Diagnosis

Rectal prolapse

Etiology

Cause [vfs]

• Congenital

• Acquired: chronic constipation, weak anal sphincter

Pathophysiology [vfs]

1. Deficient pelvic floor

2. Increased intraabdominal pressure (excessive straining during to defecation)

3. Rectum herniates through the anal canal

Risk factors [654]

• Elderly women, functional bowel disorders, chronic straining (neurological disorders, medications), multiparity, deep cul-de-sac, pregnancy, previous pelvic surgery, COPD, connective tissue disorders and hypermobility (Ehlers-Danlos syndrome), intestinal parasite infections

Epidemiology

Incidence per 100.000 [uws][dgv]

Approach

• Clinical examination [654]

• Anoscopy/rectoscopy

• Anorectal manometry

• Colonoscopy: irregular bowel habits and for colorectal cancer screening

• Pelvic floor imaging: defecography (MRI or fluoroscopic)

  • Internal prolapse

  • Anatomical defects: peritonealocele, enterocele, rectocele, or cystocele

  • Colonoscopies are typically indicated for patients

Treatment

1. Symptomatic: [654][zsz][vfs]

   • Constipation: fiber and stool softeners

   • Fecal Incontinence: avoid foods that accelerate gastrointestinal transit time (caffeine, lactose)

   • Skin breakdown: barrier ointments and absorbent pads

   • Pelvic floor physical therapy

2. Perineal procedures: preferred for elderly, frail and higher risk patients

   • Higher recurrence rates

   • Delorme procedure (mucosal sleeve resection)

   • Altemeier procedure (perineal proctosigmoidectomy)

3. Abdominal rectopexy prolapse repair:

   • Considered more durable than perineal operations

   • Rectopexy: Mobilization of the rectum and fixation to the sacral ligament

   • Laparoscopic ventral mesh rectopexy

   • Sigmoid resection + rectopexy

   • Wells procedure (posterior mesh repair)

   • Ripstein procedure (a band of mesh wrapped around the rectum)

Differential diagnoses

Colorectal polyp, Cystocele, Enterocele, Hemorrhoids, Intussusception, Proctitis, Rectocele, Urethrocele, Uterine prolapse