Richard A. FalconeJr. MD , in Pediatric Clinical Counselor (Second Edition), 2007
Basic Data
Definition
Rectal prolapse is a protrusion of the rectal wall through the anal opening. It tin be fractional, involving only a portion of the circumference of the rectum (uncommon), or consummate, involving the entire circumference of the rectum. This is distinguished from prolapse of mucosal abnormalities within the rectum, such as polyps or hemorrhoids, in which the rectal wall remains in its normal position.
Synonym
ICD‐nine‐CM Code
Epidemiology & Demographics
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Rectal prolapse can exist primary or result from a pull‐through procedure.
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Although it can occur in newborns and in older children, most cases occur in toddlers, peculiarly at the time of toilet grooming.
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There is a slight male person predominance.
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Patients normally nowadays between the ages of 2 and 5 years.
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The status is associated with toilet training and constipation.
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Information technology is occasionally seen in patients with cystic fibrosis.
Clinical Presentation
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The parent may describe the sudden advent of a fleshy ring of tissue at the anus while wiping or a small amount of claret in the toilet bowl.
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There is ofttimes a meaning history of straining and previous constipation.
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Consummate prolapse manifests with an intussuscepted segment of rectum outside of the anal verge.
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The blueprint is similar to concentric rings formed by the mucosal folds of the rectum.
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The prolapsed segment can get quite congested when the status is chronic; information technology appears as a blueish or cerise mass at or about the anal opening.
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Irritation of the mucosa leads to local bleeding and mucus formation.
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Rectal examination is performed to exclude a polyp, rectal mass, or constipation.
Etiology
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Weakness of the levator mechanism is the underlying crusade for all rectal prolapse.
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As prolapse occurs, further stretching of the supporting ligaments and mesentery of the rectum makes subsequent prolapse more than likely to occur.
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Disorders of the sacral nerves, every bit seen with myelomeningocele, extrophy of the bladder, and high imperforate anus, may exist associated with rectal prolapse.
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Cystic fibrosis may predispose to rectal prolapse and may be the presenting sign. The diagnosis of cystic fibrosis should be considered, and a sweat chloride examination should be performed.
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Generalized malnutrition or debilitation may predispose to prolapse.
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Idiopathic prolapse is the nearly frequent conclusion, and it often is acquired by constipation and toilet preparation.
Lisa M. Yerian , in Encyclopedia of Gastroenterology, 2004
Rectal Prolapse
Rectal prolapse is the descent of some or all of the layers of the rectal wall through the anal sphincter. Rectal prolapse occurs in infants, is uncommon in children and young adults, and increases in frequency subsequently age forty. Patients with rectal prolapse ofttimes complain of straining or pain during defecation, fecal incontinence, fungus belch, pruritus, rectal bleeding, a sense of obstruction of incomplete rectal evacuation, and perineal or intervaginal pressure. The presence of reddened, protruding rectal mucosa is characteristic of rectal prolapse or a palpable mass may be detected on digital rectal exam (Fig. 2). There may be surface erosion or ulceration. Because the lesions can have an endoscopic appearance and a clinical presentation similar to rectal cancer, histologic analysis is important for diagnosis. Histologic features are like to those seen in SRUS.
Figure two. Endoscopic (A) and gross resection specimen (B) images of rectal mucosal prolapse. Clinically and endoscopically the lesion was suspected to stand for rectal cancer. However, histologic analysis of the endoscopic biopsies and evaluation of the resection specimen confirmed the diagnosis of rectal mucosa prolapse.
Philip Robinson , in Pediatric Respiratory Medicine (Second Edition), 2008
RECTAL PROLAPSE
Rectal prolapse in CF was much more than common in the years immediately following Andersen's original description of CF in 1938 than it is currently, due in a large degree to improved nutrition and more efficient pancreatic enzyme therapy. The introduction of newborn screening programs for CF has as well significantly reduced the incidence of rectal prolapse. In unscreened populations, rectal prolapse occurs in approximately 20% of patients with CF, usually between 6 months and 3 years of age, and may precede the diagnosis of CF.161
The prolapse may involve only the mucosa (mucosal prolapse) or all layers of the rectum (complete prolapse or procidentia). Predisposing factors in CF include increased intra-intestinal force per unit area secondary to chronic coughing, diarrhea, malnutrition, and pelvic flooring weakness. The treatment of rectal prolapse is mainly conservative and includes optimization of pancreatic enzyme therapy, high-fiber nutrition, and improved diet. Surgical intervention may exist required for recurrent rectal prolapse refractory to conservative measures; however, in CF, this is rarely required. A simpler, less invasive, approach for refractory cases may exist perirectal injection with a sclerosing agent.162
Marian D. Pfefferkorn , Joseph F. Fitzgerald , in Pediatric Gastrointestinal and Liver Disease (Fourth Edition), 2022
Rectal Prolapse
Rectal prolapse is the aberrant protrusion of 1 or more than layers of the rectum through the anus. Mucosal or partial prolapse is less serious and less pronouncedx (Figure 48-four). A complete rectal prolapse (procidentia), consisting of all layers of the rectal wall, frequently requires manual reduction.10 Rectal prolapse is usually detected by the child'due south parents and is urgently brought to medical attention; notwithstanding, it has oftentimes spontaneously reduced by the time the child is examined by medical personnel.
Rectal prolapse occurs nigh normally under iv years of historic period and may relate to the following anatomical considerations: the vertical grade of the rectum along the directly surface of the sacrum and coccyx, the low position of the rectum in relation to other pelvic organs, the increased mobility of the sigmoid colon, the relative lack of support by the levator ani muscle, the loose attachment of the redundant rectal mucosa to the underlying muscularis, and the absenteeism of Houston's valves in virtually 75% of infants under i yr of historic period.11,12 Prolonged straining during toilet training or with constipation is a frequent cause in children.thirteen,14 Acute and chronic diarrhea, intestinal parasites, and malnutrition are other common etiologies.14-sixteen During malnutrition, the lack of ischiorectal fatty resulting in decreased perirectal support may predispose to rectal prolapse. In underdeveloped countries, this may exist further aggravated by chronic diarrhea from enteric infections.12 Rectal prolapse has been reported in upward to nineteen% of 605 patients with cystic fibrosis.17,xviii Rectal prolapse in these patients was often transient and usually resolved at 3 to 5 years of age, or following the institution of pancreatic enzyme replacement therapy.17 There accept been reports of rectal prolapse occurring with juvenile polyps (Figure 48-v), inflammatory polyps, lymphoid hyperplasia, solitary rectal ulcer, meningocele, pertussis, and Ehlers-Danlos syndrome.xix-23 Oftentimes, no underlying cause for the rectal prolapse is identified.14,16
The diagnosis is primarily historic, although it is prudent to screen patients for intestinal parasites and cystic fibrosis. Conservative management of rectal prolapse involves manual reduction and treatment of the primary inciting gene. The parents should exist trained to use disposable gloves and lubricating jelly to promptly reduce a prolapse whenever it occurs. If rectal prolapse becomes recurrent and persistent, the authors' approach has been to schedule the patient for examination under anesthesia to exclude an anatomic atomic number 82 point for the prolapse, such as a polyp. If none is found, prolapse can be treated with submucosal injection of a sclerosant, such every bit five% phenol in almond oil, 50% dextrose, 25% saline, or 1% sodium morrhuate.13,15,24,25 Resolution of rectal prolapse was reported in 91 of 100 children who were treated with rectal submucosal injection of 5% phenol in oil.26 Indications for surgical management are rare in children, just may include the development of mucosal ulceration with bleeding (solitary rectal ulcer), irreducible prolapse, no improvement with conservative treatment, and rectal prolapse longer than 3 cm27 (Figure 48-6).
Biology and Diseases of Ruminants (Sheep, Goats, and Cattle)
Wendy J. Underwood DVM, MS, DACVIM , ... Adam Schoell DVM, DACLAM , in Laboratory Animal Medicine (Third Edition), 2022
thousand Rectal Prolapse
Rectal prolapses are common in growing, weaned lambs and cattle from 6 months to 2 years old. The physical eversion of the rectum through the anal sphincter is usually secondary to other diseases or management-related circumstances. Rectal prolapses may occur secondary to gastrointestinal infection or inflammation, particularly when the colon is involved. Diseases such equally coccidiosis, salmonellosis, and intestinal parasites that crusade tenesmus may issue in prolapse. Urolithiasis may outcome in rectal prolapses as the beast strains to urinate. Any course of cystitis or urethritis, vaginal irritation or vaginal prolapse, and some forms of hepatic disease may lead to rectal prolapses. Abdominal enlargement related to advanced stages of pregnancy, excessive rumen filling or bloat, and overconditioning may cause prolapses as tin coughing during respiratory tract infections, or improper tail docking (likewise short).
Diagnosis is based on clinical signs. Early prolapses may be corrected past holding the animate being with the head downwards, while a colleague places a purse-string suture around the anus. The mucosa and underlying tissue of prolapses that accept been nowadays for longer periods of time volition frequently become necrotic, dry, friable, and devitalized and will crave surgical amputation or the placement of prolapse rings to remove the tissue. Rectal prolapses may too be accompanied by abdominal intussusceptions that will farther complicate the treatment and increase mortality. Occasionally, acute rectal prolapses with evisceration will event in daze and prompt death of the fauna. Prognosis depends on the cause, extent of the prolapse as well as timeliness of intervention. In all cases, determination and elimination of the underlying cause is essential.
Robert D. Madoff , in Goldman's Cecil Medicine (Twenty Fourth Edition), 2022
Rectal Prolapse
Epidemiology and Pathobiology
Rectal prolapse is a total-thickness protrusion of the rectum beyond the anal sphincter. The disorder can occur at any historic period, merely prolapse is most frequently seen in older patients, and approximately xc% of adult patients are women. Prolapse is caused past an internal rectal intussusception that, as it becomes more than severe, protrudes externally. Uncorrected prolapse oftentimes leads to fecal incontinence by mechanically stretching the sphincter complex and causing a stretch injury to the pudendal nerves.
Clinical Manifestations and Diagnosis
The main clinical manifestation of rectal prolapse is the protruding rectal mass (Fig. 147-iv). Most commonly the protrusion occurs with bowel movements, only with time it may occur with coughing or sneezing, and eventually information technology tin can occur spontaneously. Some patients present with complaints of fecal incontinence, and many as well complain of "constipation," which may be caused by unsuccessful attempts to evacuate the intussuscepting rectum. The protruded rectum may cause minor haemorrhage and mucus discharge. Occasional patients present with an incarcerated or strangulated prolapse.
The diagnosis of rectal prolapse is confirmed on physical examination. Full-thickness prolapse, which is characterized by concentric mucosal folds, must exist differentiated from circumferential mucosal prolapse, which is characterized past radial folds. The prolapse is often all-time demonstrated by having the patient strain on a commode. Defecography is sometimes helpful to diagnose internal rectal intussusception and associated pelvic floor abnormalities, such as rectocele and enterocele.
Treatment
Rectal prolapse is treated by surgical correction. Both transabdominal and transperineal approaches are usually used.
Jorge A. Lagares‐Garcia , ... Steven Schechter , in General Gynecology, 2007
Rectal Prolapse
Rectal prolapse or rectal procidentia occurs when the rectum protrudes through the anal culvert and sphincter machinery. The prolapsed rectum appears as a big thick tube containing full thickness mucosa/submucosa and muscle propria and its associated blood supply. The rectum is inverted in that the dentate line maintains its position while the more proximal portion of the rectum serves every bit the atomic number 82 point of the prolapse. The well-nigh common pelvic flooring abnormalities institute in patients with rectal prolapse include loss of anal sphincter tone, a deep cul‐de‐sac, poor posterior rectal fixation, diastasis of the levator ani muscles, and a redundant sigmoid colon.
Patients who present with the report of rectal prolapse are often distressed with the amount of tissue that prolapses forth with the attendant incontinence. Besides stool, patients report drainage of mucus and haemorrhage. Although the rectal prolapse occurs during straining at defecation, patients oftentimes report spontaneous prolapse, difficulty pushing the prolapse dorsum into identify, or both. This disorder tin present in childhood and may exist associated with cystic fibrosis and neurologic disorders of the spinal canal. Patients with avant-garde rectal prolapse may develop severe bleeding, incarceration, and gangrene of the rectal wall.
On physical examination, the prolapse appears to harbor full‐thickness rectal wall along with archetype circumferential mucosal folds. Prolapsed hemorrhoids accept a radial distribution. In mild cases, simply mucosal prolapse will be evident. A consummate digital test should be performed to evaluate the resting and squeeze pressures, assuasive evaluation of the internal and external anal sphincters respectively. Office sigmoidoscopy or colonoscopy is appropriate to evaluate for the presence of colorectal neoplasia. Anal manometry will allow a standardized clinical cess of the sphincter circuitous. When the internal anal sphincter pressure is below ten mm Hg, it is unlikely that patient will recover fecal continence, and the patient may require a permanent colostomy.
Rectal prolapse tin be treated surgically using an abdominal or transperineal approach (Box 25‐5). Our preferred approach is the laparoscopic. Yet, laparotomy and sigmoid colon resection with rectal intermission is performed. The rectum is then mobilized and fixated posteriorly, pulling it upwardly and tethering it to the sacral hollow just below the promontory. The reanastomosis is carried out and so that the rectum is likewise held past the splenic flexure attachment to the colon. Recurrence rates subsequently this procedure take been reported to exist less than 5%.
Unfortunately, many patients with rectal prolapse are elderly women with comorbidities that make abdominal surgery risky. Perineal repairs for rectal prolapse tin be performed with the patient under general or intravenous sedation and may be better tolerated by elderly persons. The nigh pop perineal process in the Us is the rectosigmoidectomy. In this process, the rectal prolapse is pulled into view and the bowel wall is divided with subsequent division, clamping, and tying of the claret supply. A new anastomosis is then created.
Some authors have supplemented this operation with an anterior or posterior levator ani repair. The Delorme procedure, or perineal rectal sleeve resection, is a simpler operation in that after the rectum is completely prolapsed, the patient has the mucosal and submucosal portion of the prolapse excised in sleeve‐like mode, leaving the muscular propria of the rectum and distal internal sphincter complex intact (Fig. 25‐7). A reefing upwards of the polish muscle coat and internal sphincter creates a new anal canal/internal sphincter. An anastomosis is so carried out between the rectosigmoid mucosa and anoderm. This process can be carried out in lithotomy or decumbent position with intravenous sedation, regional cake, or full general anesthesia. Although these procedures are better tolerated and therefore suited for elderly patients, the recurrence rates can vary between xv% and 20%.
Overall, patients are satisfied with the anatomic correction of the rectal prolapse, though restoration of fecal continence occurs in only ii thirds of patients. Patients with rectal prolapse who experience constipation may require some form of sigmoid resection. Conscientious evaluation of these patients is needed to identify underlying disorders, such equally colonic inertia, which volition crave a total abdominal colectomy.
Najma Due north. Ahmed Physician, MSc, FRCP(C) , Peter R. Durie MD, FRCP(C) , in Kendig & Chernick's Disorders of the Respiratory Tract in Children (8th Edition), 2022
Rectal Prolapse
Rectal prolapse occurs in approximately one fifth of patients with CF and in about 50% of cases; it may be the presenting feature of CF disease. Most cases present at a young age betwixt 1 calendar month and three years of age. Rectal prolapse is more mutual in PI patients and may be related to the bulky stools. In virtually cases, it resolves spontaneously after 3 years of age. In patients for whom this is the presenting feature of CF, the establishment of enzyme supplementation may result in improvement, but some patients will keep to prolapse for some time. In patients with constipation, treatment of the constipation is also of do good. Surgical intervention is rarely indicated.
Mohamed Due east. Ismail Aly , Ted Huang , in Total Burn Care (Fifth Edition), 2022
Rectal Prolapse
Rectal prolapse tin can occur occasionally in young children with extensive burn injuries with or without perineal involvement. The pathophysiology of the evolution of rectal prolapse in infants with extensive burns remains unclear.
Redundant rectal mucosa; the structural relationship of the rectum to other pelvic organs such equally the sacrum and coccyx, urinary bladder and uterus; and lack of muscular back up provided past the pelvic musculature are anatomical features unique to infants 1–3 years old. All this could account for the evolution of rectal prolapse in this age group. A sudden increase in intraabdominal force per unit area, malnutrition, and constipation could conceivably beal the magnitude of the rectal mucosa descending through the anal opening.four Clinically, in addition to eversion of rectal mucosa, the presence of edematous swelling involving the buttocks and perianal surface area is quite common, despite the lack of burn injuries. The onset can be quite sudden without any obvious precipitating event; still, straining or the Valsalva maneuver tin produce an eversion of the rectal canal through the anal opening.
The treatment consists of rectal padding, daily cleansing of the perineal and perianal area, and a stool softener added to the dietary regimen to facilitate bowel movement. Spontaneous resolution of the rectal mucosa prolapse is likely every bit the nutritional status of the patient improves and tissue swelling subsides (Fig. 55.5). Surgical intervention, although in most instances unnecessary, is indicated if the prolapse is non readily reducible due to the development of anal sphincter dysfunction and/or intussusception.4,five
Stephen Westward. Moore One thousand.D. , in Griffith's Instructions for Patients (Eighth Edition), 2022
Bones Information
DESCRIPTION
Rectal prolapse is a protrusion (bulging) of rectal tissues outside the anus. Partial prolapse is protrusion of the mucosa (inner lining) lonely. Consummate prolapse (procidentia) is protrusion of the unabridged thickness of the rectum. It can affect adults (usually over age 60) and children (usually under age 6).
FREQUENT SIGNS & SYMPTOMS
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Sense of fullness in the lower abdomen or rectal expanse.
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Mucus discharge sometimes tinged with claret from the rectum.
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Firm mass of tissue that can be felt at the anus. It may worsen subsequently a bowel motion.
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Hurting when having bowel movements.
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Bowel incontinence. Stool may leak from anus.
CAUSES
Weakness of muscles and ligaments holding the rectum in place. Why the weakness occurs is unknown.
Take a chance INCREASES WITH
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Aging.
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Previous surgery on the rectum or vagina.
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Constipation and straining to have bowel movements.
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Chronic diarrhea.
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Weak anal sphincter.
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Multiple sclerosis.
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Stroke, paralysis, or spinal tumor.
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Anal or pelvic injury.
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Chronic obstructive pulmonary affliction.
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Multiple pregnancies.
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Malnutrition.
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Parasitic infections.
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Cystic fibrosis (children).
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Neurological (mental) disorders.
PREVENTIVE MEASURES
None specific. Practice not strain when having bowel movements. Avert constipation and diarrhea. Eat a loftier-fiber diet.
EXPECTED OUTCOMES
Proficient prognosis with handling. In children, there is normally complete recovery.
POSSIBLE COMPLICATIONS
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Ulceration (sores) and bleeding in tissue that protrudes.
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Rectal prolapse may occur with another prolapse, such as the uterus or the bladder.
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