RECTAL PROLAPSE

PRESENTER:DR RE KHALUSHI MODERATOR:PROF LM NTLHE

CONTENTS
Background Anatomy Pathophysiology Etiology Clinical presentation Differential diagnosis Investigations Non operative management Surgical management References

BACKGROUND
Rectal prolapse was reported as early as 400-500 BC by Egyptian and Greek civilization. The first written report was found in the Ebers Papyrus of 1500 BC Rectal prolapse or procidentia is a protrusion of the rectum beyond the anus Complete (external) or full thickness rectal prolapse is the protrusion of all of the rectal wall through the anal canal Occult(internal) rectal prolapse or rectal intussusceptions is when the rectal wall has prolapsed but does not protrude through the anus

HEMORRHOIDS

RECTAL PROLAPSE

BACKGROUND
Grading of prolapse Grade 1: Occult prolapse Grade 2: prolapse to but not through the anus Grade 3: any protrusion though the anus Annual incidence of 2,5 per 100000 Occurs at extreme age-in pediatrics usually diagnosed by the age of 3 years with male and female equally affected. About 20% associated with cystic fibrosis disease In adult the peak incidence is after the 5th and 7th decade with women commonly affected representing 80 to 90%(male to female ratio 1:6)

Rectal prolapse grading

ANATOMY
Rectum is the distal 12-15 cm of the large intestine between the sigmoid colon and the anal canal It start in front the 3rd sacral vertebra as continuation of the sigmoid colon It passes downward following the curvature of the sacral and coccyx, it ends at tip of the coccyx by piercing the pelvic diaphragm Divided into 3 parts:1st third is covered by peritoneum on the anterior and lateral surface, mid third is covered by peritoneum on anterior surface, distal third devoid of peritoneum It serves as a reservoir for fecal material

PATHOPHYSIOLOGY
The pathophysiology of rectal prolapse is not completely understood or agreed upon There are two main theories: 1. Postulates that rectal prolapse is a sliding hernia through a defect in the pelvic floor 2. The rectal prolapse start as circumferential internal intussusceptions of the rectum starting 6-8 cm to the anal verge

Pathophysiology
Prerequisites for the development of rectal prolapse 1. The presence of an abnormal deep pouch of Douglass 2. The lax and atonic condition of the pelvic floor and anal canal 3. Weakness of both internal and external sphincter, often evidence by pudendal nerve neuropathy 4. The lack of normal fixation of the rectum, with a mobile mesorectum and lax lateral ligaments

Etiology
The precise cause is not well defined, however there are number of associated abnormalities 50% due to chronic straining and constipation Incontinence Pregnancy-obstetric trauma Previous surgery Cystic fibrosis(20% of paediatric rectal prolapse) Genital prolapse(24%)

Etiology
Chronic obstructive airway disease Pertussis Pelvic floor dysfunction Neurological disorder- cauda equina syndrome, spinal tumours,multiple sclerosis Parasitic infection- schistosomiasis, amebiasis Disorder of defecation Elevated intra-abdominal pressure

Clinical presentation
Early symptoms Protrusion Mucous discharge Rectal prolapse associated with bowel movement Tenesmus Late symptoms bleeding Incontinence Rectum spends most of the time prolapsed cystocele

Clinical presentation
Physical signs: Protruding rectal mucosa Thick concentric mucosal ring Sulcus noted between anal canal and rectum Solitary rectal ulcer (10-25%) Decreased anal tone

Differential diagnosis
Hemorrhoids Intussusceptions Prostates disease Anal cancer

RECTAL PROLAPSE

PROLAPSED HEMORRHOIDS

THROMBOSED HEMORRHOID

Investigations
Complete history and physical examination Screening tool- endoscopy or barium enema is recommended for adult Evaluating the rectal prolapse 1. Rigid proctosigmoidoscopy 2. Cinedefecography-asses pelvic floor movement 3. Anorectal manometer-pressure generated by sphincter 4. Electromyography-check denervation and colon transit

NON OPERATIVE MANAGEMENT

Sedation, field block with local unaesthetic prolapsed rectum can be reduced with gentle pressure Sprinkling the prolapse with either salt or sugar Other modalities-stool softener, enema

SURGICAL MANAGEMENT
More than 100 procedures were described for rectal prolapsed Aim for the treatment: 1. Control the prolapse 2. Restore continence 3. Prevent constipation Divided in to Abdominal and Pelvic procedures

Abdominal procedures
1.Suture Rectopexy First described by Cutait in 1959 involves mobilization and upward fixation of the rectum No mortality, recurrence rate 0-3%(majority) with exception of one series with recurrence of 27% Clinical outcome- symptoms were better overall in male 2.Prosthetic or Mesh Rectopexy Involves insertion of material like fascia lata,non absorbable synthetic mesh,polypropylenemarlex,polyvinyl alcohol,polytef Two types mesh rectopexy: posterior mesh rectopexy and anterior sling Rectopexy

Abdominal procedures
Posterior Mesh Rectopexy After rectal mobilization prosthetic material is inserted between rectum and sacral ,sutured in to the rectum and suture into the periosteum of sacral promontory Mortality rate 0-3%,Recurrence rate 3%, significant pelvis sepsis as major(2-16%) contributor to post operative complications Clinical outcome-improve continence

Abdominal procedures
Ripstein Procedure (anterior sling Rectopexy) First described by Repstein in 1952 After complete mobilization of the rectum, anterior sling of fascia lata or synthetic material is placed in front of the rectum and sutured to the sacral promontory Mortality 0-2,8%,recurrence rate 0-13% Clinical outcome-yield conflicting result as it improves continence and causes obstructed defecation

Abdominal procedures
3.Resection Recto sigmoid resection Mortality 0-6,7%,recurrence rate0-5% Clinical outcome- there was overall reduction with constipation, continence improved and causing less outlet obstruction

Abdominal procedures
4.Laparoscopic Rectopexy The procedure involves either suture or posterior mesh rectopexy with or without resection Mortality 0-3%,reccurence rate 0-8% in 8 and 30 months follow up Clinical outcome depends on the type of procedure done

Perineal procedure
1.Delorme operation First described Delorme in 1900 Stripping of the prolapsed rectum and suture plication of the remnant bare muscle, the mucosa is then approximated to seal the anastomosis Mortality 0-4%, recurrence rate 4-38%

continue
2.Perineal Rectosigmoidectomy First described by Mickulicz in1889 Full thickness excision of the rectum and if possible portion of sigmoid colon Mortality 0-5%,recurrence rate 0-16% 3.Stapled trans-anal rectal Resection (STARR) Few published studies Reported to be safe and effective technique for outlet obstruction

REFFERENCES
1. Lechaux D, Trecbuchet G, etal. Laparoscopic rectopexy for full thickness rectal prolapse.Surg Endosc(2005)19:514-518 2. Madiba T.E, Baig M.K,Wexner S.D.surgical management of rectal prolapse. Archive Surgery(2005)140:63-73 3. Gourgiotis S,Baratsis S.Rectal Prolapse. Int J Colorectal Dis(2007)22:231-243 4.Otto S.D,Ritz J.P, Grone J, etal. Abdominal Resection Rectopexy with an Absorbable Polyglactin Mesh:prospective evaluation of morphological and functional changes with consecutive improvement of patients symptoms. World J Surg(2010)34:27102716 5. Kodner IJ, Fry RD, Fleshman JW. Rectal prolapse and other pelvic floor abnormalities. Ann Surg 1992;24:157190 6.Cirocco WC,Brown AC.Anterior resection for the treatment of rectal prolapse:20 years experience.Am Surg.(1993)59:265-269 7. Snell R.S. Clinical Anatomy by regions.8th edition.335-380