Enter the characters you see below Sorry, we just need to make sure you’re not a robot. Note circumferential arrangement of folds in full thickness prolapse compared to radial folds in mucosal prolapse. Rectal prolapse is generally more common in elderly women, although it may occur at any age and in either sex. It is very rarely life-threatening, but the symptoms can be debilitating if left untreated. Most external prolapse cases can be treated successfully, often with a surgical procedure. The different kinds of rectal prolapse can be difficult to grasp, as different definitions are used and some recognize some subtypes and others do not. There is some controversy surrounding this condition as to its relationship with hemorrhoidal disease, or whether it is a separate entity. The term “mucosal hemorrhoidal prolapse” is also used. It includes solitary rectal ulcer syndrome, rectal prolapse, proctitis cystica profunda, and inflammatory polyps.
It is classified as a chronic benign inflammatory disorder. Rectal prolapse and internal rectal intussusception has been classified according to the size of the prolapsed section of rectum, a function of rectal mobility from the sacrum and infolding of the rectum. The height of intussusception from the anal canal is usually estimated by defecography. An Anatomico-Functional Classification of internal rectal intussusception has been described, with the argument that other factors apart from the height of intussusception above the anal canal appear to be important to predict symptomology. Patients may have associated gynecological conditions which may require multidisciplinary management. History of constipation is important because some of the operations may worsen constipation. Fecal incontinence may also influence the choice of management. Rectal prolapse may be confused easily with prolapsing hemorrhoids.
The prolapse may be obvious, or it may require straining and squatting to produce it. This investigation is used to diagnose internal intussusception, or demonstrate a suspected external prolapse that could not be produced during the examination. It is usually not necessary with obvious external rectal prolapse. Colonic transit studies may be used to rule out colonic inertia if there is a history of severe constipation. This investigation objectively documents the functional status of the sphincters. However, the clinical significance of the findings are disputed by some. May be used to evaluate incontinence, but there is disagreement about what relevance the results may show, as rarely do they mandate a change of surgical plan.
There may be denervation of striated musculature on the electromyogram. Note circumferential arrangement of mucosal folds. The appearance is of a reddened, proboscis-like object through the anal sphincters. The true incidence of rectal prolapse is unknown, but it is thought to be uncommon. As most sufferers are elderly, the condition is generally under-reported. It may occur at any age, even in children, but there is peak onset in the fourth and seventh decades. Anatomical differences such as the wider pelvic outlet in females may explain the skewed gender distribution. Associated conditions, especially in younger patients include autism, developmental delay syndromes and psychiatric conditions requiring several medications.
Initially, the mass may protrude through the anal canal only during defecation and straining, and spontaneously return afterwards. Later, the mass may have to be pushed back in following defecation. If the prolapse becomes trapped externally outside the anal sphincters, it may become strangulated and there is a risk of perforation. This may require an urgent surgical operation if the prolapse cannot be manually reduced. Micrograph showing a rectal wall with changes seen in rectal prolapse. The precise cause is unknown, and has been much debated. This theory was based on the observation that rectal prolapse patients have a mobile and unsupported pelvic floor, and a hernia sac of peritoneum from the Pouch of Douglas and rectal wall can be seen. Other adjacent structures can sometimes be seen in addition to the rectal prolapse.
Since most patients with rectal prolapse have a long history of constipation, it is thought that prolonged, excessive and repetitive straining during defecation may predispose to rectal prolapse. Some authors question whether these abnormalities are the cause, or secondary to the prolapse. Proximal bilateral pudendal neuropathy has been demonstrated in patients with rectal prolapse who have fecal incontinence. Sphincter function in rectal prolapse is almost always reduced. This may be the result of direct sphincter injury by chronic stretching of the prolapsing rectum. The assumed mechanism of obstructed defecation is by disruption to the rectum and anal canal’s ability to contract and fully evacuate rectal contents. The intussusceptum itself may mechanically obstruct the rectoanal lumen, creating a blockage that straining, anismus and colonic dysmotility exacerbate.
Some believe that internal rectal intussusception represents the initial form of a progressive spectrum of disorders the extreme of which is external rectal prolapse. The intermediary stages would be gradually increasing sizes of intussusception. However, internal intussusception rarely progresses to external rectal prolapse. Surgery is thought to be the only option to potentially cure a complete rectal prolapse. For people with medical problems that make them unfit for surgery, and those who have minimal symptoms, conservative measures may be beneficial. Dietary adjustments, including increasing dietary fiber may be beneficial to reduce constipation, and thereby reduce straining. Surgery is often required to prevent further damage to the anal sphincters. The goals of surgery are to restore the normal anatomy and to minimize symptoms. There is no globally agreed consensus as to which procedures are more effective, and there have been over 50 different operations described.
Surgical approaches in rectal prolapse can be either perineal or abdominal. Laparoscopic procedures Recovery time following laparoscopic surgery is shorter and less painful than following traditional abdominal surgery. The perineal approach generally results in less post-operative pain and complications, and a reduced length of hospital stay. These procedures generally carry a higher recurrence rate and poorer functional outcome. The perineal procedures include perineal rectosigmoidectomy and Delorme repair. The goal of Perineal rectosigmoidectomy is to resect, or remove, the redundant bowel. This is done through the perineum. The lower rectum is anchored to the sacrum through fibrosis in order to prevent future prolapse. The full thickness of the rectal wall is incised at a level just above the dentate line.
This is a modification of the perineal rectosigmoidectomy, differing in that only the mucosa and submucosa are excised from the prolapsed segment, rather than full thickness resection. The prolapse is exposed if it is not already present, and the mucosal and submucosal layers are stripped from the redundant length of bowel. This procedure can be carried out under local anaesthetic. Placing silver wire around the anus first described by Thiersch in 1891. This phenomenon was first described in the late 1960s when defecography was first developed and became widespread. Recto-rectal intussusceptions may be asymptomatic, apart from mild obstructed defecation. Recto-anal intussusceptions commonly give more severe symptoms of straining, incomplete evacuation, need for digital evacuation of stool, need for support of the perineum during defecation, urgency, frequency or intermittent fecal incontinence. 3 mm, and those that appear to cause obstruction to rectal evacuation may give clinical symptoms. Some believe that it represents the initial form of a progressive spectrum of disorders the extreme of which is external rectal prolapse.
The folding section of rectum can cause repeated trauma to the mucosa, and can cause solitary rectal ulcer syndrome. Others argue that the majority of patients appear to have rectal intussusception as a consequence of obstructed defecation rather than a cause, possibly related to excessive straining in patients with obstructed defecation. Unlike external rectal prolapse, internal rectal intussusception is not visible externally, but it may still be diagnosed by digital rectal examination, while the patient strains as if to defecate. As with external rectal prolapse, there are a great many different surgical interventions described. It is clear that there is a wide spectrum of symptom severity, meaning that some patients may benefit from surgery and others may not. Many procedures receive conflicting reports of success, leading to a lack of any consensus about the best way to manage this problem. Relapse of the intussusception after treatment is a problem.
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