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Rectal Prolapse

Overview

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Rectal Prolapse occurs when the rectum, which is the last part of the large intestine, slips out of its normal position and protrudes through the anus. This condition can vary in severity, ranging from a small amount of rectal tissue showing through the anus to a more significant portion of the rectum being visible outside the body.

This condition can vary in severity, ranging from a small amount of rectal tissue showing through the anus to a more significant portion of the rectum being visible outside the body.

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Symptoms
  • Visible Prolapse: A protruding mass from the anus that may be red or swollen. This can be seen during bowel movements or at other times.
  • Rectal Bleeding: Blood may be seen on the stool or toilet paper, or the rectum may bleed upon examination.
  • Discomfort or Pain: Pain or discomfort in the rectal area, particularly during bowel movements or when sitting.
  • Mucus Discharge: Mucous discharge from the rectum.
  • Bowel Dysfunction: Symptoms such as constipation, diarrhea, or difficulty controlling bowel movements (incontinence).
  • Feeling of Fullness: A sensation of fullness or pressure in the rectum
Complications
  • Strangulation: The protruded rectum can become trapped, leading to compromised blood supply and potential tissue death, requiring immediate medical attention.
  • Ulceration: The exposed rectal tissue can become ulcerated, leading to pain and bleeding.
  • Infection: Prolonged exposure of the rectal tissue can lead to infections.
  • Chronic Irritation: Persistent prolapse can lead to irritation and skin breakdown around the anus.
Causes
  • Weakness of Pelvic Floor Muscles: Weakness or damage to the pelvic floor muscles and connective tissues, often from childbirth or aging.
  • Chronic Constipation: Straining during bowel movements due to chronic constipation can contribute to prolapse.
  • Chronic Diarrhea: Frequent diarrhea can also strain the rectal area and contribute to prolapse.
  • Previous Surgery: Prior surgical procedures in the pelvic area can affect the rectal support structures.
  • Neuromuscular Conditions: Conditions affecting nerve function or muscle control, such as spinal cord injury or neurological disorders.
  • Genetic Factors: Some individuals may have a genetic predisposition to weakened connective tissues or pelvic floor muscles.
Prevention
  • Healthy Bowel Habits: Managing constipation and diarrhea through diet, hydration, and appropriate use of laxatives can help prevent prolapse.
  • Pelvic Floor Exercises: Performing exercises to strengthen the pelvic floor muscles, such as Kegel exercises, can help support rectal tissues.
  • Proper Lifting Techniques: Using correct lifting techniques to avoid excessive straining.
  • Managing Weight: Maintaining a healthy weight to reduce pressure on the pelvic floor.
  • Regular Check-ups: For individuals with risk factors, regular medical check-ups can help monitor and manage symptoms early.
Risk Factors
  • Age: Older adults are at higher risk due to natural weakening of pelvic tissues.
  • Gender: Women are more likely to develop rectal prolapse, especially after childbirth.
  • Childbirth: Vaginal childbirth, particularly multiple or traumatic deliveries, can weaken pelvic support structures.
  • Chronic Conditions: Conditions leading to chronic straining or muscle weakness.
  • Previous Pelvic Surgery: Past surgeries affecting the pelvic region may increase risk.
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How is it treated?

Non-Surgical Treatments

  • Lifestyle Changes: Modifying bowel habits to manage constipation or diarrhea, and incorporating pelvic floor exercises.
  • Medications: Laxatives or stool softeners to ease bowel movements and reduce straining.
  • Rectal Support Devices: Pessary devices may be used to help support the rectum and prevent prolapse.

Surgical Treatments

  • Surgical Repair: The primary treatment for rectal prolapse, which may include:
  • Perineal Procedures: Such as the Altemeier procedure, which involves removing the prolapsed tissue and securing the remaining rectum.
  • Abdominal Procedures: Such as the Abdominal Rectopexy, where the rectum is repositioned and secured to the abdominal wall.
  • Stool Management: Combining surgical repair with dietary and medication adjustments to manage bowel function.

Palliative Care

  • Symptom Management: Addressing pain, discomfort, and other symptoms with appropriate medications and supportive care.
  • Follow-Up Care: Regular follow-up to monitor for recurrence or complications post-treatment.

Summary

Rectal prolapse is a condition where the rectum protrudes through the anus, causing various symptoms and potential complications. Treatment often involves a combination of lifestyle changes, non-surgical management, and, if necessary, surgical intervention to repair the prolapse and restore normal function. Early intervention and appropriate management can help alleviate symptoms and improve quality of life for those affected.

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How is it Diagnosed?

Diagnosis of rectal prolapse begins with a thorough history and physical examination. Patients typically present with symptoms like a protruding mass through the anus, fecal incontinence, constipation, rectal bleeding, or mucous discharge. Chronic straining, a sensation of incomplete evacuation, or a bulge during defecation are suggestive clues.

During physical examination, direct inspection may reveal a circular, concentric fold of full-thickness rectal tissue protruding from the anus, distinguishing it from hemorrhoids or mucosal prolapse. If prolapse is not visible at rest, the patient may be asked to strain while in a squatting position to demonstrate the prolapse.

A digital rectal examination (DRE) assesses anal tone and sphincter integrity. Proctoscopy or sigmoidoscopy helps evaluate for mucosal abnormalities, polyps, or malignancy.

    Imaging studies provide valuable insight in ambiguous or recurrent cases:

  • Defecography (dynamic proctography) is the most definitive test, demonstrating the mechanics of defecation and degree of prolapse.
  • Colonic transit studies may be ordered if chronic constipation is a complaint.
  • MRI defecography offers high-resolution images of pelvic floor dysfunction, particularly in cases of coexisting prolapse or enterocele.
  • Anal manometry evaluates sphincter function and is useful for surgical planning.
  • In pediatric cases, cystic fibrosis should be ruled out. The diagnosis is primarily clinical but supported by imaging and functional studies where needed.

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