etiology,clinical features & management of prolapse rectum

1. PROLAPSE RECTUM
DR.SUNIL KAMBLE
ASSISTANT PROFESSOR
DEPT.OF GEN.SURGERY
MNR MEDICAL COLLEGE,SANGAREDDY

2. INTRODUCTION
• Prolapse is circumferential descent of the rectum
through the anus.
• Partial prolapse-the mucous membrane and
submucosa of the rectum protrude outside the
anus for approximately 1-4cm.
• Complete prolpase- circumferential, full-thickness
protrusion of the rectum through the anus.
• Also called as first-degree prolapse or
procidentia.

3. EMBRYOLOGY
• DEVELOPMENT OF THE
DISTAL PART OF THE
LARGE BOWEL.
• The left colic flexure,
descending colon,
sigmoid colon, rectum,
and upper half of the
anal canal are
developed from the
hindgut.

4. • Distally, this terminates
as a blind sac of
entoderm, which is in
contact with a shallow
ectodermal depression
called the proctodeum.

5. • The apposed layers of
ectoderm and
entoderm form the
cloacal membrane,
which separates the
cavity of the hindgut
from the surface.

6. • The hindgut sends off a
diverticulum, the
allantois, that passes
into the umbilical cord.
• Distal to the allantois,
the hindgut dilates to
form the entodermal
cloaca.

7. • In the interval between the allantois and the hindgut,
a wedge of mesenchyme invaginates the entoderm.
• With continued proliferation of the mesenchyme, a
septum is formed that grows inferiorly and divides
the cloaca into anterior and posterior parts.
• The septum is called the urorectal septum, the
anterior part of the cloaca becomes the primitive
bladder and the urogenital sinus, and the posterior
part of the cloaca forms the anorectal canal.

8. • On reaching the cloacal membrane, the urorectal
septum fuses with it and forms the future perineal
body.
• The anorectal canal forms the rectum and the
superior half of the anal canal.

9. SURGICAL ANATOMY
• The rectum is about 5 in. (13 cm) long and begins in
front of the third sacral vertebra as a continuation of
the sigmoid colon.
• Passes downward, following the curve of the sacrum
and coccyx, and ends in front of the tip of the coccyx
by piercing the pelvic diaphragm and becoming
continuous with the anal canal.

10. • The lower part of
the rectum is
dilated to form
the rectal
ampulla.
• The rectum
deviates to the
left, but it
quickly returns
to the median
plane.

11. LATERAL VIEW
• The rectum follows the anterior concavity of the
sacrum before bending downward and backward at
its junction with the anal canal.
• The puborectalis portion of the levator ani muscles
forms a sling at the junction of the rectum with the
anal canal and pulls this part of the bowel forward,
producing the anorectal angle.

12. • The peritoneum covers the anterior and lateral
surfaces of the first third of the rectum and only the
anterior surface of the middle third, leaving the
lower third devoid of peritoneum .
• The muscular coat of the rectum is arranged in the
usual outer longitudinal and inner circular layers of
smooth muscle.

13. • The three teniae coli of the sigmoid colon, however,
come together so that the longitudinal fibers form a
broad band on the anterior and posterior surfaces of
the rectum.
• The mucous membrane of the rectum, together with
the circular muscle layer, forms two or three
semicircular permanent folds called the transverse
folds of the rectum; they vary in position.

14. RELATIONS
POSTERIORLY
• The rectum is in contact with the sacrum and coccyx;
the piriformis, coccygeus, and levatores ani muscles;
the sacral plexus; and the sympathetic trunks.

16. ANTERIORLY
• Male-the upper two thirds of
the rectum, which is covered
by peritoneum, is related to
the sigmoid colon and coils of
ileum that occupy the
rectovesical pouch.
• The lower third of the rectum,
which is devoid of peritoneum,
is related to the posterior
surface of the bladder, to the
termination of the vas
deferens and the seminal
vesicles on each side, and to
the prostate.

17. • Female-the upper two
thirds of the rectum,
which is covered by
peritoneum, is related to
the sigmoid colon and
coils of ileum that occupy
the rectouterine pouch
(pouch of Douglas).
• The lower third of the
rectum, which is devoid
of peritoneum, is related
to the posterior surface of
the vagina.

18. BLOOD SUPPLY
• The superior, middle, and inferior rectal arteries
supply the rectum.
• The superior rectal artery is a direct continuation of
the inferior mesenteric artery and is the chief artery
supplying the mucous membrane.
• Enters the pelvis by descending in the root of the
sigmoid mesocolon and divides into right and left
branches, which pierce the muscular coat and supply
the mucous membrane.

20. • They anastomose with one another and with the
middle and inferior rectal arteries.
• The middle rectal artery is a small branch of the
internal iliac artery and is distributed mainly to the
muscular coat.
• The inferior rectal artery is a branch of the internal
pudendal artery in the perineum.
• It anastomoses with the middle rectal artery at the
anorectal junction.

21. VENOUS DRAINAGE
• The veins of the rectum correspond to the arteries.
• The superior rectal vein is a tributary of the portal
circulation and drains into the inferior mesenteric
vein.
• The middle and inferior rectal veins drain into the
internal iliac and internal pudendal veins,
respectively.
• The union between the rectal veins forms an
important portalsystemic anastomosis

23. LYMPHATIC DRAINAGE
• The lymph vessels of the rectum drain first into the
pararectal nodes and then into inferior mesenteric
nodes.
• Lymph vessels from the lower part of the rectum
follow the middle rectal artery to the internal iliac
nodes.

26. NERVE SUPPLY
• The nerve supply is from the sympathetic and
parasympathetic nerves from the inferior hypogastric
plexuses.
• The rectum is sensitive only to stretch.

28. PHYSIOLOGY OF RECTUM
• The anorectum is mainly responsible for maintaining
continence and for evacuation.
• These are highly complex and coordinated processes,
the dysfunction of which can be distressing.
• Incontinence and constipation can limit
patient’s lifestyles severely and have
devastating effects on their quality of life.

29. FECAL CONTINENCE
• Fecal continence is maintained by several factors,
both mechanical and neurologic.

30. STOOL VOLUME AND CONSISTENCY
• Stool volume and consistency play an important role
in maintaining anal continence.
• Some patients are variably continent to solid, liquid,
or gas.
• By changing the stool consistency and volume, some
patients may be made continent.

31. RECTAL CAPACITY AND COMPLIANCE
• Another mechanical factor is the reservoir function
of the rectum.
• The valves of Houston slow down the progression of
stool and provide a barrier effect.
• Rectal capacity and adaptive compliance are also
important for an effective reservoir.
• Urgency is usually felt after instilling 200 mL of saline
into the rectum.

33. • This transiently causes an increase in the intrarectal
pressure, but then the pressure returns to baseline
and the feeling of urgency disappears.
• This is called receptive relaxation.

34. ANORECTAL ANGLE
• Another important factor for maintaining continence
is the angulation of the anorectal angle.
• This is normally maintained at 80 to 90 by the
continuous tonic activity of the puborectalis muscle.

36. ANAL RESTING PRESSURE
• Anal resting pressure is maintained by the aid of the
internal anal sphincter, the external anal sphincter,
and the hemorrhoidal complex.
• The resting pressure is between 40 and 80mmHg
and is higher than the baseline intrarectal pressure.

39. ANORECTAL MANOMETRY
• Anal manometry is used to measure the anal resting
pressure.
• One of the instruments used is a four-channel probe,
with each probe oriented 90 apart.
• This instrument can provide resting pressure
measurement on four quadrants.

41. ANORECTAL SENSIBILITY
• Anorectal sensibility is the ability to discriminate
between gas, liquid, or solid.
• By allowing awareness, the external sphincter can
contract in order to postpone defecation.

42. RECTOANAL INHIBITORY REFLEX
• When feces reaches the rectum with colonic mass
movements, the rectal wall stretches and this causes
reflexive relaxation of the internal sphincter.
• This is called the rectoanal inhibitory reflex.

44. DEFECATION REFLEX
• The process of defecation is a highly coordinated and
complex process.
• Distention of the rectum stimulates contractions of
the colon and rectum.
• This is known as the defecation reflex and involves
the sacral segments of the spinal cord.
• When the rectum is distended, the rectoanal
inhibitory reflex is initiated and the internal anal
sphincter relaxes whereas the external anal sphincter
contracts.

45. • If it is not a socially acceptable time, the external
anal sphincter is voluntarily contracted while rectal
compliance allows accommodation and the urge
passes.
• On the other hand, if it is determined that it is an
appropriate time and place, a voluntary increase in
abdominal pressures assists the defecation reflex to
evacuate the rectum.

49. RECTAL PHYSIOLOGY TESTING
Anorectal physiology testing is an important part of
evaluating patients with anorectal dysfunction such as
incontinence and constipation.
• Anal manometry,
• Electromyography,
• Nerve stimulation,
• and Sensation measurements.

50. ETIOLOGY
• Rectal procidentia is the protrusion of the entire thickness of
the rectal wall through the anal sphincter.
• Two theories concerning the etiology of rectal procidentia.
• The first was proposed in 1912 by Moschcowitz.
• CONCEPT-A rectal procidentia is a sliding hernia through a
defect in the pelvic fascia.
• Based on the observation that an abnormally deep
rectovaginal or rectovesical pouch is a striking and constant
feature in most patients with complete rectal prolapse.

52. The second theory
• Broden and Snellman, who demonstrated through
cineradiography that the initial step in the genesis of
prolapse is circumferential intussusception of the
rectum, with its starting point approximately 3 inches
from the anal verge.

54. CLASSIFICATION
Altemeier et al.believed that either a sliding hernia or
an intussusception is present in different patients.
Type I:Is a protrusion of the redundant mucosal layer
(labeled as a false prolapse and usually associated with
hemorrhoids).
Type II:Is an intussusception with an associated culde-
sac sliding hernia.
Type III:Is a sliding hernia of the cul-de-sac and is the
one that they believed occurs in the vast majority of
cases.

55. BEAHRS et al. CLASSIFICATION
1. INCOMPLETE (MUCOSAL PROLAPSE)
2. COMPLETE (FULL-THICKNESS WALL PROLAPSE)
First degree
High or early, ‘‘concealed,’’ ‘‘invisible’’
Second degree
Externally visible on straining, sulcus evident
between rectal wall and anal canal.
Third degree
Exernally visible.

58. PREDISPOSING FACTORS
• Straining associated with intractable constipation-
52%
• Diarrhea 15%
• Pregnancy
• Previous operations
• Neurologic disease
• Psychiatric illness
• Progressive systemic sclerosis

59. PATHOLOGIC ANATOMY
• The anatomic defects described as occurring with
prolapse of the rectum include the following:
(A) a defect in the pelvic floor with diastasis of the
levator ani muscles and a weakened endopelvic fascia
(B) an abnormally deep cul-de-sac of Douglas
(C) a redundant rectosigmoid colon
(D) a patulous weak anal sphincter
(E) loss of the normal horizontal position of the rectum
caused by its loose attachment to the sacrum and
pelvic walls.

61. PHYSIOLOGIC DYSFUNCTION
• Pre-existing fecal incontinence ranges from 35% to
100% of cases.
• The etiology of incontinence;in some cases it is
secondary to sphincter damage resulting from the
prolapse itself while in others it occurs as a result of
internal anal sphincter relaxation induced by the
prolapse.

62. • Fecal incontinence and severe incontinence may be
clinically present in association with internal
(‘‘occult’’) rectal prolapse unassociated with
morphological sphincter damage.
• In some patients, there is difficulty in the elicitation
of the rectal anal inhibitor reflex (a measure of
innate internal sphincter function),accompanied by
an absence of internal anal sphincter
electromyographic trace.

63. • Chronic internal anal sphincter relaxation (secondary
to the presence of a prolapse itself) affects the
inherent internal anal sphincter activity.
• Reduction in rectal tone and compliance is noted (a
‘‘rectal adaptation’’), following rectal distention in
patients with full thickness rectal prolapse.

64. INCIDENCE
SEX
• Women predominate among patients with rectal
procidentia with a ratio of 6:1, as previously
mentioned.

65. AGE
• In women, the incidence of this disorder is maximal
in the fifth and subsequent decades, but in men, it is
evenly distributed throughout the age range.
• In men, the peak incidence declines after the age of
40 years, whereas in women, it climbs steadily to
reach its maximal incidence in the seventh decade.

66. CLINICAL FEATURES
SYMPTOMS
• Prolapse of the rectum vexes patients with the
misery it causes them.
• The presenting complaints may be related to the
prolapse itself or to the disturbance of anal
continence that frequently accompanies it.
• Initially the mass may extrude only with defecation,
but in a more advanced form, extrusion occurs with
any slight exertion, such as coughing or sneezing.

68. • In the early stage-difficulty in bowel regulation, discomfort,
the sensation of incomplete evacuation, and tenesmus.
• Permanently extruded rectum that is excoriated and
ulcerated, leading to mucous discharge and bleeding, which
cause soiling of the underclothes.
• Fecal incontinence.
• Constipation with straining .
• Impairment of anorectal sensation- incontinence.
• Urinary incontinence with uterine prolapse.
• The psychologic trauma-because of embarrassment, many
patients with rectal prolapse avoid all social contact.

69. PHYSICAL EXAMINATION
INSPECTION
• Large red mass.
• Initial examination-prolapse is frequently reduced.
• Anal orifice is quite patulous.
• If the patient is asked to bear down, the full thickness of the rectal
wall will prolapse, and the concentric folds can be noted readily.
• This pattern is in marked contrast to the radial folds seen in patients
with prolapsing internal hemorrhoids.
• The mucosa shows superficial ulceration caused by repeated
trauma.
• The patient is asked to sit in the squatting position and bear down
to demonstrate the prolapse.
• Aassociated uterine prolapse or cystocele.

71. PALPATION
• Digital examination usually demonstrates a
diminished tone of the sphincteric muscle.
• Voluntary contraction of this muscle on the
examining finger is either deficient or absent.
• Lack of discomfort experienced by the patient for
such an examination.
• Bidigital palpation of the prolapsing tissue will reveal
that the entire bowel wall thickness is involved.

72. SIGMOIDOSCOPY
• The first 8 to 10 cm on the anterior wall of the
rectum may appear red and inflamed, which may be
mistaken as a sign of inflammatory bowel disease.
• Granuloma formation-early telltale sign of so-called
hidden, or occult, rectal procidentia.
• Malignancy, should be ruled out.
• Prevalence of rectosigmoid carcinoma with prolapse
was 5.7% as opposed to 1.4% in a comparative
group.
• The relative risk for carcinoma was 4.2-fold over the
comparative group.

73. DIFFERENTIAL DIAGNOSIS
• When the mucosa appears hesitatingly at the anal orifice,
distinguishing between a mucosal prolapse or prolapsing internal
hemorrhoids from a complete rectal procidentia may be difficult.
• With complete procidentia the furrows are in a concentric ring,
whereas with mucosal prolapse they are radial ; with complete
procidentia the anus is in a normal anatomic position whereas with
mucosal prolapse it is everted; and with complete prolapse there is
a sulcus between the anus and the protruding bowel, whereas no
sulcus is present with only a mucosal prolapse.
• Large polypoid neoplasm of the rectum or colon.
• Associated symptoms, digital examination, sigmoidoscopy,
colonoscopy, or a barium enema will confirm this diagnosis.

74. INVESTIGATION
& RADIOLOGIC EXAMINATION
BARIUM ENEMA
• A colonic evaluation is indicated to assess for the
possible association of another disease process
such as a neoplasm, inflammatory bowel disease,
or diverticular disease.
SPINE
• Radiographs of the lumbar spine and pelvis may
provide a clue to frank neurologic disease (e.g.,
spina bifida occulta).

75. CINERADIOGRAPHY
• Suspected procidentia but not demonstrable.
• Cine-defecography may demonstrate an internal
intussusception that starts 6 to 8 cm upward in the
rectum.
• Defecography-33% incidence of occult rectal
prolapse in patients, with clinical rectoceles and
defectory dysfunction.
• Balloon proctography-loss of the anorectal angle and
lax squeeze pressures.

76. ENDORECTAL ULTRASONOGRAPHY
• The thickness and area of the internal sphincter and
submucosa will be measured at three levels.
• Qualitatively, patients with rectal prolapse will show a
characteristic elliptical morphology in the anal canal
with anterior/posterior submucosal distortion
accounting for most of the change.
• Quantitatively, internal anal sphincter and submucosal
thickness and area will be greater in all quadrants of
the anal canal (especially upper) in patients with rectal
prolapse compared with controls.
• Increases in all measured variables-rectal prolapse.

77. • The cause of sphincter distortion in rectal prolapse is
may be due to a response to increased mechanical
stress placed on the sphincter from the prolapse or
an abnormal response by the sphincter complex to
the prolapse.
• There is no correlation between internal anal
sphincter thickness and function.
• Sphincter defects are not the cause of incontinence.
• Patients with this feature on endo-anal ultrasound
may benefit from defecography to look for rectal wall
abnormalities.

78. MAGNETIC RESONANCE IMAGING
• MRI clearly shows pelvic visceral prolapse and pelvic
floor configuration on straining.
• Dynamic MRI defecography-underlying anatomic
and pathophysiologic background of pelvic floor
disorders with main diagnoses such as rectal
prolapse or intussusception, rectocele, descending
perineum, fecal incontinence, outlet obstruction, and
dyskinetic puborectalis muscle.

79. • MRI defecography- clinical results in 77.3% and
defects in addition to clinical diagnoses in combined
pelvic floor disorders in 34%.
• MRI represents a convenient diagnostic procedure in
females and to a lesser extent in males in terms of
dynamic imaging of pelvic floor organs during
defecation.
• MR defecography-bladder descent, vaginal descent.

80. • Evacuation proctography remains the first line
investigation for the diagnosis of rectal
intussusception but may not distinguish mucosal
from full thickness descent.
• MR defecography further complements evacuation
proctography by giving information on movements of
the whole pelvic floor, 30% of the patients studied
having associated abnormal anterior and/or middle
pelvic organ descent.

81. • If operation is planned for patients with rectal
intussusception, MR defecography provides useful
information regarding the presence and degree of
anterior pelvic compartment descent that may need
to be addressed if a good functional outcome is to be
achieved.

82. TRANSIT STUDIES
• Abnormal transit time- the choice of operation.
• If the patient should suffer from total colonic inertia,
they would consider performing a proctopexy with
total abdominal colectomy and ileorectal
anastomosis in a continent patient.

83. COLONOSCOPY
• A growing number of colorectal surgeons have
adopted colonoscopy to rule out other colonic
disease rather than use of barium enema.
• Certainly for patients 50 years, screening for
colorectal carcinoma would be appropriate in any
event.

84. ANORECTAL MANOMETRY
• Patients with rectal procidentia have specific
abnormalities detectable through manometry, and
such studies may help in the earlier diagnosis of this
condition.
• Physiologic abnormalities included an impaired
sphincteric function as manifested by reduced
resting and maximal voluntary squeeze pressures
and a reduced physiologic rectal capacity as
measured by the critical volume and constant
relaxation volume.

85. ELECTROMYOGRAPHIC STUDIES
• Electromyographic studies have demonstrated
abnormalities in patients with rectal prolapse.
• Although it is appropriate to conduct these studies in
patients with rectal procidentia in an effort to
understand the disease better, the information
gathered to date is not sufficient enough to define a
treatment strategy based on these physiologic studies
alone.
• Investigations using cineradiography, transit studies,
anorectal manometry, and electromyography are all of
interest but, in the usual case of rectal procidentia, do
not change the operative plan.

86. OPERATIVE REPAIR
• The Ripstein technique involves mobilization of the rectum
• down to the tip of the coccyx by opening the lateral
peritoneal folds and freeing the bowel from the sacrum.
• It may be necessary to divide the upper portion of the
lateral stalks to allow secure placement of the sling.
• The free ends of a 5-cm band of rectangular mesh (Teflon
or Marlex) are placed around the rectum at the level of the
peritoneal reflection and are sutured firmly to the presacral
fascia approximately 5 cm below the promontory.
• Nonabsorbable sutures are placed approximately 1 cm
from the midline,while presacral blood vessels are carefully
avoided.

87. RIPSTEIN TECHNIQUE

91. CONCLUSIONS
• The recurrence rate for this operation, 2.3%.
• The reported complication rate of 16.5% is related to
the specific placement of the sling; if to this are
added nonspecific complications such as
Urinary problems
Pulmonary problems
and Wound infections
which were reported as approximately 13%, the
overall complication rate may approximate 30%.

92. IVALON SPONGE WRAP OPERATION

95. ABDOMINAL PROCTOPEXY AND SIGMOID
RESECTION

97. RECTOPEXY

98. PERINEAL PROCEDURES
PERINEAL RECTOSIGMOIDECTOMY

101. PERINEAL PROCTECTOMY, POSTERIOR
RECTOPEXY, AND
LEVATOR ANI MUSCLE REPAIR

102. DELORME PROCEDURE

103. MODIFIED DELORME TECHNIQUE

105. THIERSCH OPERATION

106. COMPLICATIONS
• Incarceration,
strangulation, and
gangrene

107. RUPTURE OF PROLAPSE

108. ULCERATION AND HEMORRHAGE
• Minor ulceration of the exposed mucosa may cause
minimal bleeding, but more extensive ulcerations on
very rare occasions may cause a severe hemorrhage.

109. PROLAPSE IN CHILDREN
• In children, the incidence of prolapse is highest in the first2
years of life and declines thereafter.
• Boys are affected slightly more frequently than girls.
• The condition is usually the mucosal type.
• Predisposing factor-absence of the sacral curve, causing the
patient’s rectum and anal canal in the sitting or standing
position to form an almost vertical straight tube.
• Prolapse may be associated with any illness that leads to
excessive straining at stool such as diarrhea, over-
purgation, constipation, frequent coughing, or
malnutrition.
• Mucoviscidosis also may be associated with rectal
prolapse.

110. • The parent may complain that when the child
defecates,the rectum projects from the anus.
• Associated with a slight discharge of mucus or blood.
• Examination may reveal that the ring of prolapsing
mucosa projects 2 to 4 cm beyond the anal orifice.
• Palpation of the prolapsing tissue reveals that only
two layers of mucosa are present.
• Rarely, complete rectal procidentia may occur.
• Sphincteric tone may be lax.

111. • Differential diagnosis-prolapsed rectal polyp or the apex of
an intussusception protruding through the anus.
• In children, prolapsing rectal mucosa is a selflimiting
disease.
• Treatment-correcting constipation and instituting proper
habits of defecation.
• Correction of malnutrition.
• Strapping the buttocks-only buys time until the self-
limiting disease resolves.
• In patients who do not respond to the above forms of
therapy, submucosal injection of a sclerosing agent, such as
phenol in almond oil, has proved effective.

112. • Complete rectal prolapse-perirectal injections of sclerosing
agents to stimulate periproctitis and to fix the rectum to
the sacrum.
• other treatments-excision of a mucosal prolapse, presacral
packing with gauze or Gelfoam, linear cauterization of the
anorectum, transsacral rectopexy, transcoccygeal
rectopexy, puborectalis plication, perineal
proctosigmoidectomy, and transanal rectopexy.
• Actual surgical resection for prolapse in children is a very
rare necessity, but emergency rectosigmoidectomies for
large irreducible prolapses in children can be done.
• Long-standing prolapse-rectopexy can be performed as it is
done in the adult, but rarely is this indicated.

113. RECURRENT RECTAL PROLAPSE
• In 41% of cases,most often attributable to problems
with the mesh following the Ripstein procedure.
• Preoperative incontinence and constipation-
unchanged by the operation for recurrent prolapse.
• Bowel dysfunction still remains in 60% of patients.
• The average time for recurrence-14 months.
• Initial operations were perineal proctectomy and
levatorplasty, anal encirclement , Delorme’s
procedure , and anterior resection .

114. • Operative procedures for recurrence-perineal
proctectomy and levatorplasty, sacral rectopexy
(abdominal approach), anterior resection with
rectopexy , Delorme’s procedure, and anal
encirclement .
• The operative management of recurrent rectal
prolapse can be expected to alleviate the prolapse,
but not necessarily fecal incontinence.

115. • There were no differences between the groups in
preoperative incontinence score in mortality, in
mean hospital stay, in anastomotic complications, in
wound infection, and in postoperative incontinence
or recurrence rate between the two groups.
• The overall success rate for recurrent rectal prolapse-
85.2%.
• The outcome of operation for rectal prolapse is
similar in cases of primary or recurrent prolapse and
the same surgical operations are valid in both
scenarios.

116. • In the selection of operations for recurrent rectal procidentia,
the surgeon must be cautious not to perform an Altemeier
procedure following a previous sigmoid resection unless the
anastomosis is integrated in the resection and similarly should
not perform a sigmoid resection following an Altemeier
procedure because of the risk of creating a devascularized
segment of bowel.
• Perineal proctectomies can be safely repeated.
• Non-resectional procedures such as Delorme’s procedure
should be considered in the management of recurrent rectal
prolapse if a resectional procedure was performed initially
and failed.

117. HIDDEN PROLAPSE (INTERNAL PROCIDENTIA)
• ‘‘Hidden’’ prolapse refers to the earliest stage of procidentia, when
the intussuscepting rectum occupies the rectal ampulla but has not
yet continued through the anal canal.
• The most common complaint is difficulty in emptying the bowel,
often described as a sensation of incomplete evacuation or
obstruction.
• The second most common symptom is incontinence (33%).
• Other symptoms include bloody mucus (51%), perineal pain (16%),
and soiling (24%).
• Digital rectal examination reveals anterior rectal wall prolapse in
84%.
• Sigmoidoscopic findings include a solitary ulcer (49%) or hyperemia
and edema of the mucosa of the anterior rectal wall for a distance
of 8 to 10 cm from the anus.

118. • Bulging edematous mucosa may be seen.
• Colitiscystica profunda may be found, and hidden
prolapse, a solitary rectal ulcer, and colitis cystica
profunda may represent a spectrum of one syndrome.
• Defecography is probably the most useful diagnostic
procedure for identifying internal intussusception.
• Abnormalities may include small residual folds
occurring 3 to 7cm from the anal canal located mainly
in the posterior wall, anterior rectal wall prolapse, and
circular prolapse creating a funnel like configuration as
seen in complete rectal prolapse.

119. SUMMARY
• Bachoo et al. tried to determine the best choice of operation
for rectal procidentia.
The following specific issues were addressed.
1. Whether surgical intervention is better than no treatment.
2. Whether an abdominal approach to surgery is better
than a perineal approach.
3. Whether one method for performing rectopexy is better
than another.
4. Whether laparoscopic access is better than open access
for operation.
5. Whether resection should be included in the procedure.

120. REFERENCES
• MAINGOT’S ABDOMEN OPERATIONS,11TH EDITION.
• SABISTON TEXTBOOK OF SURGERY 20TH EDITION.
• SCHWARTZ PRINCIPLES OF SURGERY 10TH EDITION.
• BAILEY & LOVE’S SHORT PRACTICE OF SURGERY 26TH EDITION.
• FARQUHARSON’S TEXTBOOK OF OPERATIVE GENERAL
SURGERY 9TH EDITION.
• SHACKELFORD'S SURGERY OF THE ALIMENTARY TRACT 6TH
EDITION.
• PRINCIPLES AND PRACTICE OF SURGERY FOR THE COLON,
RECTUM, AND ANUS 3RD EDITION BY PHILIP H. GORDON.

121. • MODERN SURGICAL CARE-PHYSIOLOGIC FOUNDATIONS AND
CLINICAL APPLICATIONS BY THOMAS A.MILLER 3RD EDITION
• SNELL’S ANATOMY 8TH EDITION
• MASTERY OF SURGERY 5TH EDITION