Rectal prolapse occurs when the lower rectum protrudes out of the anus. Prolapse can be partial, full or internal and is commonly associated with a history of chronic constipation and straining.
Causes
- Long history of straining with bowel movement
- Loss of muscle strength and stretching of the ligaments with aging
- Childbirth
- Pelvic floor dysfunction
- Neurologic disorders
Symptoms
- Rectal pressure
- Mucous discharge
- Rectal bleeding
- Constipation and fecal incontinence
- Once prolapse occurs, fecal incontinence and rectal bleeding may occur more often than constipation.
- Rectal prolapse initially occurs with bowel movements but can occur with standing and exercise.
- The need for manual replacement of the rectum is common.
Hemorrhoids or prolapse?
Rectal prolapse is not the same as hemorrhoids although the symptoms may be similar. Occasionally, hemorrhoids can be mistaken for partial prolapse. Hemorrhoids occur near the anal opening in the anal canal while rectal prolapse involves a higher segment of bowel within the body. Hemorrhoids rarely cause rectal prolapse.
Testing & diagnosis
History and physical: Discussion of your symptoms and a physical examination by your physician is necessary to identify rectal prolapse. Examination of the anal canal reveals the extent of the loss of anal tone. Straining on a toilet or commode may be necessary to allow visualization of the prolapse by your physician. If the prolapse cannot be demonstrated in the office setting, additional test may be performed.
Defocography: X-ray pictures and video that demonstrate how the rectum empties and determines if any other organs are involved. Barium contrast medium is introduced into the patient’s rectum, and the patient is asked to evacuate the barium as if having a bowel movement. Video X-rays are also taken while the patient is asked to cough, strain and bare down while sitting on a radiology commode.
Colonic transit studies: Transit studies to measure the rate at which stool moves through the colon. The test, commonly referred to as a Sitz marker test, involves swallowing a capsule that contains tiny rings visible on X-ray. The patient has X-rays taken three and five days later, the rings are identified and their location documented. The rate at which the rings move through the colon defines the patient’s colonic transit time.
Surgical treatment
The surgical treatment for rectal prolapse can be done through the abdomen or the rectum. Surgical therapy must be tailored to the individual patient, taking into account factors such as age, physical condition, co-morbidities and severity of prolapse.
Abdominal suture rectopexy: This procedure is done through an incision in the abdomen and can be done with or without bowel resection. Sutures (stitches) are used to secure the rectum in its proper position.
Resection rectopexy: This procedure is done through an incision in the abdomen and is performed by removing the section of the colon that is prolapsing and securing the rectum in its proper position.
Ripstein procedure: This procedure is done through an incision in the abdomen. Surgical mesh is used to secure the rectum to the sacrum (bone between the spine and tailbone).
Perineal proctosigmoidectomy: This procedure is done through an anal incision. The prolapsing rectal tissue and a portion of the sigmoid colon are removed and sutures are used to reconnect the bowel.
Anal encirclement: This procedure is generally done in high-risk patients who are not candidates for more invasive surgery. A thin, circular band is placed under the skin of the anus, narrowing the anal opening and preventing the rectum from prolapsing.
How successful is treatment?
Most patients are helped significantly with surgery. Success depends on a variety of factors including the status of the anal sphincter and the condition of the patient before surgery. If the anal sphincter muscles have been damaged by the rectal prolapse, it may take up to a year to regain some strength. Some patients never regain good bowel control. Chronic constipation and straining after surgical correction needs to be avoided to prevent recurrent prolapse. Recurrence rates after an abdominal procedure are generally less than those after a perineal procedure, but postoperative complications can be higher. Abdominal procedures are generally reserved for patients who can tolerate general anesthesia. Recurrence rates do increase over time with both the perineal approach and abdominal approach.