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Rectal prolapse describes a condition where either the lining or entire wall of the rectum becomes loose and falls into, or even out of, the rectum through the anus.
TYPES OF RECTAL PROLAPSE
- Partial thickness rectal prolapse is where the lining of the rectum (mucosa) becomes loose and falls downs into the lumen of the anal canal when straining. Because it is not full thickness, it rarely prolapses enough to protrude through the anus. It may cause some degree of blockage in the rectum when straining, and may be a contributing factor to constipation.
- Full thickness rectal prolapse is where the entire wall of the rectum becomes so loose that on straining it telescopes on itself to such an extent that it falls out being visible external to the anus. Full thickness rectal prolapse is often mistaken for a hemorrhoid.
Rectal prolapse is caused by weakening of the muscular pelvic floor and ligaments that support the rectum keeping it in place. Rectal prolapse may be associated with advanced age, long term constipation, long term straining during defecation, pregnancy and multiple childbirths.
The commonest symptom of rectal prolapse is mucous discharge from the anus. Occasionally the prolapse is noticed as bulging mucosa typically on straining. Rectal prolapse may give the sensation of incomplete emptying when having a bowel motion.
Full thickness prolapse is clearly evident with bearing down with eversion of the rectum and a protruding bulge.
Colonoscopy - All patients with rectal prolapse and symptoms of constipation, particularly those considering surgery, require a complete colonoscopy to rule out other pathology of the colon that can result in obstructive defecation, mucous discharge and or bleeding.
Defecating proctography - is useful for documenting partial thickness rectal prolapse causing obstructive defecation.
Transit studies - Those with constipation, should have transit studies to exclude slow transit constipation prior to surgery to correct their rectal prolapse such as laparoscopic rectopexy.
Rectal prolapse, may undergo progression and become more advanced with time. Initially it begins with partial thickness prolapse, and over time in a minority, can progress to full thickness prolapse. Typically prolapse occurs during straining when having a bowel movement, or when sneezing or coughing. As it develops, it occurs more frequently, even throughout daily activities such as walking. Finally it may be prolapse continually, and in the worse form, ceases to retract.
The constipating effects of partial thickness rectal prolapse may be treated by a diet high in fiber. This leads to less firm stools and the avoidance of straining. If this doesn’t work, laxatives may be needed.
Perineal surgery is where the surgery is performed on the rectum approached from the anus. It does not involve major abdominal surgery, and is particularly suited in the elderly and those with multiple medical conditions that would make abdominal surgery unsafe. But have a higher recurrence rate of up to 20-30%.
- Delorme’s procedure is where the redundant mucosa is excised, and re-joined after plication of the underlying muscle wall of the rectum. This plication helps serve as extra bulk to the anal sphincter, and is thought to improve incontinence.
- Altimeier’s procedure, is full thickness excision of the portion of rectum that is prolapsed, and the two ends are sewn together. This is more suitable than Delorme’s, when the prolapse is excessive or non-reducible, or where the patient also has constipation. It has a lower recurrence rate than the Delorme’s procedure, but requires a bowel resection, and therefore carries a risk of 1-2% of a leak at the join (anastomosis),
Abdominal surgery is increasing being performed laparoscopically (key hole) with benefits of small incisions and less pain than traditional open surgery.
- Laparoscopic/ Robotic sutured rectopexy is performed with mobilization of the rectum all the way to the pelvic floor, with placement of the rectum back up where it belongs by securing the connective tissue surrounding the rectum (mesorectum) to the bony sacral promontory of the pelvis. It has the disadvantage of exacerbating constipation in those already constipated.
- Laparoscopic resection rectopexy - In patients with significant constipation, a portion of bowel may need to be resected to allow a straighter colon (laparoscopic resection rectopexy). This is a larger operation with the main risk of complication being an anastomotic leak at the bowel join (anastomosis), which occurs in 1-2% of cases.