Rectal Prolapse is a condition in which the rectum (i.e. the last few inches of the large intestine) or a part of it, loses its normal attachments inside the body, and protrudes out through the anal opening. Although it is never an emergency problem, it does leave the patient uncomfortable and anxious, with a significant negative impact on the quality of life.

    It is more common in females (especially >50 years) than in males.

Symptoms and causes of Rectal Prolapse
Rectal Prolapse
types and treatment of Rectal Prolapse


CAUSES OF RECTAL PROLAPSE

  • Long standing constipation with history of straining to defecate.


  • Chronic diarrhoea


  • Old age - Due to laxity of the pelvic floor muscle and reduced anal sphincter tone.


  • Pregnancy, difficult vaginal delivery, multiple vaginal deliveries.


  • Chronic cough due to COPD or any other cause


  • Neurological conditions like multiple sclerosis, injury to the lower back or pelvis, spinal tumours.


  • Cystic fibrosis in children


SYMPTOMS OF RECTAL PROLAPSE

  • The most common symptom is something lump/ swelling coming out of the anal opening. In the early stages, this may happen only during a bowel movement, but as the condition progresses it may happen on coughing, sneezing and standing up as well.
         Initially it may be possible to push back the swelling inside with your fingers. With time, even this may not be possible and it may persistently stay out.
  • In case of Occult prolapse there is no swelling coming out but there may be a sense of incomplete evacuation after a bowel movement, as though something is still left in the rectum.
  • Fecal incontinence leading to soiling of clothes. There may be leaking of gas, liquid/solid stools or mucus/ blood stained discharge. The anal sphincter is made of muscles that allow one to hold on to their stool when there is an urge to defecate. When the rectum prolapses, it goes past the anal sphincter, and this allows stools and mucus to pass in an uncontrolled fashion.
  • Constipation - Seen in upto 30-50% of patients, constipation may result because of bunching up of the rectum, creating a blockage that worsens with straining.
  • Pain/ discomfort in the region.
  • With time, the prolapsed mucosa may become thick and ulcerated causing bleeding.

DIAGNOSIS OF RECTAL PROLAPSE

A brief clinical history of your symptoms followed by examination of the rectum is done. Your doctor may ask you to strain or cough during the examination. A digital rectal examination is performed followed by Proctoscopy ( visualisation of the rectum by inserting a scope ).

Other tests may include

  • MRI Defecography - This test shows how much stool the rectum can hold, how well it can hold and how well it can release the stool.
  • Colonoscopy - This is an examination of the large intestine/colon, with the help of a flexible tube that has an inbuilt camera. It is done to rule out any associated condition.
  • Anal manometry - This test measures the strength of the anal sphincters, how tightly the sphincters can close.

TYPES OF RECTAL PROLAPSE


  • PARTIAL OR MUCOSAL PROLAPSE
    Only the inner lining of the rectum protrudes through the anus. It is usually <2cm and produces radial folds.
  • FULL THICKNESS RECTAL PROLAPSE / PROCIDENTIA
    Part of the wall (including all three layers) protrudes through the anus. It is about 2-5cm and produces concentric rings.
  • OCCULT or INTERNAL INTUSSUSCEPTION
    The rectum folds on itself but does not protrude through the anus.


     Although an operation is not always needed, the definitive treatment of rectal prolapse requires a surgery. The goal of the treatment is to prevent prolapse, restore defecation function and prevent constipation or incontinence.

WHAT HAPPENS IF A PATIENT CHOOSES TO NOT UNDERGO TREATMENT FOR THE RECTAL PROLAPSE???

   A patient may be diagnosed as having rectal prolapse by a colorectal surgeon, but she/he may choose to not undergo any surgical treatment. This usually happens in the early stages. Left untreated, the prolapse will only grow larger with time and worsen. If a patient chooses to delay the treatment for too long, they must know that the longer a prolapse is left untreated, the greater the chances of having permanent problems with fecal incontinence, as the anal sphincter is repeatedly stretched out and the chance of nerve damage is increased. However, in some cases the prolapse is very small or the patient is too old/ sick to undergo an operation. In such cases supportive garments could be of help.

  If left untreated, rectal prolapse does not turn into cancer.

I SURGICAL TREATMENT OF RECTAL PROLAPSE

There are several surgical techniques to repair a rectal prolapse. It is best to leave the final decision about the choice of procedure with your surgeon. The surgeon's choice depends on patients age, other existing health problems, extent of the prolapse, results of tests and the surgeons preference with certain techniques.

Basically, there are two general approaches to surgery for rectal prolapse:

  • Abdominal approach - Through the belly.
  • Perineal approach - Through the bottom.

II TREATMENT OF COMPLETE PROLAPSE - PROCIDENTIA


1. THIERSCH PROCEDURE

This is a simple procedure in which a prosthesis is used, that narrows the anus. Although initially a silver wire was used, presently, instead of wires, sutures and nylon, dacron, silastic, teflon and silicon rubber materials are used.

Although this procedure corrects the prolapse, it has no effect on the associated constipation if present. This constipation is managed with dietary and lifestyle modifications.

The procedure takes about 20-30 minutes and is done under short general anaesthesia. It is very safe in the elderly and those with associated medical conditions. The patient is generally discharged on the same day of the procedure.

2. RECTOPEXY ( Abdominal/ Laparoscopic )

In this procedure, the loose rectal attachments are divided from the pelvic walls all the way to the floor of the pelvis. A rectopexy is then performed, whereby the rectum is pulled upwards and secured to the sacrum (back wall of the pelvis) in various ways. At times, this procedure is accompanied by resection of a portion of the bowel.

Although rectopexy fixes the problem, the function ( incontinence or constipation ) may not always improve. On the contrary, in about 15% cases, patients develop constipation for the first time after surgery. In about 50% patients, the constipation that was there previous to surgery gets worsened.

Rectopexy is a major surgery done under general anaesthesia. Patient is not allowed to take anything by mouth for upto 3-4 days and may remain hospitalised for upto a week.