T.Cristina Sardinha and Steven D.Wexner
The definition of rectal prolapse is the protrusion of the full thickness of the rectal wall through the anus (Figure 86.1). This protrusion differs from mucosal prolapse and internal intussusception. In cases of mucosal prolapse, only the inner mucosal rectal layer protrudes through the anus (Figure 8-6.2). Conversely, in cases of rectoanal internal intussusception, the prolapsed tissue remains confined within the rectal lumen. The preoperative knowledge of this type of prolapse will help direct the appropriate therapeutic option.
The etiology of rectal prolapse is unclear. However, factors involved in the development of rectal prolapse may be congenital or acquired. Moreover, there are conditions that can be associated or predispose to the development of rectal prolapse. These problems include intestinal disorders such as constipation and chronic straining, neurologic diseases, especially spinal cord abnormalities and depression, nulliparity, lack of rectal fixation to the sacrum, previous anorectal surgery, and pelvic floor defects. In addition, rectal prolapse is almost always a condition of the female gender.1 Despite the implication of multiple pregnancies in the etiology of rectal prolapse, this pathology is more frequent in nulliparous patients.
The true incidence of rectal prolapse is unknown. However, rectal prolapse is more common in the fourth and seventh decades of life. The majority of these patients are elderly females. Moreover, a small number of children, usually younger than 3 years of age, are affected with rectal prolapse. In these individuals, the treatment differs from adult patients.
The patients with rectal prolapse often complaint of a mass protruding out of the anus, initially with straining then progressing to exteriorization with any increase in abdominal pressure and finally prolapse even at rest. Chronic prolapse is often associated with inflamed, irregular, and edematous mucosa, mucous discharge, ulceration, and bleeding. Nonetheless, incarceration and gangrene are rare phenomena. Fecal incontinence is reported in 50% to 75% of patients with rectal prolapse. This may be a consequence of sphincteric disruption or pudendal stretching.
However, the association of rectal prolapse with chronic constipation is less well understood. A history of constipation is found in 25% to 50% of patients with rectal prolapse.1,2
The clinical assessment of a patient with rectal prolapse often includes the reproduction of the prolapse; thus, the patient may need to strain in the sitting position (toilet) in order to evaluate the extent of the prolapse. The use of enemas or suppositories (especially in children) may induce straining, facilitating the evaluation and extent of the prolapse. Full-thickness rectal prolapse presents with concentric rectal folds and double rectal wall on palpation, whereas mucosal prolapse is visualized as radial folds that rarely protrude greater than 5 cm.
Digital rectal examination often reveals weakened anal sphincters and may not always be required. However, colonoscopy or barium enema should be performed to exclude associated lesions such as tumors and rectal ulcer. Biopsies may also be obtained to exclude colitis cystica profunda or solitary rectal ulcer.
More than 100 procedures have been described for the management of rectal prolapse. We will describe the most frequently performed operations and their outcomes. Basically, operations for rectal prolapse are divided into perineal and abdominal approaches.
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