinician sees >5 cm of rectum emerging, it is most likely a complete prolapse. Asking the patient to strain may allow the mucosa to prolapse. However, this is obviously not helpful in a really young patient.
• A polyp is differentiated in that it is plum colored and does not involve the entire anal circumference.
• In an intussusception, it is possible to insert the finger around the prolapsing apex of the intussusception, between it and the lining of the anal canal.

Rectal Prolapse - tests

Rectal Prolapse - lab

• Sweat test: All children with rectal prolapse should have a sweat test to rule out cystic fibrosis. This is a simple, noninvasive, inexpensive test with good specificity and sensitivity when performed by an experienced clinician in a qualified facility.
• Stool cultures for bacterial and parasitic infestations, if diarrhea could be causative
• Other tests for the above conditions as clinically indicated

Rectal Prolapse - imaging

Evacuation proctography: A barium enema is given, and movement of barium is observed under fluoroscopy during defecation. This may reveal an internal prolapse not easily recognizable on physical examination. This is not commonly used in children, because full cooperation is essential.

Rectal Prolapse - differencial diagnosis

• Tumors
• Prolapsing rectal tumor: Very rare
• Trauma
• Sexual abuse (e.g., result of anal penetration)
• Metabolic
• Cystic fibrosis: From 10% to 50% of patients diagnosed with cystic fibrosis >4 years of age have experienced rectal prolapse (either at the time of the diagnosis or as a past event), but few individuals with rectal prolapse have cystic fibrosis.
• Anatomic abnormality (such as absence of Houston valves in infants)
• Solitary rectal ulcer syndrome: An uncommon benign condition usually affecting older children (teenagers). Rectal bleeding on defecation common. Some studies report an association between this entity and rectal prolapse.
• Prolapsing polyp
• Large hemorrhoids
• Colonic intussusception
• Constipation
• Ehlers–Danlos syndrome
• Hirschsprung disease
• History of imperforate anus
• Pertussis/Pneumonia
• Ulcerative colitis
• History of meningomyelocele

Rectal Prolapse - TREATMENT

Rectal Prolapse - initial stabilization

Palliative:

• Reassurance of patient and/or family and caregivers
• Although surgery seems to be a quicker and more definite solution, in most cases it is more prudent to allow time and medical management to solve the problem. Surgical procedures are not foolproof and may lead to further complications (>130 procedures exist, more effective in patients <4 years of age).

Rectal Prolapse - general measures

• Rectal prolapse has a tendency to resolve spontaneously over time (90%; unlikely if 1st episode is in patient >4 years of age)
• The prolapse will resolve more successfully and quickly if the patient is treated for constipation. This should include both dietary manipulations (e.g., increased fiber, hydration) and improved defecation methods. It also will usually require the use of supplemental aids such as mineral oil and laxatives (polyethylene glycol). A small child should try to defecate on a regular toilet and not a potty. In this way, the feet are off the floor, thus relieving pressure on the child’s abdomen.
• In the rare case of stool infection with diarrhea as the underlying etiology, the appropriate therapy for that infection should be instituted.

Rectal Prolapse - diet

• Increase consumption of liquids.
• Add larger amounts of fiber to diet (5 g + age in years)

Rectal Prolapse - medication

• Stool softeners (i.e., polyethylene glycol) to relieve constipation or medication with the associated condition
• In a patient with cystic fibrosis, addition of pancreatic enzyme supplementation, if not already a part of the regimen, has been shown to improve rectal prolapse dramatically.

Rectal Prolapse - surgery

Numerous (>130) approaches have been attempted and advocated with varying degrees of enthusiasm, suggesting that none is perfect. These include:

• Perianal sutures: Poor results and high complication rate
• Delorme procedure: Rectal mucosa is excised, and underlying rectal muscle is placated with sutures.
• Abdominal rectopexy: Rectum is mobilized and attached to the sacrum by prosthetic material. Although the procedure provides good results, it has a high complication rate of constipation (exceeding 50%).
• Anterior resection rectopexy: Resection of the sigmoid loop and upper rectum; good results, but again, high complication rate because of anastomosis
• Perineal resection: Perineal rectosigmoidectomy with a coloanal anastomosis; good results
• Circumferential injection procedures (90–100% success rate): Injection of phenol, oil, normal saline, dextrose 50% solution (500 g/L), or ethyl alcohol to promote adhesion and stabilization of the rectum
• Lockhart–Mummery operation (near 100% success): Mesh pack is placed temporarily in the retrorectal space (8–10 days) to promote adhesions that stabilize rectum.

Rectal Prolapse - FOLLOW UP

Rectal Prolapse - prognosis

• With proper medical management, excellent prognosis; surgery not usually required
• Treatment of constipation should continue indefinitely, or until the child has demonstrated regular bowel habits on a high-fiber diet on his or her own without evidence of prolapse for at least several months.
• Over a period of months to years on a good dietary and behavioral regimen

Rectal Prolapse - complications

• In some older patients who may also have an overactive external sphincter, the need to generate high rectal pressures to defecate, together with the rectal prolapse, may cause venous congestion; it may lead to the solitary rectal ulcer syndrome.
• Repetitive trauma to mucosa can produce proctitis.
• Surgical complications of repair
• Frequent recurrence

Rectal Prolapse - patient monitoring

Ask caregiver to watch whether the child is beginning to strain to defecate.

Rectal Prolapse - bibliography

1. Antao B, Bradley V, Roberts JP, Shawis R, et al. Management of rectal prolapse in children. Dis Colon Rectum. 2005;48(8):1620–1625.
2. Bartolo DC, Kamm MA, Kuijpers H, et al. Working party report: Defecation disorders. Am J Gastroenterol. 1994;89:S154.
3. Chan WK, Kay SM, Laberge JM, et al. Injection sclerotherapy in the treatment of rectal prolapse in infants and children. J Pediatr Surg. 1998;33(2):255–258.
4. Koivusalo A, Pakarinen M, Rintala R. Laparoscopic suture rectopexy in the treatment of persisting rectal prolapse in children: A preliminary report. Surg Endosc. 2006;20(6):960–963.
Reyes H, Block G, Moossa A, eds. Rectal prolapse. In: Operative Colorectal Surgery. Philadelphia, PA: WB Saunders; 1994:573–578.Rowe M. Rectal prolapse. In: Essentials of Pediatric Surgery. St. Louis, MO: Mosby-Year Book; 1995:600–601.
5. Siafakas C, Vottler TP, Andersen JM. Rectal prolapse in pediatrics. Clin Pediatr. (Phila) 1999;38(2):63–72.
6. Steele SR, Goetz LH, Minami S, et al. Management of recurrent rectal prolapse: Surgical approach influences outcome. Dis Colon Rectum. 2006;49(4):440–445.

Rectal Prolapse - CODES

Rectal Prolapse - icd9

569.1 Rectal prolapse

Rectal Prolapse - FAQ

• Q: What should I do if my child has a rectal prolapse but I cannot reduce it?
• A: You should wrap the prolapse in moist towels and bring your child to the emergency department. Physicians there will try to reduce it. Rarely, if a prolapse is irreducible and left for a period of time, it can cause bowel ischemia and may require surgery.
• Q: My child has rectal prolapse and now he is supposed to have a sweat test to determine whether he has cystic fibrosis. Is this very likely?
• A: No. Although it is important to rule out this disease, most patients with rectal prolapse do not have cystic fibrosis. However, many children with cystic fibrosis suffer from rectal prolapse.
• Q: My child, who has rectal prolapse, is in day care. How will I know if he is having the prolapse?
• A: You should inform someone in the school (a teacher or guardian) of his condition and he or she should check the child for prolapse after a bowel movement. Although, if present, it usually resolves spontaneously, the teacher should inform you so you can do a manual reduction, if necessary.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

More About Rectocele

• Back to disease: Rectocele: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

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