for medical students

1. Kushal Kumar

2. • Prolapse of the mucous membrane or the entire rectum
outside the anal verge.This condition is common in
children and elderly patients.
• TYPE
• Partial prolapse
• Complete prolapse

3. Aetiology
• Decreased sacral curvature and decreased anal canal tone are the
probable causes in infants.
• Diarrhea, cough, malnutrition are the additional factors in children.
• It may be due to reduced ischiorectal fossa fat, neurological causes,
fibrocystic disease of pancreas or poorly developed pelvis.
• In adults, it is common in females, common in multipara—repeated
birth injuries to perineum results in damage to the perineal nerve
supply.
• It is due to weakening of supporting tissue and levator ani muscle,
atony of the sphincter, increased intraabdominal pressure due to any
cause like chronic cough, stricture urethra.

4. Partial prolapse
• Here only mucosa and submucosa of the rectum
descends, not more than 3.75 cm.There is no descent of
the muscular layer. It is the commonest type of rectal
prolapse.
• Clinical Features
• History of mass per anum, which can be observed when child is
allowed to strain in squatting position.
• It is pink in colour and circumferential.
• It differs from piles (differential diagnosis), the piles are not
circumferential and are plum or blue coloured (not pink).

5. Treatment
In infants and young children
• Digital repositioning
• The parents are taught to replace the protrusion, and any underlying
causes are addressed.
• Submucosal injections
• If digital repositioning fails after 6 weeks’ trial, injections of 5%
phenol in almond oil are carried out under general anaesthestic. As a
result of the aseptic inflammation following these injections, the
mucous membrane becomes tethered to the muscle coat.
• Surgery
• Occasionally, surgery is required and, in such cases, the child is
placed in the prone jack-knife position, the retrorectal space is
entered, and the rectum is sutured to the sacrum.

6. In adults
• Local treatments
• Submucosal injections of phenol in almond oil or the
application of rubber bands are sometimes successful in cases
of mucosal prolapse.
• Excision of the prolapsed mucosa
• When the prolapse is unilateral, the redundant mucosa can be
excised or, if circumferential, an endoluminal stapling
technique can be used.

7. Complete Prolapse
• • Also called as procidentia, is less common than partial prolapse
• It is common in females (6 : 1 :: female : male).
• It is due to weakened levator ani and supporting pelvic tissues.
• The descent is always more than 3.75 cm, contains all layers of the
rectum (i.e. including muscular layer). Often descends down up to
10-15 cm.
• It is often associated with the uterine descent (uterine prolapse).
• It is also thought to be as an intussusception of the rectum.
• Once complete prolapse is more than 5 cm, anteriorly it drags
peritoneum as pouch which often contains small intestine. On
digital pushing it reduces with gurgling.
• Patulous anal sphincter is typical with mucus discharge and faecal
incontinence

8. Aetiological factors
• Weak anus, external sphincter and pelvic muscle
• Lax, mobile rectum
• Obliterated ano-rectal angle
• Abnormally mobile rectum with descent

9. Clinical Features
• Complete descent of the rectum which is red in colour and
often painful, as mass per anum.
• Faecal incontinence is very common. It is due to disruption of
the anal sphincter and prolapsed rectal mucosal discharge.
• Pain per anum.
• Bleeding can occur because of the congestion
• Sepsis, discharge, fever, anaemia are other features.
• P/R examination shows lax sphincter. Anteriorly, peritoneal
sac comes down as a pouch which may contain small bowel.

10. Investigations
• Defecography reveals increased mobility of the rectum
from sacral fixation point with redundant mesorectum
and funnel formation. It is fluoroscopic and spot filming
in lateral projection after instilling radioopaque material
into the rectum done in sitting posture over a
radiolucent commode.
• Cinedefecography, triple contrast cinedefecography,
dynamic MRI defecography, colpocystodefecography
are helpful to delineate complex pelvic floor problems.
• Defecography abnormalities- megarectum,
incontinence, nonrelaxing puborectalis, abnormal
perineal descent (2.5 cm), mucosal prolapse, solitary
ulcer rectocoele, enterocele.
• Sigmoidoscopy. • Anal manometry. • Pudendal nerve
latency study.

11. Treatment
• Surgery is required, and the operation can be performed
via the perineal or the abdominal approaches. An
abdominal rectopexy has a lower rate of recurrence but,
when the patient is elderly and very frail, a perineal
operation is indicated. As an abdominal procedure risks
damage to the pelvic autonomic nerves, resulting in
possible sexual dysfunction, a perineal approach is also
usually preferred in young men.

12. Perineal approach
• Thiersch operation
• This procedure, which aimed to place a steel wire or, more
commonly, a silastic or nylon suture around the anal canal, has
become obsolete.The reasons for its lack of popularity were that
the suture would often break or cause chronic perineal sepsis, or
both, or the anal stenosis so created would produce severe
functional problems. Delorme’s operation is now the preferred
perineal operation.

13. • Delorme’s operation
• In this procedure, the rectal mucosa is removed circumferentially
from the prolapsed rectum over its length.The underlying
muscle is then plicated with a series of sutures, such that, when
these are tied, the rectal muscle is concertinaed towards the anal
canal.The anal canal mucosa is then sutured circumferentially to
the rectal mucosa remaining at the tip of the prolapse.The
prolapse is reduced, and a ring of muscle is created above the
anal canal, which prevents recurrence.
• Altemeier’s procedure
• This consists of excision of the prolapsed rectum and associated
sigmoid colon from below, and construction of a coloanal
anastomosis.

14. Abdominal approach
• The principle of all abdominal operations for rectal prolapse is to
replace and hold the rectum in its proper position.They are
recommended in patients with complete prolapse who are otherwise
in good health.
• Many variations have been described: inWells’ operation, the rectum
is fixed firmly to the sacrum by inserting a sheet of polypropylene
mesh between them; Ripstein’s operation involves hitching up the
rectosigmoid junction by aTeflon sling to the front of the sacrum;
many surgeons simply suture the mobilised rectum to the sacrum
using four to six interrupted non-absorbable sutures – so called
sutured rectopexy.
• Recently, the technique has been performed laparoscopically, thus
reducing the operative trauma and limiting the time in hospital.

15. Complications of Surgery
• Injury to hypogastric nerve causing impotence.
• Bladder dysfunction.
• Bleeding from sacral venous plexus.
• Injury to rectum and colon causing faceal fistula.
• Constipation after rectopexy is a known complication.
• Recurrence of prolapse.
• Improper correction of continence occurs in 50% cases.
• Infection – proctitis/pelvic abscess, etc

16. Defecographic grading of rectal
prolapse
• N – Normal rectal fixation and sphincter relaxation and rectal
emptying.
• 1 – Nonrelaxed puborectalis.
• 2 – Mild intussusception
• 3 – Moderate intussusception.
• 4 – Severe intussusception.
• 5 – Prolapse.
• R – Rectocele.

17. Solitary Rectal Ulcer
Syndrome

18. • Clinical condition characterized by rectal bleeding, copious
mucous discharge, anorectal pain and difficult evacuation
• SRUS can have single rectal ulcer, multiple ulcers or even
no ulcers
• When present, ulcers usually occur on the anterior rectal
wall just above the anorectal ring
• Ulcers usually appear as shallow lesions with punched out
gray-white base that is surrounded by hyperemia
• Cause unclear, associated with chronic inflammation or
trauma (internal intussception or prolapse of the rectum,
direct digital trauma, or forces to evacuate hard stool)

19. Management
• Conservative therapy (e.g. high fiber diet, lifestyle
changes etc) should be tried first
• Pharmacologic therapy (e.g. anti-inflammatory
enemas and suppositories), limited success but
worth trying
• If symptoms persists, localized resection may be
considered
• Patients with prolapse, prolapse need to be treated
either with perineal procedures or abdominal
procedures