A Presentation On Rectal Prolapse: Dr. Jabin Sultana Tonni FCPS Part-2 Trainee (Surgery) Su-4, SSMCMH

A Presentation on
Rectal Prolapse
Dr. Jabin Sultana Tonni
FCPS Part-2 Trainee(Surgery)
SU-4,SSMCMH
Outline
• Introduction
• Types of prolapse
• Epidemiology
• Etiology
• Predisposing factors and risk factors
• Clinical presentation
• Clinical examination
• Differential diagnosis
continued
• Investigation
• Treatment options
• Solitary rectal ulcer syndrome
Introduction
• What is rectal prolapse?

Rectal prolapse refers to a
circumferential,full-thickness
protrusion of the rectum
through the anus.
Types of Rectal Prolapse
• Partial or Mucosal Prolapse-
When the mucosa and sub
mucosa of the rectum protrude
outside the anus for
approximately 1-4 cm
• Complete or full thickness

prolapse-
When protrusion of the full
thickness of the rectal wall
through anus.More than 4cm
and commonly 10-15cm in
length
Internal Rectal
Prolapse
More accurately described as
internal intussusception.
It refers to the invagination of
the rectal tube during
defecation.
The prolapse descends
towards anal canal but
doesn’t protrude.
• Rectal prolapse is an uncommon
condition affecting 0.5% of general
population.
• Incidence is bimodal-
• 1st peak in children within first 5
Epidemiology year of life,usually mucosal and
should be treated conservatively
• 2nd peak in after seven decade.
• More common in elderly female than
male.
• Female:Male=6:1
Though etiology is still unknown,some
anatomical defects are seen such as-
• Diastasis of the levator ani muscle
Etiology- • Abnormally deep cul-de-sac
• Redundant sigmoid colon
• Patulous anus
• Lack of facial attachments of the
rectum against sacrum
• Acute or Chronic Diarrhoea
• Cystic fibrosis
Predisposing • Neurological Disorders
factors in • Hirschsprung’s disease
Children • Rectal polyps
• Maldevelopment of pelvis
• Age over 40
• Female
• Prior pelvic surgery
Risk • Chronic straining and constipation
Factors in • Chronic diarrhoea
• Vaginal delivery
adults
• Multiparity
• Pelvic floor dysfunction due to
anatomical defects and neurological
disorders
• Symptoms-
• Tenesmus
• Sensation of something coming out from
anus(may be reduced spontaneously or
Clinical not)
• Sensation of incomplete evacuation
Presentation • Mucus discharge and leakage
• Incontinence
• Bleeding
Clinical Examination
• Position of patients-Standard left lateral position
-sitting or squatting position
during straining
• DRE findings-lax anal spinchter
• On palpation between two finger,double thickness of wall
of rectum will be palpable in complete rectal prolapse
• Proctoscopy- erythematous rectal mucosa.

Differential Diagnosis
Rectal Prolapse Prolapsed Haemorrhoid
• Circumferential tissue folds • Radial tissue folds

• On palpation,double rectal wall • Haemorrohoidal plexus can be
palpable between two finger palpable
• On resting and squeeze pressure • Not decreased in size
decreased in size
• Fluroscopic /MRI defecography-
gives informations about coexisting
disorders like rectocele,cystocele,vaginal
vault prolapse,enterocele,sigmoidocele
Investigations
• Colonoscopy-
To exclude other colonic pathology and
malignancy.
continued
Others-
• colonic transit studies
• Anorectal manometry
• Puedendal nerve terminal motor latency
• EMG
• Non Surgical-
1.Digital Repositioning –in case of
infants and children.
2.Submucosal injection of sclerosing

Treatment agents or banding-
options- Both in children and adults with
mucosal prolapse.
• Surgical
Surgery is must for full thickness rectal
prolapse.
• Goals of surgery-
1.Eliminate the prolapse
Surgical 2.Correct anatomical and functional
abnormalities
Management
•Choice of Procedure based upon-
• Patient’s Co-morbidities
• Age
• Bowel function
• Surgeon’s preference
Abdominal
Surgical
Approaches
Perineal
Abdominal Approach
• Goals-To fix the rectum in its normal position.

• It may be Open or laparascopic/robotic.
• Candidates-physically fit,younger patients
• Many options available like-
• Rectopexy- Can be done with suture or mesh
• Resection Rectopexy-
includes abdominal rectopexy with resection of the Sigmoid
colon
Sutured Rectopexy-
• Simply suturing the mobilized rectum to the sacrum using four

to six interrupted non absorbable sutures
• Mesh rectopexy-
Posterior mesh rectopexy-
1. Rectum mobilized posteriorly and
Laterally down to the levator ani
Muscles
2.Mesh is fixed to the presacral fascia,below
the sacral promontory and to the rectum
laterally.
• Ventral Mesh rectopexy-
Mesh fixed to the anterior rectal
wall &
Suspended to the sacral
promontory.
• Who are the candidates?
Ans-elderly patients and medically unfit
patients
Advantages-
Perineal  minimal post operative pain
Approach-  Early mobility
 Low levels of morbidity
Disadvantages-Higher Recurrence Rate
continued Most frequently used
procedures-
Thiersch’s operation-
largely obsolete
Delorme’s operation
Altemeire’s Procedure
Delorme’s Operation
• Steps-
• Rectal Mucosa is stripped circumferentially from
rectum along the length.
• Muscle is plicated with a series of sutures.
• Muscle is concertinaed towards anal canal.
• Excess mucosa is excised and anastomosis

between distal and proximal part.
Preferred in Short
segment full prolapse
continued
Drawbacks-Recurrence
rate is higher
Altemeier’s Procedure
•Also called perineal proctectomy or
proctosigmoidectomy is True
rectosigmoidectomy.
•How it’s done?

•Full-thickness resection performed
incorporating associated colonic prolapse
•Restoration of colorectal continuity by
hand sewn/stapled anastomosis.
continued
Preferred in Advantages-
Disadvantages-Poor
Incarcerated and recurrence rate
bowel control with
strangulated lower than
feacal soiling
prolapse delorme’s operation
• When Indicated ?
If it can be demonstrated on
Treatment proctography
& causes obstructed defecation.
of Internal
rectal Surgical options
prolapse 1.Perineal approach-Delorme’s Procedure
2.Abdominal approach- LVMR(laparoscopic
ventral mesh rectopexy)
• It may cause –
• Ulceration
If rectal • Haemorrhage
• Irreducibility and gangrene
prolapse is
• Spontaneous rupture with
not treated? evisceration
• Manifestation of Obstructed Defecation
Solitary Syndrome
• Formation of ulcer on anterior wall of
Rectal rectum,6-8cm from anal verge
Ulcer • Mistaken for Ca Rectum,Crohn’s disease
Syndrome
• How to diagnosed?
• Proctgraphic studies-accompying
Rectal Intussusception or anterior
continued rectal prolapse
• Histology –confirms the diagnosis
• Treatment-
• Symptomatic relief from bleeding by
continued contolling straining with re-coordination
with defecation using biofeedback therapy
• Surgical options-STARR procedure(Stapled
Transanal resection of the intussusception)
Thank you

A Presentation On Rectal Prolapse: Dr. Jabin Sultana Tonni FCPS Part-2 Trainee (Surgery) Su-4, SSMCMH

Uploaded by

Copyright:

Available Formats

A Presentation On Rectal Prolapse: Dr. Jabin Sultana Tonni FCPS Part-2 Trainee (Surgery) Su-4, SSMCMH

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

A Presentation On Rectal Prolapse: Dr. Jabin Sultana Tonni FCPS Part-2 Trainee (Surgery) Su-4, SSMCMH

Uploaded by

Copyright:

Available Formats

A Presentation on

• What is rectal prolapse?

• Complete or full thickness

• Proctoscopy- erythematous rectal mucosa.

Rectal Prolapse Prolapsed Haemorrhoid

• Circumferential tissue folds • Radial tissue folds

2.Submucosal injection of sclerosing

• Goals-To fix the rectum in its normal position.

• Simply suturing the mobilized rectum to the sacrum using four

• Muscle is plicated with a series of sutures.

• Muscle is concertinaed towards anal canal.

• Excess mucosa is excised and anastomosis

•How it’s done?

You might also like