Rectal prolapse

Answer 1

Definition

Rectal prolapse is when the tissue that lines the rectum falls down into or sticks through the anal opening.

Causes, incidence, and risk factors

Rectal prolapse occurs most often in children under age 6 and in the elderly. It is often associated with the following conditions:

• Constipation
• Cystic fibrosis
• Malnutrition and malabsorption (celiac disease is an example)
• Pinworms (enterobiasis)
• Prior injury to the anus or pelvic area
• Whipworm infection (trichuriasis)

Symptoms

The main symptom is a reddish-colored mass that sticks out from the opening of the anus, especially following a bowel movement. The lining of the rectal tissue may be visible and may bleed slightly.

Signs and tests

The health care provider will perform a physical exam, which may include a rectal exam. Tests will be done to determine the underlying cause.

Treatment

Call your health care provider if a rectal prolapse occurs. In some cases, the prolapse can be treated at home.

The rectal mucosa must be returned to the rectum manually. A soft, warm, wet cloth is used to apply gentle pressure to the mass to push it back through the anal opening. The affected person should be in a knee-chest position before applying pressure to allow gravity to help return the prolapse.

Immediate surgery for repair is seldom needed. The underlying condition must be treated.

Expectations (prognosis)

Treating the underlying condition usually cures the problem. In otherwise-healthy elderly patients with recurrent rectal prolapse, surgery can repair anatomic problems that predispose them to prolapse.

Complications

• Constipation
• Malnutrition or malabsorption
• Other complications of the condition that caused the prolapse

Calling your health care provider

Call your health care provider promptly if there is a rectal prolapse.

Prevention

Treating the underlying condition usually prevents further rectal prolapse.

Answer 2

Definition

Rectal prolapse repair is surgery to fix a rectal prolapse, in which the rectum (the last part of the colon) protrudes through the anus.

Description

Rectal prolapse may be partial, involving only the mucosa. Or it may be complete, involving the entire wall of the rectum. It can occur in children but is much more common in older people.

Rectal prolapse in infants often gets better on its own and does not require surgery. Children with the following conditions are at greatest risk:

• Bladder exstrophy
• Cystic fibrosis
• Myelomeningocele

Rarely the condition can be caused by acute diarrhea or straining to pass stool while constipated.

Rectal prolapse is most common in older adults with a long history of constipation or weakness of the pelvic floor muscles. It is more common in women, especially those who have had a hysterectomy.

SYMPTOMS:

The symptoms of rectal prolapse include:

• Pain in the anus and rectum (anorectal pain)
• Bleeding
• Mucus discharge from the anus
• Incontinence
• Rectal tissue sticking out while having bowel movements (it may need to be pushed back in manually)

This condition can be confused with hemorrhoids but is different.

SURGERY:

Surgery is required to correct rectal prolapse in adults and in some children. Most surgical procedures for rectal prolapse are done under general anesthesia. For older or sicker patients, epidural or spinal anesthesia may be used.

There are three basic types of surgery to repair rectal prolapse. Your surgeon will decide which one is best for you.

For healthy adults, an abdominal procedure has the best chance of success. While you are under general anesthesia, the doctor makes a surgical cut in the abdomen and removes a portion of the colon. The rectum may be attached (sutured) to the surrounding tissue.

Sometimes a soft piece of mesh is wrapped around the rectum to help it stay in place. This procedure can also be done with laparoscopic surgery (also known as "keyhole" or "telescopic" surgery).

For older adults or those with other medical problems, an approach from below (perineal approach) might be less risky. However, with the perineal procedure, the condition will be more likely to come back (recur).

While you are under general, epidural, or spinal anesthesia, the prolapsing rectum or colon can be treated from the pelvic floor (perineum). The doctor will either remove a portion of the colon or suture the rectum to the surrounding tissues, or both.

Very frail or sick patients may need a small procedure to reinforce the sphincter muscles. This technique encircles the muscles with a band of soft mesh or a silicone tube. This approach provides only temporary improvement and is rarely used.

Indications

For children, rectal prolapse does not always require surgery. However, children whose rectal prolapse does not improve over time may need surgery. Infant prolapse often disappears without treatment.

Surgery to repair rectal prolapse is advised for most adults.

Risks

Risks for any anesthesia include the following:

• Breathing problems, pneumonia
• Heart problems
• Reactions to medications

Risks for any surgery include the following:

• Bleeding
• Infection

Other risks include:

• Constipation is very common, although most patients have constipation before the surgery.
• Incontinence after surgery. This is often an improvement over incontinence that is present before the surgery. However, in a small number of patients, incontinence can get worse.
• Return of prolapse during abdominal repairs and perineal repairs.

Expectations after surgery

The surgery is usually effective in repairing the prolapse. The long-term prognosis is good. Constipation and incontinence can be a problem for some patients.

Convalescence

Hospital time depends on the procedure used. Average stay for open abdominal procedures is 5-8 days and is shorter for laparoscopic surgery. Average stay for perineal surgery (approach from below) is 2-3 days. Expect complete recovery in 4-6 weeks.

References

Fry RD, Mahmoud N, Maron DJ, Ross HM, Rombeau J. Colon and Rectum. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL. Townsend: Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 50.

Answer 3

Definition

Rectal prolapse occurs when the tissue that lines the rectum falls down into or sticks through the anal opening.

Causes, incidence, and risk factors

Rectal prolapse occurs most often in children under age 6 and in the elderly. It is often associated with the following conditions:

• Constipation
• Cystic fibrosis
• Malnutrition and malabsorption (celiac disease is an example)
• Pinworms (enterobiasis)
• Prior injury to the anus or pelvic area
• Whipworm infection (trichuriasis)

Symptoms

The main symptom is a reddish-colored mass that sticks out from the opening of the anus, especially following a bowel movement. The lining of the rectal tissue may be visible and may bleed slightly.

Signs and tests

The health care provider will perform a physical exam, which may include a rectal exam. Tests will be done to determine the underlying cause.

Treatment

Call your health care provider if a rectal prolapse occurs. In some cases, the prolapse can be treated at home.

The rectal mucosa must be returned to the rectum manually. A soft, warm, wet cloth is used to apply gentle pressure to the mass to push it back through the anal opening. The affected person should be in a knee-chest position before applying pressure to allow gravity to help return the prolapse.

Immediate surgery for repair is seldom needed. The underlying condition must be treated.

Expectations (prognosis)

Treating the underlying condition usually cures the problem. In otherwise healthy elderly patients who have repeated rectal prolapse, surgery can repair physical problems that make prolapse more likely to occur.

Complications

• Constipation
• Other complications of the condition that caused the prolapse

Calling your health care provider

Call your health care provider promptly if there is a rectal prolapse.

Prevention

Treating the underlying condition usually prevents further rectal prolapse.

References

Lembo AJ, Ullman SP. Constipation. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisinger & Fordtran's Gastrointestinal and Liver Disease. 9th ed. Philadelphia, Pa: Saudners Elsevier;2010:chap 18.

Fry RD, Mahmoud N, Maron DJ, Ross HM, Rombeau J. Colon and rectum. In: Townsend CM Jr., Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier;2007:chap 50.

Reviewed By

Review Date: 07/05/2010

Linda J. Vorvick, MD, Medical Director, MEDEX Northwest Division of Physician Assistant Studies, University of Washington School of Medicine; and George F. Longstreth, MD, Department of Gastroenterology, Kaiser Permanente Medical Care Program, San Diego, California. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

Answer 4

Definition

Rectal prolapse repair is surgery to fix a rectal prolapse , in which the last part of the colon (called the rectum) sticks out through the anus.

Description

Rectal prolapse may be partial, involving only the mucosa. Or it may be complete, involving the entire wall of the rectum. It can occur in children, but is much more common in older people.

Surgery is needed to correct rectal prolapse in adults and some children. Most surgical procedures for rectal prolapse are done under general anesthesia. For older or sicker patients, epidural or spinal anesthesia may be used.

There are three basic types of surgery to repair rectal prolapse. Your surgeon will decide which one is best for you.

For healthy adults, an abdominal procedure has the best chance of success. While you are under general anesthesia, the doctor makes a surgical cut in the abdomen and removes a portion of the colon. The rectum may be attached (sutured) to the surrounding tissue.

Sometimes a soft piece of mesh is wrapped around the rectum to help it stay in place. This procedure can also be done with laparoscopic surgery (also known as "keyhole" or "telescopic" surgery).

For older adults or those with other medical problems, an approach from below (perineal approach) might be less risky. However, with the perineal procedure, the condition will be more likely to come back (recur).

While you are under general, epidural, or spinal anesthesia, the prolapsing rectum or colon can be treated from the pelvic floor (perineum). The doctor will remove a portion of the colon, suture the rectum to the surrounding tissues, or both.

Very frail or sick patients may need a small procedure to reinforce the sphincter muscles. This technique encircles the muscles with a band of soft mesh or a silicone tube. This approach provides only temporary improvement and is rarely used.

Why the Procedure is Performed

For children, rectal prolapse does not always require surgery. However, children whose rectal prolapse does not improve over time may need surgery. Infant prolapse often disappears without treatment.

Surgery to repair rectal prolapse is advised for most adults.

Risks

Risks for any anesthesia include the following:

• Breathing problems, pneumonia
• Heart problems
• Reactions to medications

Risks for any surgery include the following:

• Bleeding
• Infection

Other risks include:

• Constipation is very common, although most patients have constipation before the surgery.
• Incontinencethat is present before the surgery often improves. However, in a small number of patients, incontinence can get worse.
• Prolapse can return after either abdominal or perineal surgery.

Before the Procedure

During the 2 weeks before your surgery:

• Two weeks before surgery, you may be asked to stop taking drugs that make it harder for your blood to clot. These include aspirin, ibuprofen (Advil, Motrin), and naprosyn (Aleve, Naproxen).
• Ask your doctor which drugs you should still take on the day of your surgery.
• If you smoke, try to stop. Ask your doctor for help.
• Always let your doctor know if you have been sick before your surgery. This includes a cold, flu, herpes flare-up, or any other illness.
• Eat high-fiber foods and drink 6 - 8 glasses of water every day.

The day before your surgery:

• Eat a light breakfast and lunch.
• You may be told to drink only clear liquids such as broth, clear juice, and water after noon.
• Do NOT drink anything after midnight, including water. Sometimes you will not be able to drink anything for up to 12 hours after surgery.
• Your doctor or nurse may ask you to use enemas or laxatives to clear out your intestines. They will give you instructions.

On the day of your surgery:

• Take any medications that your doctor told you to take with a small sip of water.
• Your doctor or nurse will tell you when to arrive at the hospital.

After the Procedure

How long you stay in the hospital depends on the procedure. The average stay for open abdominal procedures is 5 - 8 days. You will go home sooner if you had laparoscopic surgery. The average stay for perineal surgery is 2 - 3 days. You should make a complete recovery in 4 - 6 weeks.

Outlook (Prognosis)

The surgery is usually effective in repairing the prolapse. The long-term outlook is good. Constipation and incontinence can be problems for some patients.

References

Fry RD, Mahmoud N, Maron DJ, Ross HM, Rombeau J. Colon and Rectum. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL. Townsend: Sabiston Textbook of Surgery. 18th ed. Philadelphia, Pa: Saunders Elsevier; 2008:chap 50.

Reviewed By

Review Date: 05/17/2010

Shabir Bhimji, MD, PhD, Specializing in Cardiothoracic and Vascular Surgery, Midland, TX. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.