Rectal Prolapse

Basics & Types - Descent Unpacked

Rectal prolapse: Protrusion of rectal wall(s) beyond the anal verge.

• Types:
  • Full-Thickness Rectal Prolapse (FTRP) / Procidentia:
    • Entire rectal wall (all layers) protrudes.
    • Concentric/circumferential mucosal folds.
    • Sulcus present between prolapse and anal margin.
  • Mucosal Prolapse (Partial Prolapse):
    • Only rectal mucosa protrudes.
    • Radial mucosal folds.
    • No sulcus.
  • Internal Prolapse (Occult / Rectal Intussusception):
    • Rectum telescopes internally; no external protrusion.
    • Diagnosed via defecography or MRI.

⭐ Concentric mucosal folds are pathognomonic for full-thickness rectal prolapse (procidentia), differentiating it from the radial folds of mucosal prolapse.

Etiology & Risks - Why It Slips Out

• Pelvic Floor Weakness:
  • Multiparity, advancing age
  • Prior pelvic surgery (e.g., hysterectomy)
  • Connective tissue disorders (Ehlers-Danlos, Marfan)
• Chronic Straining / ↑ Intra-abdominal Pressure:
  • Chronic constipation, severe diarrhea
  • Benign Prostatic Hyperplasia (BPH)
  • Chronic cough (COPD, asthma)
• Anatomical Factors:
  • Deep Pouch of Douglas
  • Redundant sigmoid colon, poor fixation
  • Patulous anus, weak anal sphincters
  • Levator ani muscle diastasis
• Neurological Impairment:
  • Pudendal neuropathy (childbirth, chronic straining)
  • Cauda equina syndrome, spinal injuries
• Other Key Factors:
  • Female sex (predominant, ~6:1 F:M ratio)
  • Certain psychiatric conditions (prolonged straining)
  • Cystic fibrosis (especially in children)

⭐ Pudendal neuropathy, often from obstetric trauma or chronic straining, is a crucial factor contributing to pelvic floor weakness, fecal incontinence, and rectal prolapse.

Clinical Features & Dx - Spotting the Protrusion

• Cardinal Symptom: Mass protruding from anus (esp. on straining).

• Associated Symptoms:

  • Rectal bleeding (bright red)
  • Fecal incontinence (flatus, liquid, stool)
  • Mucus discharge, perianal irritation
  • Dull ache, pelvic pressure, tenesmus
  • Obstructed defecation/constipation

• Key Sign (Examination):

  • Concentric mucosal folds on protruded mass (visible on straining).
  • Reduced anal sphincter tone may be present.

• Diagnostic Aids:

  • Primarily clinical diagnosis.
  • Proctosigmoidoscopy: Rule out lead point (polyp, tumor).
  • Defecography (cinedefecography/MRI): For occult/internal prolapse, assess pelvic floor dynamics.
  • Colonoscopy: If bleeding or other colonic pathology suspected (e.g., in older patients).

⭐ Complete rectal prolapse (procidentia) is characterized by concentric mucosal folds on examination, distinguishing it from hemorrhoidal prolapse (radial folds).

Management Approaches - Fixing the Fall

• Conservative Management:

  • Indications: Medically unfit, minimal/asymptomatic prolapse.
  • Methods: High-fiber diet, stool softeners, pelvic floor exercises (Kegel).

• Surgical Management: Tailored to patient (age, comorbidities, bowel function) & surgeon expertise.

• Perineal Approaches: (Preferred for older, high-risk patients)

  • Delorme's: Mucosal sleeve resection & muscle plication.
  • Altemeier's (Perineal Rectosigmoidectomy): Full-thickness resection. Good for irreducible/gangrenous prolapse.

• Abdominal Approaches: (Preferred for younger, fit patients; lower recurrence)

  • Rectopexy: Fixation of rectum to sacrum (e.g., Ripstein - anterior mesh, Wells - posterior mesh, Suture rectopexy).
  • Resection Rectopexy: Sigmoid resection + rectopexy (e.g., Frykman-Goldberg); addresses associated constipation.
  • Laparoscopic approach is standard for many abdominal procedures.

⭐ Abdominal rectopexy generally has lower recurrence rates (e.g., <10%) compared to perineal procedures (e.g., Delorme's 10-15%, Altemeier's 5-10%, though some perineal can be higher).

High‑Yield Points - ⚡ Biggest Takeaways

• Rectal prolapse: Protrusion of rectal layers; full-thickness (procidentia) common in elderly women.
• Etiology: Weak pelvic floor, chronic straining, multiparity, pudendal nerve injury.
• Diagnosis: Clinical, often requiring straining or squatting to demonstrate.
• Altemeier procedure (perineal proctosigmoidectomy) for elderly/high-risk patients.
• Abdominal rectopexy (e.g., Ripstein) offers lower recurrence but risks postoperative constipation.
• Delorme procedure: Perineal mucosal resection and muscle plication for shorter prolapses.
• Key complications: Recurrence, fecal incontinence, and constipation.