1. Basic Science September 28, 2005
Rectal Prolapse
Basic Science
September 28, 2005

2. Which of the following are risk factors for rectal prolapse?
Chronic constipation
Chronic diarrhea
Mental retardation
Prior history of intussusception
Female sex

3. Which of the following are risk factors for rectal prolapse?
Chronic constipation
True
Chronic diarrhea
Mental retardation
Prior history of intussusception
False- Rectal prolapse is thought of as a type of intussusception- having intussusception at an anatomically distant location doesn’t increase risk, but rectal prolapse does tend to recur and progress.
Female sex
True- but childbearing is only part of the reason- half of patients are men or nulliparous women

4. All of the following are anatomic abnormalities seen in patients with rectal prolapse except:
Deep rectovaginal or rectovesical pouch
Lax pelvic floor musculature
Failure of normal relaxation of the external sphincter
Foreshortened mesorectum
Redundant sigmoids

5. All of the following are anatomic abnormalities seen in patients with rectal prolapse except:
Deep rectovaginal or rectovesical pouch
Lax pelvic floor musculature
Failure of normal relaxation of the external sphincter
Foreshortened mesorectum
Redundant sigmoids

6. Classification of rectal prolapse:
Partial:
Complete:
Grade 1:
Grade 2:
Grade 3:

7. Classification of rectal prolapse:
Partial: prolapse of rectal mucosa only
Complete: prolapse with all layers
Grade 1: occult prolapse
Grade 2: prolapse to but not through anus
Grade 3: any protrusion through anus

8. True or False: Urinary incontinence is associated with prolapse
Colonoscopy is useful for the diagnosis of prolapse
In grade 3 prolapse, rectal prolapse is easily confused with hemorrhoids

9. True or False: Urinary incontinence is associated with prolapse
Colonoscopy is useful for the diagnosis of prolapse
False
In a grade 3 prolapse, rectal prolapse is easily confused with hemorrhoids
False- grade 2 prolapse can be confused with prolapsing hemorrhoids

10. Complications of prolapse include:

11. Complications of prolapse include:
Ulceration
Strangulation
Urinary and fecal incontinence
Spontaneous rupture with evisceration

12. Perineal rectosigmoidectomy is appropriate for:
Younger patients who want to minimize recurrence
Patients with a grade 3 prolapse protruding at least 3 cm
Patients who are poor candidates for trans abdominal surgery

13. Perineal rectosigmoidectomy is appropriate for:
Younger patients who want to minimize recurrence
False- better suited for elderly patients that are poor candidates for abd surgery due to high recurrence rate
Patients with a grade 3 prolapse protruding at least 3 cm
True
Patients who are poor candidates for trans abdominal surgery

14. Are associated with problems with defecation and constipation
Transabdominal approaches to rectal prolapse repair (ie transabdominal rectopexy):
Are associated with problems with defecation and constipation
Have a lower recurrence rate than transperineal approaches
Require resection of the redundant sigmoid

15. Are associated with problems with defecation and constipation
Transabdominal approaches to rectal prolapse repair (ie transabdominal rectopexy):
Are associated with problems with defecation and constipation
true
Have a lower recurrence rate than transperineal approaches
Require resection of the redundant sigmoid
not necessarily

16. Fecal incontinence is corrected by surgical repair of prolapse in:
90% of patients
70%
50%
30%
10%

17. Fecal incontinence is corrected by surgical repair of prolapse in:
90% of patients
70%- return of continence may take as long as 1 year
50%
30%
10%

18. 1) Rectal prolapse-
is due to sliding herniation through pouch of Douglas through pelvic floor fascia into anterior aspect of rectum
Is a full thickness rectal intusseception starting ~3inches above dentate line and extending beyond anal verge
Is six times more common in males than females
Peak incidence in the 7th decade of life
Young male patients tend to have psychiatric disorders

19. 1) Rectal prolapse-
B) Is a full thickness rectal intusseception starting ~3inches above dentate line and extending beyond anal verge
D) Peak incidence in the 7th decade of life
E) Young male patients tend to have psychiatric disorders

20. 2) Chronic or lifelong constipation w/ component of straining has been found to be present in ~what percentage of patients w/ prolapse?
15%
35%
100%
50% 5%

21. 2) Chronic or lifelong constipation w/ component of straining has been found to be present in ~what percentage of patients w/ prolapse?
D) Present in over 50% of patients according to case reviews aimed at elucidating predisposing factors other than the frequently found anatomic characteristics- ex. diasthesis of levator ani; abnormally deep cul-de-sac; redundant sigmoid colon; patulous anal sphincter; loss of rectal sacral attachments

22. 3) Rectal prolapse can be distinguished from prolapsed incarcerated internal hemorroids by the characteristic _______ (invaginated/concentric) folds of rectal prolapse and by the _______ (painful/painless) reduction if not incarcerated.

23. 3) Rectal prolapse can be distinguished from prolapsed incarcerated internal hemorroids by the characteristic concentric folds of rectal prolapse and by the painless reduction if not incarcerated.

24. 4) Two predominant approaches, ________ and _________, are considered in operative repair of rectal prolapse. Generally believed that the _______ approach results in less perioperative morbidity and pain an reduced length of hospital stay.

25. 4) Two predominant approaches, abdominal and perineal, are considered in operative repair of rectal prolapse. Generally believed that the perineal approach results in less perioperative morbidity and pain an reduced length of hospital stay.

26. Most located on posterior aspect of rectum 4-12 cm from anal verge
5) Solitary rectal ulcer syndrome (SRUS)-
Gross pathology always demonstrates the typical crater like ulcer with fibrinous central depression
Typical patient is young and female w/ history of straining and difficult evacuation
Most located on posterior aspect of rectum 4-12 cm from anal verge
Diagnostic evaluation by defecography is radiologic procedure of choice

27. 5) Solitary rectal ulcer syndrome (SRUS)-
C) Typical patient is young and female w/ history of straining and difficult evacuation
D) Diagnostic evaluation by defecography is radiologic procedure of choice
* Always located on anterior aspect of rectum. Gross pathology can range from typical ulcer to polypoid lesion.

28. 6) Rectocele is abnormal sac like projection of anterior rectum that extends from distal rectum to distal anal canal. Usually begins just _____ (above/below) the sphincter complex. Rectal pressures are ______ (higher/lower) than in the vagina. Major symptom of rectocele is ________ ( diarrhea/stool trapping).

29. 6) Rectocele is abnormal sac like projection of anterior rectum that extends from distal rectum to distal anal canal. Usually begins just above the sphincter complex. Rectal pressures are higher than in the vagina. Major symptom of rectocele is stool trapping.

30. 7) It is rare that a rectocele less than ____ is symptomatic.
0.5cm
1cm
2cm
3cm
5cm

31. 7) It is rare that a rectocele less than ____ is symptomatic.
C) 2cm; although small rectoceles are common. Criteria for operative intervention include symptomatic stool trapping requiring digital evacuation or vaginal support and large protruding rectoceles pushing vaginal mucosa past introitus producing dryness, ulceration and discomfort

32. 8) Colonic inertia
A) Estimated that 10% of population suffers from chronic, unremitting functional constipation B) Majority of patients are female w/ mean age older than 50. C) Delay in gastric emptying and small bowel follow through has been noted in these patients implying global motility problem D) Barium enema is useful initial examination

33. 8) Colonic inertia
C) Delay in gastric emptying and small bowel follow through has been noted in these patients implying global motility problem D) Barium enema is useful initial examination
* Estimated that 2% of population suffers from chronic functional constipation. Majority of patients female with mean age younger than 30. Abdominal pain, bloating and nausea usually accompany the constipation.

34. 9) Neurologic constipation
As a group 50% of these patients are male
Responds well to medical management
Commonly presents as slow transit constipation in presence of dilated colon
Includes adult Hirschsprung’s disease, Chagas’ disease and neuronal intestinal dysplasia

35. 9) Neurologic constipation
A) As a group 50% of these patients are male
C) Commonly presents as slow transit constipation in presence of dilated colon
D) Includes adult Hirschsprung’s disease, Chagas’ disease and neuronal intestinal dysplasia

36. 10) Laparoscopic colon resection-
Benefits similar to those mentioned for lap cholecystectomy- shorter hospital stay; less post op pain; earlier return of bowel function
Most colon and rectal diseases are amenable to lap approach except can not do for sigmoid resection for diverticulitis
Port site recurrence appears equivalent to recurrence of cancer in incision of patients treated by conventional operation
Post operative recovery of lap colectomy is prolonged on average if hand assisted techniques are used or if anastamosis has to be performed extracorporeally

37. 10) Laparoscopic colon resection-
A) Benefits similar to those mentioned for lap cholecystectomy- shorter hospital stay; less post op pain; earlier return of bowel function
C) Port site recurrence appears equivalent to recurrence of cancer in incision of patients treated by conventional operation according to Sabiston