Anorectal: Rectal Prolapse (Procidentia)

Rectal Prolapse (Procidentia)

Basics

  • Full Thickness Intussusception of the Rectal Wall Through the Anus
  • 20% Have Concurrent Cystocele or Uterine Prolapse

Risk Factors

  • Female
  • Elderly
  • Prior Pregnancy
  • Chronic Strain
  • Chronic Constipation/Diarrhea
  • Psychiatric Disorders
  • Redundant Sigmoid

Symptoms

  • Physical Prolapse
  • Rectal Pain/Pressure
  • Blood/Mucous Drainage
  • Fecal Incontinence
  • Constipation

Workup

  • Diagnosis: Physical Exam
    • Concentric Circular Folds/Rings (Differentiates from Hemorrhoids)
  • Preoperative Workup:
    • Colonoscopy (Rule Out CA)
    • Defecography (Evaluate Anatomy/Function)

Treatment

  • Acute Prolapse: Reduce
    • Adjuncts:
      • Table Sugar (Absorbs Excess Water & Reduce Edema)
      • Perianal Muscle Paralysis
      • General Anesthesia (Relaxation)
    • If Strangulated: Emergent Surgery
  • Chronic Prolapse:
    • Peds: Medical Management (Fiber)
    • Adults: Surgery if Able
      • Medical Management if Unfit for Surgery

Surgical Approach

  • Healthy/Low-Risk: Transabdominal Procedure (LAR & Colonopexy)
  • Frail/High-Risk: Perineal Procedure
    • *See Anorectal: Rectal Prolapse Procedures
    • Higher Recurrence but Lower Morbidity
    • Procedure:
      • Short Segment (< 5 cm): Delorme’s Procedure
      • Long Segment (> 5 cm): Altemeier’s Procedure Mn
    • If Recurs: Can Repeat Perineal Procedure (Must Include Prior Anastomosis in Resected Specimen)

Rectal Prolapse 1

Delorme Procedure 2

Altemeier Procedure 3

Mnemonics

Surgical Repair for Frail/High-Risk Patients

  • Alzheimer’s in Elderly/Frail: Altemeier in Frail

References

  1. Gunther KH, Spessart KM, Main LA. Wikimedia Commons. (License: CC BY-3.0)
  2. Fazeli MS, Kazemeini AR, Keshvari A, Keramati MR. Delorme’s Procedure: An Effective Treatment for a Full-Thickness Rectal Prolapse in Young Patients. Ann Coloproctol. 2013 Apr;29(2):60-5. (License: CC BY-NC-3.0)
  3. Bayar R, Djebbi A, Mzoughi Z, Talbi G, Gharbi L, Arfa N, Mestiri H, Khalfallah MT. Prolapsus rectal étranglé de l’adulte jeune: à propos d’un cas et revue de la littérature [Strangled rectal prolapse in young adults: about a case and review of the literature]. Pan Afr Med J. 2016 Oct 3;25:60. (License: CC BY-2.0)