Rectal Prolapse

Description

Several types

• Partial prolapse
  • Involves only mucosa
  • Frequently follows operative anal procedures (radial rectal folds prolapsed through anus)
• Complete prolapse
  • Involves the entire rectal wall (procidentia)
  • Due to pelvic floor weakness, neuropathy, colonic motility disorder
• Grades
  • Grade 1: occult prolapse (internal rectal prolapse or rectal intussusception)
  • Grade 2: prolapse but not through anus
  • Grade 3: protrusion beyond anus

Epidemiology

Incidence

• Predominant age: <3 years in children, 5th decade in adults
• Predominant sex: female aged 50 years > male in adults; 80–90% of adult patients are female; male = female in children
• 4/1,000 overall; 10/1,000 >65 years of age
• Peak age in 7th decade

Geriatric Considerations
Common problem in the elderly

Pediatric Considerations
Idiopathic type is most common in children.

Etiology and Pathophysiology

The anatomic basis for prolapse is a weak pelvic floor.

• Contributing factors in children:
  • Idiopathic (most common)
  • Abnormal innervation of levator ani complex, puborectalis, anal sphincter, or abnormal anatomic relation of these muscles
• Contributing factors in adults:
  • Diastasis of levator ani
  • Loose endopelvic fascia
  • Sacral nerve root damage (diabetes, neoplasm)
  • Weak anal sphincter (internal or external)
  • Abnormally deep pouch of Douglas
  • Lack of normal mesorectum
  • Lateral ligament weakness
  • Pudendal neuropathy
  • Redundant sigmoid colon
  • Loss of rectal–sacral attachments
  • Chronic constipation and colonic dysmotility (1)[A]

General Prevention

Avoid constipation and diarrhea.

Commonly Associated Conditions

• Cystic fibrosis (CF)
• Myelomeningocele
• Chronic constipation (25–50%) or diarrhea
• Imperforate anus
• Nerve damage (stroke or diabetes)
• Fecal incontinence (50–75%)
• Vaginal vault or uterine prolapse (13–30%)
• Intellectual disability
• Marfan syndrome
• Ehlers-Danlos disease
• Urinary incontinence (found in 25–35% of patients with rectal prolapse)
• Renal calculi (particularly bladder stones)
• Nutritional disorders
• Progressive systemic sclerosis
• Chronic constipation or diarrhea