CASE REPORT VI

RECTAL PROLAPSE
Fatia Anindita 1102009108
SUPERVISOR :
Dr. Herry Setya !d"a Uta#a$ S%&$ 'H(e)$ FinaC)
DEPART'E*T OF SUR+ER
AR,A-I*A*+U* CIRE&O* +E*ERAL HOSPITAL
'edi.a/ Fa.!/ty 01 ARSI Uni2er)ity
Ar3a4inan5!n 2016
CASE REPORT
I. IDE*TIT
Name : Mrs. M
Age : 57 tahun
Gender : Female
Ou!at"#n : $#use%"&e
Address : Panguragan 'ul#n
(ate #& Adm"ss"#n : ) Se!tem*er +,-.
II. A*A'*ESA 7ALLOA*A'*ESIS8
'ain Sy#%t0# : &eel t"ssue !r#trud"ng &r#m the anus
Additi0na/ Sy#%t0#) : d"sharge &r#m the !r#trud"ng t"ssue
Pre)ent I//ne)) :
Mrs. M /F0 )) 1.#2 #m!la"ned a*#ut a *um! ame #ut &r#m anus s"ne ) da1s ag# .
Or"g"nall1 *um!s %hen the !at"ent an *e "n and #ut #& de&eat"#n. Pre3"#usl12 !at"ents #&ten
stra"n"ng dur"ng de&eat"#n . Small *um! #ut /a l"ttle0 then ame #ut great and an n#t *e "n
an1m#re. She als# ga3e a h"st#r1 #& *r"ght red *l##d !er retum and !assage #& muus and
4t"ssue5 %"th eah *#%el m#3ement. Pat"ents #uld de&eate *ut small *la6 sha!ed2 #uld
&latus2 n# nausea and 3#m"t"ng . She ga3e n# h"st#r1 #& an1 anal "nter#urse2 trauma2 #r
#ther s"gn"&"ant !ast med"al h"st#r1. There had *een n# !re3"#us an#retal #r a*d#m"nal
surger1 and she had n# s"gn"&"ant &am"l1 h"st#r1.
III. PHSICAL E9A'I*ATIO*
GENERA7 STATE
General A!!earene :
C#ns"#usness : C#m!#s ment"s
Tanda V"tal : 8l##d Pressure : -),9:, mm$g
Pulse : ;: <9men"t
Tem!erature : ):25
#
C
Res!"rat"#n : +. <9 men"t
$ead : N#rm#e!hal
E1es : C#n=unt"3a anem"s >9>
Slera "ter" >9>
Pu!"l Re&let >9>
Ne6 : Th1r#"d enlargement />0 2 71m!h n#des enlargemenr />0
Th#ra< :
Ins!et"#n : $em"th#ra< are s1mmetr"al r"ght and le&t "n a state #& stat"
and d1nam"
Pal!at"#n : V#al and tat"le &rem"tus are s1mmetr"al r"ght and le&t 2
Tenderness / > 0 .
Peruss"#n : S#n#r #n *#th hem"th#ra<.
Ausultat"#n : Pulm# : V8S >9>2 r#n6" >9>2 %h >9>
C#r : $eart s#unds I>II reguler2murmur />02Gall#! />0
A*d#men
Ins!et"#n : #n3e< 2 s1mmetr" 2 surg"al %#und / > 0
Ausultat"#n : 8#%el s#unds / ? 0 n#rmal
Peruss"#n : T"m!an" %h#le a*d#m"nal @uadrant
Pal!at"#n : s#&t 2 tenderness / ? 0 "n the l#%er r"ght @uadrant 2 a !al!a*le
mass / > 0 l"3er !al!a*le ; m
E<trem"t"es
le&t and r"ght su!er"#r : udem />0 2 a6ral hangat
le&t and r"ght "n&er"#r : udem />0 2 a6ral hangat
7#al state : lum! dense 2 he%1 2 an n#t *e "n at anal
IV. PE'ERI(SAA* PE*U*,A*+
-"0/e &/00d
$aem#gl#*"ne: -.2) gr 9 d7
7eu#1te : -,2, < -, 9 7
$aemat#r"t : .525A
Tr#m*#1te : ).B < -, 9 7
LFT
SGOT : ++ mg 9 d7
SGPT : ), mg 9 d7
Eletr#l1te
Natr"um : -):2.
'al"um : )2;-
Chl#r"da : -,+27
Cals"um : -2BB
Magnes"um : ,2B-
Ph#s&#r : ,2B:
RFT
Creat"n"n serum: -2-
8CN : +-
Cre" : .5
Pur"n : .27
&/00d )!5ar /e2e/) : 10:
V. DIFERE*TIAL DIA+*OSE
Pr#la!se Retum
$aem#rh#"d
Retal P#l1!s
VI. FI*AL DIA+*OSE
Pr#la!se Retum
VII. FURTHER E9A'I*ATIO*
> 8NO IVP

VIII. 'A*A+E'E*T
> O*ser3at"#n
> Surg"al med"at"#n
I9. PRO+*OSIS
Ad V"tam : ad *#nam
Ad Funt"#nam : du*"a ad *#nam
RECTAL PROLAPSE
&a.;5r0!nd
Retal !r#la!se /see the "mage *el#%0 %as desr"*ed as earl1 as -5,, 8C. Retal !r#la!se
#urs %hen a mu#sal #r &ull>th"6ness la1er #& retal t"ssue !r#trudes thr#ugh the anal #r"&"e.
D-E
Pr#*lems %"th &eal "n#nt"nene2 #nst"!at"#n2 and retal ulerat"#n are #mm#n.
Retal !r#la!se.
Three d"&&erent l"n"al ent"t"es are #&ten #m*"ned under the um*rella term retal !r#la!se:
Full>th"6ness retal !r#la!se
Mu#sal !r#la!se
Internal !r#la!se /"nternal "ntussuse!t"#n0
Treatment #& these ) ent"t"es d"&&ers.
Full>th"6ness retal !r#la!se /see the "mage *el#%0 "s de&"ned as !r#trus"#n #& the &ull
th"6ness #& the retal %all thr#ugh the anusF "t "s the m#st #mm#nl1 re#gn"Ged t1!e. Mu#sal
!r#la!se2 "n #ntrast2 "s de&"ned as !r#trus"#n #& #nl1 the retal mu#sa /n#t the ent"re %all0 &r#m the
anus. Internal "ntussuse!t"#n ma1 *e a &ull>th"6ness #r a !art"al retal %all d"s#rder2 *ut the
!r#la!sed t"ssue d#es n#t !ass *e1#nd the anal anal and d#es n#t !ass #ut #& the anus.
Full>th"6ness retal !r#la!se.
M#st #& th"s art"le &#uses #n &ull>th"6ness retal !r#la!se2 %h"h %"ll *e re&erred t# as
retal !r#la!se.
Anat0#y
The retum "s the d"stal -+>-5 m #& the large "ntest"ne *et%een the s"gm#"d #l#n and the
anal anal. It !r"mar"l1 ser3es as a reser3#"r &#r &eal mater"al. The mu#sa "s the "nner l"n"ng #& the
"ntest"nal trat. The dentate l"ne "s the =unt"#n #& the et#derm and end#derm "n the anal anal.
The "nternal anal s!h"nter "s a sm##th musle that "s the m#st d"stal e<tens"#n #& the "nner
"rular sm##th musle #& the #l#n and the retum. It "s +.5>. m l#ng and n#rmall1 +>) mm th"6.
The "nternal s!h"nter "s n#t under 3#luntar1 #ntr#l and "s #nt"nu#usl1 #ntrated t# !re3ent
un!lanned l#ss #& st##l.
The e<ternal anal s!h"nter "s str"ated musle that &#rms a "rular tu*e ar#und the anal
anal. M#3"ng !r#<"mall12 "t merges %"th the !u*#retal"s musle and the le3at#r an" t# &#rm a
s"ngle #m!le<. C#ntr#l #& the e<ternal anal s!h"nter "s 3#luntar1.
Pat"0%"y)i0/05y
The !ath#!h1s"#l#g1 #& retal !r#la!se "s n#t #m!letel1 underst##d #r agreed u!#n. There
are + ma"n the#r"es2 %h"h essent"all1 are d"&&erent %a1s #& e<!ress"ng the same "dea.
The &"rst the#r1 !#stulates that retal !r#la!se "s a sl"d"ng hern"a thr#ugh a de&et "n the
!el3" &as"a. The se#nd the#r1 h#lds that retal !r#la!se starts as a "rum&erent"al "nternal
"ntussuse!t"#n #& the retum *eg"nn"ng :>; m !r#<"mal t# the anal 3erge. H"th t"me and stra"n"ng2
th"s !r#gresses t# &ull>th"6ness retal !r#la!se2 alth#ugh s#me !at"ents ne3er !r#gress *e1#nd th"s
stage.
The !ath#!h1s"#l#g1 and et"#l#g1 #& mu#sal !r#la!se m#st l"6el1 d"&&er &r#m th#se #& &ull>
th"6ness retal !r#la!se and "nternal "ntussuse!t"#n.
D+E
Mu#sal !r#la!se #urs %hen the
#nnet"3e t"ssue attahments #& the retal mu#sa are l##sened and strethed2 thus all#%"ng the
t"ssue t# !r#la!se thr#ugh the anus. Th"s #&ten #urs as a #nt"nuat"#n #& l#ng>stand"ng
hem#rrh#"dal d"sease and "s treated as suh.
O&ten2 !r#la!se *eg"ns %"th an "nternal !r#la!se #& the anter"#r retal %all and !r#gresses t#
&ull !r#la!se.
Eti0/05y
The !re"se ause #& retal !r#la!se "s n#t de&"nedF h#%e3er2 a num*er #& ass#"ated
a*n#rmal"t"es ha3e *een &#und. As man1 as 5,A #& !r#la!se ases are aused *1 hr#n" stra"n"ng
%"th de&eat"#n and #nst"!at"#n.
Other !red"s!#s"ng #nd"t"#ns "nlude the &#ll#%"ng:
Pregnan1
Pre3"#us surger1
("arrhea
8en"gn !r#stat" h1!ertr#!h1
Chr#n" #*strut"3e !ulm#nar1 d"sease /COP(0
C1st" &"*r#s"s
Pertuss"s /"e2 %h##!"ng #ugh0
Pel3" &l##r d1s&unt"#n
Paras"t" "n&et"#ns I Ame*"as"s2 sh"st#s#m"as"s
Neur#l#g" d"s#rders > Pre3"#us l#%er *a6 #r !el3" trauma9lum*ar d"s6 d"sease2 auda
e@u"na s1ndr#me2 s!"nal tum#rs2 mult"!le sler#s"s
("s#rdered de&eat"#n /eg2 st##l %"thh#ld"ng0
Certa"n anat#m" &eatures &#und dur"ng surger1 &#r retal !r#la!se are #mm#n t# m#st !at"ents.
These &eatures "nlude a !atul#us #r %ea6 anal s!h"nter %"th le3at#r d"astas"s2 dee! anter"#r
(#uglas ul>de>sa2 !##r !#ster"#r retal &"<at"#n %"th a l#ng retal mesenter12 and redundant
ret#s"gm#"d. Hhether these anat#m" &eatures are the ause #r result #& the !r#la!s"ng retum "s
n#t 6n#%n.
D)E
In h"ldren2 retal !r#la!se "s !r#*a*l1 related t# the 3ert"al #r"entat"#n #& the retum2 the
m#*"l"t1 #& the s"gm#"d #l#n2 the relat"3e %ea6ness #& the !el3" &l##r musle2 mu#sa that "s
!##rl1 &"<ed t# su*mu#sa2 and redundant retal mu#sa.
E%ide#i0/05y
United State) )tati)ti.)
Retal !r#la!se "s un#mm#nF h#%e3er2 the true "n"dene "s un6n#%n *eause #&
underre!#rt"ng2 es!e"all1 "n the elderl1 !#!ulat"#n. Pea6s "n #urrene are n#ted "n the &#urth and
se3enth deades #& l"&e2 and m#st !at"ents /;,>B,A0 are %#men.
The #nd"t"#n "s #&ten #nurrent %"th !el3" &l##r desent and !r#la!se #& #ther !el3" &l##r
#rgans2 suh as the uterus #r the *ladder. Alth#ugh mult"!le !regnan"es are #&ten "m!l"ated "n the
et"#l#g12 )5A #& !at"ents are null"!ar#us. A small su*set #& h"ldren "s a&&eted2 usuall1 *e&#re the
age #& ) 1ears. E3aluat"#n and treatment #& h"ldren %"th retal !r#la!se "s addressed else%here.
Internati0na/ )tati)ti.)
The annual "n"dene #& retal !r#la!se "n F"nland %as &#und t# *e +.5 !er -,,2,,, !#!ulat"#n.
D.E
A5e<re/ated de#05ra%"i.)
Alth#ugh all ages an *e a&&eted2 !ea6 "n"denes are #*ser3ed "n the &#urth and se3enth
deades #& l"&e. Ped"atr" !at"ents usuall1 are a&&eted %hen 1#unger than ) 1ears2 %"th the !ea6
"n"dene "n the &"rst 1ear #& l"&e. Mu#sal !r#la!se "s m#re #mm#n than #m!lete !r#la!se
/!#ss"*l1 *eause #& !##r &"<at"#n #& the su*mu#sa t# the mu#sa "n !ed"atr" !at"ents0. The
"n"dene #& !r#la!sed retum "n h"ldren %"th 1st" &"*r#s"s a!!r#ahes +,A.
Se=<re/ated de#05ra%"i.)
In the adult !#!ulat"#n2 the male>t#>&emale rat"# "s -::. Alth#ugh "n adults %#men #m!r"se
;,>B,A #& ases2 "n the !ed"atr" !#!ulat"#n2 "n"dene #& retal !r#la!se "s e3enl1 d"str"*uted
*et%een males and &emales.
D5E
Pr05n0)i)
The !r#gn#s"s generall1 "s g##d %"th a!!r#!r"ate treatment. S!#ntane#us res#lut"#n usuall1
#urs "n h"ldren. O& !at"ents %"th retal !r#la!se %h# are aged B m#nths t# ) 1ears2 B,A %"ll need
#nl1 #nser3at"3e treatment. C#nt"nene usuall1 "s "n"t"all1 %#rse a&ter surg"al treatment2 *ut "n
m#st !at"ents "t "m!r#3es #3er t"meF h#%e3er2 the degree #& "m!r#3ement "s un!red"ta*le.
Cntreated retal !r#la!se an lead t# "narerat"#n and strangulat"#n /rare0. M#re #mm#nl12
"nreas"ng d"&&"ult"es %"th retal *leed"ng /usuall1 m"n#r02 ulerat"#n2 and "n#nt"nene #ur.
P#st#!erat"3e m#rtal"t1 "s l#%2 *ut reurrene rate an *e as h"gh as -5A2 regardless #& the
#!erat"3e !r#edure !er&#rmed /see *el#%0. The m#st #mm#n !#st#!erat"3e #m!l"at"#ns "n3#l3e
*leed"ng and deh"sene at the anast#m#s"s. Other #m!l"at"#ns "nlude mu#sal ulerat"#n and
ner#s"s #& the retal %all. O!erat"3e #m!l"at"#ns are h"gher &#r a*d#m"nal #!erat"#ns2 %"th a
l#%er reurrene rateF the #!!#s"te "s true &#r !er"neal #!erat"#ns2 %h"h ha3e a muh l#%er
#m!l"at"#n rate2 *ut h"gher reurrene.
Re.!rren.e
The reurrene rate &#r anter"#r reset"#n %"th#ut saral &"<at"#n "s a*#ut 7>BA2 %"th a
m#r*"d"t1 rate #& -5>+BA. Th"s reurrene rate "s h"gher than that &#r #ther a*d#m"nal !r#edures.
The reurrene rate &#r Marle< ret#!e<1 ranges &r#m +A t# -,A2 %"th a m#r*"d"t1 rate #&
)>+BA. C#nt"nene "s "m!r#3ed "n 5,>7,A #& !at"ents. C#nst"!at"#n2 h#%e3er2 "s n#t "m!r#3ed and
ma1 %#rsen a&ter th"s #!erat"#n. The results #& suture ret#!e<1 are #m!ara*le.
The reurrene rate &#r reset"#n and ret#!e<1 "s )>.A2 %"th se3eral stud"es re!#rt"ng a ,A
reurrene rate. M#r*"d"t1 ranges &r#m .A t# +)A. 8eause the redundant #l#n "s als# reseted2
#nst"!at"#n "m!r#3es "n :,>;,A #& !at"ents2 and #nt"nene "m!r#3es "n )5>:,A.
The reurrene rate &#r (el#rme mu#sal slee3e reset"#n ranges &r#m 5A t# +:A2 %"th a
3ar"a*le m#r*"d"t1 that "s usuall1 related t# the !at"entJs underl1"ng #m#r*"d"t"es. Feal
"n#nt"nene and #nst"!at"#n "m!r#3e "n a*#ut 5,A #& !at"ents.
The reurrene rate &#r Alteme"er !er"neal ret#s"gm#"det#m1 ranges &r#m ,A t# 5,A2
%"th an a3erage #& a!!r#<"matel1 -,A. C#nt"nene ma1 *e "m!r#3ed "& a le3at#r !l"at"#n "s added
t# the !r#edure. A stud1 *1 Alt#mare et al "nd"ated that rest#rat"#n #& #nt"nene %"th th"s
!r#edure an *e un!red"ta*le.
D:E
Hi)t0ry
Pat"ents %"th retal !r#la!se re!#rt a mass !r#trud"ng thr#ugh the anus. In"t"all12 the mass
!r#trudes &r#m the anus #nl1 a&ter a *#%el m#3ement and usuall1 retrats %hen the !at"ent stands
u!. As the d"sease !r#ess !r#gresses2 the mass !r#trudes m#re #&ten2 es!e"all1 %"th stra"n"ng and
Valsal3a maneu3ers suh as sneeG"ng #r #ugh"ng. F"nall12 the retum !r#la!ses %"th da"l1 at"3"t"es
suh as %al6"ng and ma1 !r#gress t# #nt"nual !r#la!se.
As the d"sease !r#gresses2 the retum n# l#nger s!#ntane#usl1 retrats2 and !at"ents ma1
ha3e t# manuall1 re!lae "t. Th"s #nd"t"#n ma1 then !r#gress t# a !#"nt at %h"h the retum
!r#la!ses "mmed"atel1 a&ter *e"ng re!laed and "s #nt"nu#usl1 !r#la!sed. Rarel12 the retum
*e#mes "narerated2 and !at"ents ann#t re!lae the retum.
Pa"n "s 3ar"a*le. Ten t# +5A #& !at"ents als# ha3e uter"ne #r *ladder !r#la!se2 and )5A ma1 ha3e an
ass#"ated 1st#ele. C#nst"!at"#n #urs "n -5>:5A #& ases. There ma1 als# *e retal *leed"ng.
In add"t"#n t# a !r#trud"ng mass &r#m the anus2 !at"ents #&ten re!#rt &eal "n#nt"nene /+;>
;;A0. In#nt"nene #urs &#r + reas#ns. F"rst2 the anus "s d"lated and strethed *1 the !r#trud"ng
retum2 d"sru!t"ng the &unt"#n #& the anal s!h"nter. Se#nd2 the mu#sa #& the retum "s "n #ntat
%"th the en3"r#nment and #nstantl1 seretes muus2 thus ma6"ng the !at"ent a!!ear t# *e
hr#n"all1 %et and "n#nt"nent.
A deta"led h"st#r1 t# e3aluate "n#nt"nene2 #nst"!at"#n2 #r *#th "s "m!#rtant *eause "t
!la1s a r#le "n determ"n"ng the a!!r#!r"ate surg"al !r#edure.
Pat"ents %"th mu#sal !r#la!se ha3e s"m"lar !r#*lems *ut n#t t# the same degree. Pat"ents
%"th "nternal "ntussuse!t"#n #&ten re!#rt d"&&"ult1 %"th de&eat"#n and a sensat"#n #& "n#m!lete
e3auat"#n.
P"y)i.a/ E=a#inati0n
Ph1s"al s"gns #& retal !r#la!se "nlude the &#ll#%"ng:
Pr#trud"ng retal mu#sa
Th"6 #nentr" mu#sal r"ng
Sulus n#ted *et%een anal anal and retum
S#l"tar1 retal uler /-,>+5A0
(ereased anal s!h"nter t#ne
Retal !r#la!se "s a l"n"al d"agn#s"s that !h1s""ans sh#uld *e a*le t# #n&"rm "n the #&&"e.
The !at"ent "s as6ed t# s"t #n a t#"let and stra"n2 a&ter %h"h the retum sh#uld !r#la!se. I& "t d#es
n#t !r#la!se %"th =ust stra"n"ng2 the adm"n"strat"#n #& a !h#s!hate enema usuall1 !r#dues the
!r#la!se. In a small h"ld2 a gl1er"n su!!#s"t#r1 an *e used "nstead.
The !r#trud"ng mass sh#uld sh#% #nentr" r"ngs #& mu#sa. In ases #& small !r#la!se2 "t
"s s#met"mes d"&&"ult t# d"st"ngu"sh *et%een mu#sal and &ull>th"6ness retal !r#la!se. Mu#sal
!r#la!se t1!"all1 e<h"*"ts rad"al &#lds "nstead #& #nentr" r"ngs. I& these ann#t *e l"n"all1
d"st"ngu"shed2 a de&e#gram /see H#r6u!0 ma1 *e #& hel! "n d"&&erent"at"ng these + #nd"t"#ns. A
de&e#gram "s unneessar1 "n the !resene #& an #*3"#us retal !r#la!se.
Dia5n0)ti. C0n)iderati0n)
The &#ll#%"ng #nd"t"#ns sh#uld *e "nluded "n the d"&&erent"al d"agn#s"s:
$em#rrh#"ds
Intussuse!t"#n
Pr#t"t"s
Retal !#l1!s sh#uld als# *e #ns"dered.
A%%r0a." C0n)iderati0n)
Retal !r#la!se "s usuall1 #nl1 a s1m!t#m2 and e3aluat"#n sh#uld &#us #n d"s#3er1 #& an
underl1"ng d"s#rder.
In h"ldren2 retal !r#la!se "s usuall1 a *en"gn #nd"t"#n that alls &#r e3aluat"#n #& the
underl1"ng #nd"t"#n. E3aluate !ed"atr" !at"ents &#r 1st" &"*r#s"sF a s"gn"&"ant !erentage "s
a&&eted %"th th"s d"s#rder.
La>0rat0ry Te)t)
The #nl1 !ert"nent la*#rat#r1 stud"es &#r a !at"ent %"th retal !r#la!se are th#se stud"es that
are d"tated *1 the !at"entJs age and #m#r*"d"t"es. There are n# s!e"&" tests that a"d "n the
e3aluat"#n #& retal !r#la!se "tsel&.
Per&#rm a s%eat hl#r"de test &#r !ed"atr" !at"entsF as man1 as --A #& h"ldren %"th retal
!r#la!se ha3e 1st" &"*r#s"s. C#ns"der a st##l e<am"nat"#n and ulture &#r "n&et"#us agents2
!art"ularl1 "n !ed"atr" !at"ents.
&ari!# Ene#a and C0/0n0).0%y
8e&#re "n"t"at"ng surg"al treatment #& retal !r#la!se /see Treatment02 "t "s "m!#rtant t#
e3aluate the ent"re #l#n "n #rder t# e<lude an1 #ther #l#n" les"#ns that sh#uld *e s"multane#usl1
addressed. The !resene #& suh les"#ns ma1 a&&et the h#"e #& the !r#edure t# *e !er&#rmed.
E3aluat"#n #& the #l#n ma1 *e a#m!l"shed *1 means #& #l#n#s#!1 #r *ar"um enema.
8ar"um enema "s a *etter "nd"at#r #& the redundan1 #& the #l#n.
Vide0 De1e.05ra%"y
V"de# de&e#gra!h1 "s used t# hel! d#ument "nternal !r#la!se #r t# d"st"ngu"sh retal
!r#la!se &r#m mu#sal !r#la!se "& "t "s n#t l"n"all1 #*3"#us. It "s n#t neessar1 &#r l"n"all1
d"agn#sed &ull>th"6ness retal !r#la!se. (e&e#gra!h1 ma1 re3eal "ntussuse!t"#n #& !r#<"mal
#l#n #r !el3" #utlet #*strut"#n.
Rad"#!a@ue mater"al /usuall1 *ar"um !aste0 "s "nst"lled "nt# the retum2 and the !at"ent "s
as6ed t# de&eate #n a rad"#luent t#"let. S!#t &"lms and 3"de#ta!es are made and an *e used t#
determ"ne "& the retum "ntussuse!ts #n de&eat"#n.
Ri5id Pr0.t0)i5#0id0).0%y
R"g"d !r#t#s"gm#"d#s#!1 sh#uld *e !er&#rmed t# assess the retum &#r add"t"#nal les"#ns2
es!e"all1 s#l"tar1 retal ulers. These ulers are !resent "n a*#ut -,>+5A #& !at"ents %"th e"ther
"nternal #r &ull>th"6ness !r#la!se. I& ulerat"#n "s !resent2 the area a!!ears as a s"ngle uler #r as
mult"!le ulers #n the anter"#r retal %all. The edges are #&ten hea!ed u!2 and the area ma1 *e
*leed"ng.
8"#!s1 sh#uld *e !er&#rmed t# #n&"rm the d"agn#s"s and t# e<lude #ther !ath#l#g1.
S#l"tar1 retal ulers an usuall1 *e "dent"&"ed *1 an e<!er"ened !ath#l#g"st. The !r#la!sed retum
ma1 ha3e ulerated mu#sa *ut "s #ther%"se h"st#l#g"all1 n#rmal.
Ot"er Te)t)
Anal>retal man#metr1 "s s#met"mes used t# e3aluate the anal s!h"nter musles. In alm#st
all !at"ents2 the results sh#% a derease "n rest"ng !ressure "n the "nternal s!h"nter and an a*sene
#& the an#retal "nh"*"t#r1 re&le<. The s"gn"&"ane #& these results "s unlear2 and m#st surge#ns d#
n#t use th"s test.
The S"tG mar6er stud1 "s #as"#nall1 used t# measure #l#n" trans"t "n a !at"ent %"th
#nst"!at"#n and retal !r#la!se t# hel! determ"ne the need &#r #l#n" reset"#n.
Pudendal ner3e term"nal m#t#r laten1 assesses &#r neur#l#g" "n=ur1 #r d1s&unt"#n.

A%%r0a." C0n)iderati0n)
In adult !at"ents2 treatment #& retal !r#la!se "s essent"all1 surg"alF n# s!e"&" med"al
treatment "s a3a"la*le. /Ch"ldren2 h#%e3er2 an usuall1 *e treated n#nsurg"all1 and *1 manag"ng
the underl1"ng #nd"t"#n.0 Hh"h re!a"r #nst"tutes the *est treatment "s the ma"n #ntr#3ers1 "n
surger1 &#r retal !r#la!se.
D7E
All #& the !r#edures ha3e the"r !r#!#nents2 and there "s n# r"ght
ans%er.
A la!ar#s#!" a!!r#ah t# retal !r#la!se re!a"r has *e#me "nreas"ngl1 !#!ular. Th"s
a!!r#ah has "ntens"&"ed the #ntr#3ers1 *eause "t has dereased the m#r*"d"t1 #& the a*d#m"nal
a!!r#ah t# retal !r#la!se "n a!!r#!r"ate and"dates. 7#ng>term results #& the la!ar#s#!"
a!!r#ah are st"ll *e"ng stud"ed.
D;2 B2 -,E
Initia/ 'ana5e#ent
Generall12 a !r#la!sed retum an *e redued %"th gentle d"g"tal !ressureF an "narerated
retal !r#la!se "s rare. Se3eral maneu3ers t# hel! redue the !r#la!se ha3e *een desr"*ed and
"nlude sedat"#n2 &"eld *l#6 %"th l#al anesthet"2 and s!r"n6l"ng the !r#la!se %"th e"ther salt #r
sugar t# derease the edema and t# redue the !r#la!se.
Alth#ugh n# med"al treatment "s a3a"la*le &#r retal !r#la!se2 "nternal !r#la!se sh#uld
al%a1s *e &"rst treated med"all1 %"th *ul6"ng agents2 st##l s#&teners2 and su!!#s"t#r"es #r enemas.
8"#&eed*a6 ma1 *e hel!&ul "& !arad#<"al !el3" &l##r #ntrat"#n als# e<"sts.
C#ntr"*ut"ng &at#rs2 suh as #nst"!at"#n and d"arrhea2 sh#uld *e addressed and el"m"nated
"& !#ss"*le. Su!!#rt"3e are sh#uld *e !r#3"ded a#rd"ng t# the l"n"al !"ture2 !art"ularl1 "n the
!resene #& an "rredu"*le !r#la!se and %"th gangrene #r ru!ture #& the retal mu#sa. O*ta"n a
!r#m!t surg"al e3aluat"#n "& anal "n#nt"nene "s !resent.
I& the !r#la!se ann#t *e redued and the 3"a*"l"t1 #& the *#%el "s "n @uest"#n2 emergen1
reset"#n "s re@u"red. Ru!ture #& the retum als# #nst"tutes a surg"al emergen1. O*ta"n a !r#m!t
surg"al #nsultat"#n %"th a general surge#n #r a #l#retal surge#n.
In ases #& un#m!l"ated retal !r#la!se2 arrange surg"al &#ll#%>u! are &#r &urther
e3aluat"#n and de&"n"t"3e treatment.
Se/e.ti0n 01 S!r5i.a/ A%%r0a."
C#ntra"nd"at"#ns t# surg"al #rret"#n #& retal !r#la!se are *ased #n the !at"entJs
#m#r*"d"t"es and h"s #r her a*"l"t1 t# t#lerate surger1. Surg"al treatments an *e d"3"ded "nt# +
ateg#r"es #n the *as"s #& the a!!r#ah used t# re!a"r the retal !r#la!se: a*d#m"nal !r#edures and
!er"neal !r#edures. The h#"e *et%een an a*d#m"nal !r#edure and a !er"neal !r#edure "s
ma"nl1 d"tated *1 the !at"entJs age and #m#r*"d"t"es.
D--2 -+2 -)E
On the %h#le2 the a*d#m"nal !r#edures ha3e a l#%er reurrene rate *ut a h"gher
m#r*"d"t1. A#rd"ngl12 #lder2 de*"l"tated !at"ents /%h#se l"&e e<!etan1 "s sh#rter0 are generall1
treated %"th !er"neal !r#edures2 %hereas 1#unger2 health"er !at"ents are t1!"all1 treated %"th
a*d#m"nal !r#edures. It sh#uld *e n#ted2 h#%e3er2 that man1 surge#ns %"th #!"#us e<!er"ene
and l#% reurrene rates als# ad3#ate !er"neal !r#edures &#r the"r 1#unger2 health"er !at"ents.
The h#"e #& !r#edure "s als# d"tated *1 the !resene #r a*sene #& #nst"!at"#n. Ch"ldren are
treated %"th l"near auter"Gat"#n.
Surg"al thera!1 &#r "nternal !r#la!se "s usuall1 a3#"ded *eause results are !##r2 %"th
dura*le rel"e& #& s1m!t#ms #urr"ng "n &e%er than 5,A #& !at"ents.
Regardless #& the t1!e #& !r#edure *e"ng !lanned2 &ull mehan"al and ant"*"#t" *#%el
!re!arat"#n sh#uld *e arr"ed #ut *e&#re surger1. Intra3en#us /IV0 ant"*"#t"s sh#uld al%a1s *e
adm"n"stered !re#!erat"3el1F "& a &#re"gn mater"al "s *e"ng "m!lanted2 !#st#!erat"3e adm"n"strat"#n
#& ant"*"#t"s ma1 als# *e #ns"dered.
A>d0#ina/ S!r5i.a/ Pr0.ed!re)
As n#ted2 a*d#m"nal re!a"rs are t1!"all1 !er&#rmed "n 1#unger2 health"er !at"ents2 %h#se
l"&e e<!etan1 "s l#nger. F#r these !at"ents2 !r#edures %"th l#%er reurrene rates *ut h"gher
m#r*"d"t"es are m#st a!!r#!r"ate. The h#"e #& a*d#m"nal !r#edure "s #&ten d"tated *1 the e<tent
#& the ass#"ated #nst"!at"#n and *1 the surge#nJs !re&erene.
7a!ar#s#!" surg"al ret#!e<1 !r#edures ha3e *een de3el#!ed that ha3e #ut#mes as
g##d as th#se #& #!en a*d#m"nal !r#edures *ut are ass#"ated %"th sh#rter h#s!"tal sta1s and
greater !at"ent #m&#rt.
D-.2 -5E
Anteri0r re)e.ti0n
Pat"ents %"th retal !r#la!se and #nst"!at"#n #&ten ha3e a redundant #l#n2 and
s#me surge#ns *el"e3e that reset"#n #& th"s alle3"ates #nst"!at"#n and dereases reurrene
#& retal !r#la!se.
In an anter"#r reset"#n &#r retal !r#la!se2 the retum "s m#*"l"Ged t# the le3el #& the
lateral l"gaments2 and the redundant #l#n /s"gm#"d0 "s reseted. The le&t #l#n "s then
anast#m#sed t# the t#! #& the retum. Th"s anast#m#s"s "s !er&#rmed %"th#ut la<"t1 "n the
#l#n s# that the retum "s held "n !lae and an n# l#nger !r#la!se. At !resent2 &e%
#l#retal surge#ns !er&#rm th"s !r#edure2 *eause "t "s n#t th#ught t# address anat#m"
a*n#rmal"t"es suh as !##r retal &"<at"#n.
'ar/e= re.t0%e=y
In a Marle< ret#!e<1 /R"!ste"n !r#edure02 the ent"re retum "s m#*"l"Ged d#%n t#
the #1< !#ster"#rl12 the lateral l"gaments laterall12 and the anter"#r ul>de>sa anter"#rl1
/see the "mage *el#%0. A n#na*s#r*a*le mater"al2 suh as Marle< mesh #r an I3al#n s!#nge2
"s &"<ed t# the !resaral &as"a. The retum "s then !laed #n tens"#n2 and the mater"al "s
!art"all1 %ra!!ed ar#und the retum t# 6ee! "t "n !#s"t"#n. T# !re3ent a "rum&erent"al
#*strut"#n2 the anter"#r %all #& the retum "s n#t #3ered %"th the s!#nge #r mesh. The
I3al#n s!#nge "s n#t used "n the Cn"ted States.
Marle< ret#!e<1
The !er"t#neal re&let"#ns are then l#sed t# #3er the &#re"gn *#d1. The Marle<
mesh #r s!#nge auses an "ntense "n&lammat#r1 reat"#n that sars and &"<es the retum "nt#
!lae. Th"s !r#edure sh#uld n#t *e !er&#rmed #n !at"ents %h# ha3e a large #m!#nent #&
#nst"!at"#n #r a 3er1 redundant s"gm#"d #l#n2 *eause the s1m!t#ms are l"6el1 t# %#rsen.
I& the retum "s "nad3ertentl1 entered dur"ng m#*"l"Gat"#n2 the &#re"gn mater"al sh#uld n#t *e
"m!lanted2 *eause #& the r"s6 #& "n&et"#n.
Hh"le the rate #& Marle< er#s"#n "nt# the retum "s l#%2 management "s e<tremel1
d"&&"ult2 and2 &#r th"s reas#n2 man1 surge#ns !re&er reset"#n %"th suture ret#!e<1 /see
*el#%0 t# Marle< &"<at"#n.
S!t!re re.t0%e=y
A suture ret#!e<1 "s essent"all1 the same as a Marle< ret#!e<12 e<e!t that the
retum "s &"<ed t# the !resaral &as"a %"th suture mater"al rather than mesh #r an I3al#n
s!#nge.
Re)e.ti0n re.t0%e=y
A reset"#n %"th ret#!e<1 /Fr16man>G#ld*erg !r#edure0 "s a #m*"nat"#n #& an
anter"#r reset"#n and a Marle< ret#!e<1F "t "s a g##d #!t"#n &#r !at"ents %"th a s"gn"&"ant
#m!#nent #& #nst"!at"#n. The retum "s #m!letel1 m#*"l"Ged t# the #1< !#ster"#rl12 t#
the lateral l"gaments laterall1 /s#me surge#ns d"3"de the lateral l"gaments02 and t# the ul>de>
sa anter"#rl1.
The redundant s"gm#"d #l#n "s then reseted2 and the rema"n"ng #l#n "s
anast#m#sed t# the t#! #& the retum. The lateral l"gaments /#r the retal &as"a0 are then
sutured t# the !resaral &as"a %"th the retum #n tens"#n2 %h"h 6ee!s the retum "n !lae
and !re3ents &urther retal !r#la!se. The ret#!e<1 "s a#m!l"shed %"th suture "nstead #&
n#na*s#r*a*le mesh *eause the *#%el "s #!ened &#r the anast#m#s"s and the mesh ma1
*e#me #ntam"nated.
Perinea/ S!r5i.a/ Pr0.ed!re)
Per"neal !r#edures ha3e h"gher reurrene rates *ut l#%er m#r*"d"t"es and are #&ten
!er&#rmed "n elderl1 !ers#ns #r "n !at"ents &#r %h#m general anesthes"a "s #ntra"nd"ated.
Ana/ en.ir./e#ent
H"th anal en"rlement /Th"ersh %"re02 a n#na*s#r*a*le *and "s !laed
su*utane#usl1 ar#und the anus. The !ur!#se #& th"s !r#edure "s t# 6ee! the retum &r#m
!r#la!s"ng *1 restr"t"ng the s"Ge #& the anal lumen. Alth#ugh the !r#edure %as "n"t"all1
desr"*ed as us"ng a %"re2 "t n#% em!l#1s #ther mater"als /eg2 S"last" tu*"ng and
n#na*s#r*a*le suture mater"al0 "nstead. Anal en"rlement "s e&&et"3e "n mehan"all1
!re3ent"ng the retum &r#m !r#la!s"ng2 *ut "t d#es n#t treat the underl1"ng d"s#rder.
C#m!l"at"#ns &r#m th"s !r#edure "nlude #*strut"#n %"th &eal "m!at"#n and
er#s"#n #& the %"re %"th "n&et"#n. Anal en"rlement "s n# l#nger #mm#nl1 !er&#rmedF "t "s
usuall1 reser3ed &#r #nl1 the m#st de*"l"tated !at"ents and &#r !at"ents %"th the h"ghest
surg"al r"s6s2 "n %h#m !all"at"#n "s the g#al. Anal en"rlement arr"es a 3er1 h"gh r"s6 #&
&eal "m!at"#n.
De/0r#e #!.0)a/ )/ee2e re)e.ti0n
In a (el#rme mu#sal slee3e reset"#n /see the "mage *el#%02 a "rum&erent"al
"n"s"#n "s made thr#ugh the mu#sa #& the !r#la!sed retum near the dentate l"neF %"th the
eletr#auter12 the mu#sa "s str"!!ed &r#m the retum t# the a!e< #& the !r#la!se and
e<"sed. The denuded !r#la!sed musle "s then !leated %"th a suture and ree&ed u! l"6e an
a#rd"#n2 and the transeted edges #& the mu#sa are sutured t#gether. Th"s !r#edure "s
#&ten used &#r small !r#la!ses *ut ma1 als# *e used &#r large #nes.
(el#rme mu#sal slee3e reset"#n.
A/te#eier %erinea/ re.t0)i5#0ide.t0#y
In an Alteme"er !er"neal ret#s"gm#"det#m12 a &ull>th"6ness "rum&erent"al
"n"s"#n "s made "n the !r#la!sed retum a*#ut ->+ m &r#m the dentate l"ne /see the "mage
*el#%0. The hern"a sa "s entered2 and the !r#la!se "s del"3ered. The mesenter1 #& the
!r#la!sed *#%el "s ser"all1 l"gated unt"l n# &urther redundant *#%el an *e !ulled d#%n. The
*#%el "s transeted and e"ther hand>se%n t# the d"stal anal anal #r sta!led %"th a "rular
sta!ler. 8e&#re anast#m#s"s2 s#me surge#ns !l"ate the le3at#r an" musles anter"#rl12 %h"h
ma1 hel! "m!r#3e #nt"nene.
Alteme"er !er"neal ret#s"gm#"det#m1.
In a stud1 #& the l#ng>term #ut#me #& Alteme"er !er"neal ret#s"gm#"det#m12
Alt#mare et al re3"e%ed the med"al re#rds #& B) !at"ents and #nluded that th"s #!erat"#n
"s relat"3el1 sa&e and e&&et"3e "n &ra"l2 #lder !at"ents2 %"th !#st#!erat"3e m#r*"d"t1 *e"ng
l#%.
D:E
$#%e3er2 the reurrene rate a&ter the !r#edure %as n#t negl"g"*le2 and the #!erat"#n
%as &#und t# *e un!red"ta*le "n terms #& rest#r"ng #nt"nene. Reurrenes an *e treated
%"th a re!eat Alteme"er !r#edure.
He#0rr"0ide.t0#y
Mu#sal !r#la!se "s treated %"th a hem#rrh#"det#m1.
Perinea/ )ta%/ed %r0/a%)e re)e.ti0n
In a stud1 #& )+ !at"ents %"th e<ternal retal !r#la!se2 $etGer et al #nluded that
!er"neal sta!led !r#la!se reset"#n "s a &ast and e&&et"3e treatment &#r th"s #nd"t"#n.
D-:E
The
#!erat"#n2 as !er&#rmed "n the stud12 "n3#l3ed !ull"ng #ut the !r#la!se #m!letel1 andKat )
and B #Jl#62 "n l"th#t#m1 !#s"t"#nKa<"all1 utt"ng "t #!en %"th a l"near sta!ler. Reset"#n
%as !er&#rmed %"th a ur3ed C#nt#ur Transtar sta!ler.
The "n3est"gat#rs re!#rted n# "ntra#!erat"3e #m!l"at"#ns2 alth#ugh + !at"ents
e<!er"ened m"n#r !#st#!erat"3e #m!l"at"#ns.
D-:E
Med"an surg"al t"me and h#s!"tal sta1
%ere ), m"nutes and 5 da1s2 res!et"3el1. At &#ll#%>u! /med"an2 : m#nths02 at %h"h t"me
data %as a3a"la*le &#r )- !at"ents2 B,A #& #h#rt mem*ers n# l#nger had the se3ere &eal
"n#nt"nene that had e<"sted !re#!erat"3el12 %"th the #h#rtJs med"an He<ner s#re
dr#!!"ng &r#m -: t# -. N# ne% ases #& #nst"!at"#n %ere re!#rted t# ha3e de3el#!ed.
Tshu#r et al stud"ed B !at"ents %h# under%ent !er"neal sta!led !r#la!se reset"#n
&r#m +,,7>+,--. The1 #nluded that alth#ugh the !r#edure "s &ast and sa&e2 the l#ng>term
&unt"#nal #ut#me %as !##r2 and the reurrene rate %as ..A.
D-7E
P0)t0%erati2e Care
A>d0#ina/ %r0.ed!re)
A&ter a*d#m"nal !r#edures &#r retal !r#la!se2 !at"ents usuall1 ha3e "leus and "n"s"#nal
!a"n. IV &lu"ds are ma"nta"ned unt"l l"@u"ds are started %"th the return #& *#%el &unt"#n #r earl"er2
de!end"ng #n %hether an anast#m#s"s has *een !er&#rmed. As *#%el &unt"#n "m!r#3es2 d"et an *e
ad3aned. Pat"ents %"th an anast#m#s"s are ma"nta"ned #n a l#%>&"*er d"et &#r +>) %ee6s and are
then started #n &"*er su!!lementat"#n t# hel! !re3ent the return #& #nst"!at"#n and stra"n"ng.
Pat"ents %"th#ut an anast#m#s"s an *e started #n a h"gh>&"*er d"et s##ner.
A F#le1 atheter "s !laed !er"#!erat"3el1 and "s le&t "n !lae &#r se3eral da1s *eause the
retal d"sset"#n an "nh"*"t *ladder &unt"#n. The length #& h#s!"tal sta1 a3erages )>7 da1s and "s
usuall1 de!endent #n the return #& *#%el &unt"#n and the #ntr#l #& "n"s"#nal !a"n.
Perinea/ %r0.ed!re)
Pat"ents %h# ha3e underg#ne !er"neal !r#edures d# %ell !#st#!erat"3el12 %"th m"n"mal
!a"n and a sh#rt h#s!"tal sta1. In"t"all12 the1 ree"3e n#th"ng *1 m#uth &#r a!!r#<"matel1 -+>+.
h#urs. A&ter th"s !er"#d2 l"@u"ds are "nst"tuted2 and !at"ents are ra!"dl1 ad3aned t# a regular d"et.
8#%el &unt"#n returns @u"6l1 *eause there "s n# a*d#m"nal "n"s"#n2 and !at"ents an #&ten *e
d"sharged +.>7+ h#urs a&ter the !r#edure.
'ana5e#ent 01 P0)t0%erati2e C0#%/i.ati0n)
Ser"#us #m!l"at"#ns a&ter retal !r#la!se surger1 "nlude "n&et"#n2 *leed"ng2 "ntest"nal
"n=ur12 anast#m#t" lea6age2 *ladder and se<ual &unt"#n alterat"#ns2 and #nst"!at"#n #r #utlet
#*strut"#n. The &re@uen1 #& these #m!l"at"#ns "s related t# the t1!e #& !r#edure. Other
#m!l"at"#ns /eg2 suh as m1#ard"al "n&art"#n2 !ulm#nar1 em*#lus2 dee! 3e"n thr#m*#s"s2 and
hern"a0 an #ur *ut are n#t d"sussed *eause the1 are n#t un"@ue t# retal !r#la!se re!a"r.
In1e.ti0n
The m#st #mm#n s#ure #& "n&et"#n "n a*d#m"nal !r#edures "s s6"n #rgan"sms "n the
%#und. I& &#re"gn mater"al has *een "m!lanted2 "n&et"#n an ensue2 m#st #&ten &r#m s6"n
#rgan"smsF and the mater"al must *e rem#3ed2 "& !#ss"*le. Intense &"*r#s"s an ma6e rem#3al #&
!r#sthet" mater"al t## danger#usF "n these sett"ngs2 l#ng>term ant"*"#t" thera!1 has ha3e *een
used. 7#ng>term results are unlear. In&et"#n a&ter !er"neal !r#edures #urs rarel1F m#re
#mm#nl12 there an *e a se!arat"#n at the !er"neal anast#m#s"s /see *el#%0.
&/eedin5
8leed"ng m#st #mm#nl1 #urs "n + s"tuat"#ns. The &"rst s"tuat"#n "n3#l3es tear"ng #& the
!resaral 3e"ns dur"ng a*d#m"nal !r#edures2 %hen mesh #r the retum "s d"retl1 a&&"<ed t# the
!resaral &as"a. Th"s an lead t# a !resaral hemat#ma #r t# t#rrent"al *leed"ng.
Suh *leed"ng an *e d"&&"ult t# #ntr#l *eause the 3e"ns e<"t d"retl1 &r#m the *#ne. The "n"t"al
maneu3er sh#uld a!!l1 d"ret !ressure t# the area &#r -,>-5 m"nutes. I& th"s &a"ls t# #ntr#l the
*leed"ng2 t"tan"um thum*ta6s an *e !laed "nt# the *#ne t# tam!#nade the 3essels. ("sset"#n "n
the !resaral s!ae #&ten "nreases *leed"ng and sh#uld *e a3#"ded.
The se#nd #mm#n s"tuat"#n &#r *leed"ng #urs dur"ng the mu#sal str"!!"ng "n a (el#rme
!r#edure #r &r#m %#und se!arat"#n !#st#!erat"3el1.
&04e/ in3!ry
8#%el "n=ur1 ma1 #ur dur"ng m#*"l"Gat"#n #& the retum. I& "t "s re#gn"Ged2 the "n=ur1 an
usuall1 *e re!a"red %"th#ut need &#r "ntest"nal d"3ers"#n. F#re"gn mater"al sh#uld n#t *e "m!lanted
"& the *#%el "s "n=ured. Cnre#gn"Ged "n=ur1 an lead t# a*sess &#rmat"#n and !el3" se!s"s /see
a*#3e0. Cnre#gn"Ged *#%el "n=ur"es ma1 #ur %"th a la!ar#s#!" a!!r#ah *1 se3eral
mehan"sms and2 "& n#t d"agn#sed @u"6l1 %hen the !at"ent &a"ls t# "m!r#3e2 an lead t# se!s"s and
death.
Ana)t0#0ti. /ea;a5e
All !r#edures "n3#l3"ng an anast#m#s"s arr1 a r"s6 #& anast#m#t" lea6age. A*d#m"nal
!r#edures #m!l"ated *1 a lea6 ma1 n#t re@u"re ree<!l#rat"#n "& the lea6 "s small and #nta"ned2
and the !at"ent "s sta*le. The #llet"#n an *e dra"ned !erutane#usl12 and these lea6s #&ten res#l3e
%"th su!!#rt"3e are. I& the !at"ent &a"ls t# "m!r#3e2 a*d#m"nal %ash#ut %"th !r#<"mal &eal
d"3ers"#n *e#mes neessar1.
I& the lea6 "s large and n#t #nta"ned2 #r "& the !at"ent "s n#t sta*le2 urgent ree<!l#rat"#n "s
"nd"ated. Pel3" se!s"s ma6es &urther d"sset"#n "n the !el3"s halleng"ng as %ell as danger#us &#r
the !at"ent2 and %ash#ut %"th !r#<"mal d"3ers"#n "s the !r#edure #& h#"e. Rarel1 %"ll the
anast#m#s"s *e #m!letel1 d"sru!tedF "n th"s sett"ng2 e<ter"#r"Gat"#n #& the d"stal !#rt"#n as an end
#l#st#m1 %"th sta!l"ng #r #3erse%"ng #& the retal stum! "s needed.
Rarel12 anast#m#t" lea6age an als# #ur a&ter !er"neal ret#s"gm#"det#m1. I& lea6age #urs
a&ter th"s !r#edure2 the "n&et"#n "s l#al"Ged and !el3" se!s"s "s rare.
A/tered >/adder and )e=!a/ 1!n.ti0n
Alterat"#n #& *ladder and se<ual &unt"#n sh#uld *e a rare #m!l"at"#n "n a !r#!erl1
!er&#rmed a*d#m"nal !r#edure. The !el3" s1m!athet" and !aras1m!athet" ner3es run al#ng the
retumF "& d"sset"#n "s n#t arr"ed #ut "n the !r#!er !lane2 "n=ur1 an #ur2 lead"ng t# *ladder
d1s&unt"#n2 "m!#tene2 #r retr#grade e=aulat"#n. Th"s "s an "m!#rtant #ns"derat"#n "n the
selet"#n #& the re!a"r !r#edure2 es!e"all1 "n men2 alth#ugh the r"s6 #& "n=ur1 sh#uld *e less than
->+A.
C0n)ti%ati0n?0!t/et 0>)tr!.ti0n
Per"neal !r#edures and anter"#r reset"#n ha3e a l#% r"s6 #& #utlet #*strut"#n. $"st#r"all12
a*d#m"nal !r#edures that ta6ed the retum t# the sarum aused a h"gh rate #& #utlet #*strut"#n
%hen the retum %as %ra!!ed "rum&erent"all12 #&ten neess"tat"ng release #& the &"<at"#n t# treat
the !r#*lemF &#r th"s reas#n2 the %ra!2 %hen !er&#rmed2 "s n#% #nl1 d#ne !#ster"#rl1 and !art"all1
ar#und the s"des #& the retum.
L0n5<Ter# '0nit0rin5
F#ll#%>u! are a&ter the "mmed"ate !#st#!erat"3e !er"#d de!ends #n %h"h t1!e #& surg"al
!r#edure the !at"ent under%ent2 *ut "t usuall1 #ns"sts #& ->+ 3"s"ts #3er the ensu"ng m#nth t#
ensure that all "n"s"#ns are %ell healed and that the !at"ent "s n#t ha3"ng d"&&"ult"es %"th *#%el
e3auat"#n.
Further &#ll#%>u! are "s usuall1 unneessar12 *eause the !at"ent %"ll read"l1 n#t"e "& the
!r#la!se returns and an shedule &urther #ut!at"ent 3"s"ts as neessar1.
'edi.ati0n S!##ary
There "s n# s!e"&" med"al treatment &#r retal !r#la!se. St##l s#&teners an *e used t#
hel! derease *#%el m#3ement stra"n"ng aused *1 #nst"!at"#n.
St00/ )01tener)
C/a)) S!##ary
In add"t"#n t# d"etar1 m#d"&"at"#n2 st##l s#&teners hel! t# derease *#%el m#3ement
stra"n"ng se#ndar1 t# #nst"!at"#n.
P0/yet"y/ene 5/y.0/ )0/!ti0n 7'ira/a=$ D!/.0/a= &a/an.e8
P#l1eth1lene gl1#l "s an #sm#t" st##l s#&tener used &#r treatment #&
#as"#nal #nst"!at"#n. In the#r12 there "s less r"s6 #& deh1drat"#n #r eletr#l1te
"m*alane %"th "s#t#n" !#l1eth1lene gl1#l than %"th h1!ert#n" sugar s#lut"#ns. A
la<at"3e e&&et "s generated *eause !#l1eth1lene gl1#l "s n#t a*s#r*ed and
#nt"nues t# h#ld %ater *1 #sm#t" at"#n thr#ugh the small *#%el and #l#n2
result"ng "n mehan"al leans"ng.
P#l1eth1lene gl1#l "s su!!l"ed %"th a measur"ng a! mar6ed t# #nta"n -7 g
#& la<at"3e !#%der %hen &"lled t# the "nd"ated l"ne. It ma1 re@u"re +>. da1s /.;>B:
h#urs0 t# !r#due *#%el m#3ement.
'inera/ 0i/ 7(0ndre#!/$ F/eet 'inera/ Oi/ Ene#a8
M"neral #"l lu*r"ates the "ntest"ne and &a"l"tates the !assage #& st##l *1
dereas"ng %ater a*s#r!t"#n &r#m the "ntest"ne.
La.t!/0)e 7En!/0)e$ +ener/a.$ (ri)ta/0)e$ C0n)t!/0)e8
7atul#se "s an #sm#t" agent and amm#n"um det#<"&1"ng agent. It !r#dues
an #sm#t" e&&et "n the #l#n that results "n d"stent"#n and !r#m#tes !er"stals"s.

REFFERE*CES
-. G#urg"#t"s S2 8arats"s S. Retal !r#la!se. Int J Colorectal Dis. Mar +,,7F++/)0:+)->.).
DMedl"neE.
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retal !r#la!seL. Colorectal Dis. Aug +,-,F-+/;0:;++>),. DMedl"neE.
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!at"ents %"th retal "ntussuse!t"#n and !r#la!se: "s th"s a !r#gress"3e s!etrum #& d"seaseL.
Dis Colon Rectum. Mun +,-)F5:/:0:7;,>5. DMedl"neE.
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#& Alteme"erNs !r#edure &#r retal !r#la!se. Dis Colon Rectum. A!r +,,BF5+/.0::B;>7,).
DMedl"neE.
7. Elmal"6 '2 (agash $2 Sha%"s RN. A*d#m"nal !#ster"#r ret#!e<1 %"th an #mental !ed"le
&#r "ntrata*le retal !r#la!se: a m#d"&"ed tehn"@ue. Pediatr Surg Int. Aug +,,BF+5/;0:7-B>
++. DMedl"neE.
;. de $##g (E2 $eems6er6 M2 N"eman F$2 3an Gemert HG2 8aeten CG2 8#u31 N(.
Reurrene and &unt"#nal results a&ter #!en 3ersus #n3ent"#nal la!ar#s#!" 3ersus r#*#t>
ass"sted la!ar#s#!" ret#!e<1 &#r retal !r#la!se: a ase>#ntr#l stud1. Int J Colorectal
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