Rectal Prolapse - Know Signs Of It!

Rectal prolapse means complete rectal prolapse where the rectal walls have prolapsed to a degree where they protrude out of the anus and are visible outside the body.

Types

The different types of prolapse are as-Internal prolapse (internal intussusception). Full thickness or a partial rectal wall is affected but the prolapsed tissue does not pass out of the anus.

1. External Prolapse- If they protrude from the anus and are visible externally. Full thickness, circumferential, true intussusception of the rectal wall which protrudes from the anus and is visible externally.
2. Full-thickness rectal prolapse- A full thickness of the rectal wall protrudes through the anus.
3. Mucosal prolapse- Protrusion of only the rectal mucosa (not the entire wall) from the anus.
4. Circumferential- Where the whole circumference of the rectal wall prolapse.
5. Segmental- Where only parts of the circumference of the rectal wall prolapse.

Grades of Prolapse

Grade I: Non-relaxation of the sphincter mechanism

Grade II: Mild intussusception

Grade III: Moderate intussusception

Grade IV: Severe intussusception

Grade V: Rectal prolapse

Causes

1. Pelvic floor dysfunction
2. Parasitic infections such as Amoebiasis, schistosomiasis
3. Pregnancy
4. Cystic fibrosis
5. Pertussis (whooping cough)
6. Neurologic disorders - Previous lower back or pelvic trauma/lumbar disk disease, cauda equina syndrome, spinal tumors, multiple sclerosis
7. Disordered defecation (stool withholding)
8. Previous surgery
9. Diarrhea
10. Benign prostatic hypertrophy
11. Chronic obstructive pulmonary disease (COPD)

Symptoms of Rectal Prolapse
History of a protruding mass- Initially, the mass protrudes from the anus only after a bowel movement and usually retracts when the patient stands up. As the disease process progresses, the mass protrudes more often, especially with straining and valsalva maneuvers such as sneezing or coughing.

• Degrees of fecal incontinence which may simply present as a mucous discharge
• Fecal leakage
• A sensation of obstructed defecation (tenesmus)
• Pelvic pain
• A feeling of bearing down
• Rectal bleeding
• Diarrhea
• Constipation(20%-50% of patients) also described as tenesmus (a sensation of incomplete evacuation of stool) and obstructed defecation
• Erratic bowel habits 

Signs of Rectal Prolapse 

• Sulcus noted between anal canal and rectum
• Solitary rectal ulcer (10%-25%)
• Decreased anal sphincter tone
• Protruding rectal mucosa
• Thick concentric mucosal ring

How will you Diagnose?

1. Proctoscopy/ sigmoidoscopy/ colonoscopy
2. Colonic transit studies
3. Anorectal manometry
4. Anal electromyography/Pudendal nerve testing
5. Differential
6. Diagnosis
7. Hemorrhoids
8. Intussusception
9. Proctitis 

Treatment

1. Conservative- Dietary adjustments, including increasing dietary fiber may be beneficial to reduce constipation. 
2. Surgery- Surgical approaches in rectal prolapse can be either perineal or abdominal.

A perineal approach refers to surgical access to the rectum and sigmoid colon via an incision around the anus and perineum. Abdominal approach (trans-abdominal approach) involves the surgeon cutting into the abdomen and gaining surgical access to the pelvic cavity.

• Laparoscopic procedures 
• Perineal procedures
• Perineal rectosigmoidectomy