Prolapse Syndromes

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Rectal prolapse occurs when the full thickness of the rectal wall protrudes through the anus. It is the most common type of distal digestive tract prolapse. In mucosal prolapse, only the mucosa of the rectal wall protrudes through the anus. In contrast, internal intussusception can be full or partial thickness but the prolapse does not pass beyond the anus. Intussusception is common in normal, healthy volunteers (up to 50%) and may be normal. It seldom leads to full prolapse.9

The first description of rectal prolapse is said to be in the Ebers papyrus 1500 BC. The first treatment as outlined by Hippocrates involved hanging patients by their heels and shaking them.10 Obviously, this was rarely successful in the long term. The true incidence of rectal prolapse (mucosal or complete) is unknown mostly because of underreporting. It is associated with long-standing constipation, chronic straining, pregnancy, prior surgery, female gender, aging, neurologic disease, mental illness (up to 53% in a study by Vongsangnak et al.), and other pelvic floor disorders.11,12

The peak incidence of prolapse is seen in the fourth and seventh decades of life,and women are affected more often, outnumbering men 10 to 1.13 In fact, the incidence increases with age in women, but not in men. Approximately two-thirds of women with rectal prolapse have neu-rogenic weakness of the pelvic floor, which is usually a consequence of childbirth.14 The incidence of prolapse, however, does not seem to be lower in nulliparous women, although they are less likely to have associated fecal incon-tinence.14 In a study by Karulf et al.,15 35% of patients with rectal prolapse were nulliparous. Other associated conditions with rectal prolapse include rectosigmoid cancer, systemic sclerosis, laxative abuse, malnutrition, and increased intraabdominal pressure. Up to 40% of patients with rectal prolapse have fecal incontinence, and up to 60% have constipation.16

Solitary rectal ulcer syndrome (SRUS) is a condition described classically as a single ulceration of the rectal mucosa usually anteriorly between 5 and 12 cm from the anal verge.17,18 The name of the syndrome, however, can be misleading, because patients do not need to have ulceration to be diagnosed with this condition. Typically, patients present with symptoms of bleeding (56%), passage of mucous, straining, or a sense of incomplete evacuation. Endoscopic findings range from mucosal ulcerations to mild erythema. It is thought that years of straining because of chronic constipation or birth-related injuries may weaken the pelvic floor with resultant pudendal nerve damage. Pudendal nerve damage leads to weakened sphincters and thus prolapse. Intussuscepted mucosa may lead to direct mucosal injury or ischemia, which leads to rectal mucosal injury or ulceration. Associated conditions include rectal prolapse, failure of puborectalis relaxation, increased anorectal angle, abnormal perineal descent, and decreased anorectal sensitivity to balloon inflation.19 Abnormal perineal descent has been seen in patients with SRUS, and behaviors such as digitization have been related. Other disorders such as defecation disorders, constipation, fecal impaction, erythema nodosum, and lupus have also been associated with SRUS.20

The annual incidence of SRUS is 1 to 4 per 100000. Eighty percent of patients are less than 50 years old. Females are affected slightly more often than males.9 The mean age of presentation is 49, but 25% of patients present after age 60.9 As noted above, many authors believe rectal prolapse is the etiology. It is proposed that prolapse causes ischemia, which leads to ulceration; however, only 30% of patients with SRUS have rectal prolapse.19

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