Rectal Prolapse By: John N. Afthinos, M.D.

Definition Descent of mucosa or the entire thickness of the rectum through the anus

Etiology Poor bowel habits, especially constipation Female gender Nulliparity Redundant rectosigmoid Deep pouch of Douglas

Etiology Patulous anus Diastasis of levator ani Lack of fixation of rectum to sacrum Intussusception Tumor can be lead point Prior colorectal surgery

Clinical Features Peak at 6th decade of life Most common complaint: protrusion (3/4) Worsens with time because sphincters weakened by dilation Occurs on Valsalva Incontinence and problems with bowel regulation ½ with constipation

Clinical Features Preceive obstruction or incomplete evacuation May need to apply manual pressure to fully defecate Mucous discharge from protrusion Hemorrhage only if massive or irreducible

Differential Diagnosis Large thrombosed hemorrhoids Prolapsing polypoid mass Ectropion—mucosal prolapse Rectocele Enterocele

Evaluation H&P DRE Proctosigmoidoscopy Cinedefecography Examine tone Degree of prolapse Proctosigmoidoscopy Evaluate mucosa and for mass Cinedefecography

Treatment If active prolapse—must reduce Manually Put sugar on it to decrease swelling Manually under anesthesia If irreducible, emergent resection may be needed

Treatment Non-operative Correction of constipation Perineal strengthening exercises Adhesive strapping of buttocks Injection of sclerosing agent

Treatment Operative goals are to accomplish 2 or more of the following: Narrow anal orifice Obliterate Pouch of Douglas Restore pelvic floor Resect redundant bowel Suspend or fix the rectum

Narrowing the Anal Orifice Thiersch Repair Placement of a material around anus, subcutaneously to narrow it Suture material, silastic tubing, mesh, fascia lata, etc Size opening with No. 16 or 18 Hegar dilator Can be done on older, high-risk patients

Narrowing the Orifice Complications: Silastic material may be best Fecal impaction: can be relieved only under anesthesia Wound infection must remove prosthesis Can prolapse post-procedure May be irreducible Silastic material may be best

Obliteration of Pouch of Douglas Serial purse string sutures placed in a cephalad direction into pelvic floor About 1/2 recur when done as a stand alone treatment

Restoration of Pelvic Floor Plication of levators anterior to rectum to strengthen the floor Often falls apart

Bowel Resection Anterior resection Removes redundant bowel Dissect to lateral ligaments of rectum Anastomosis near sacral promontory Rectum can be sutured to sacral periosteum Recurrence rate of about 7-10% Anastomotic leak, incisional hernia, obstruction are complications

Altemeier Procedure Perineal resection of redundant sigmoid Entry into peritoneal cavity and delivery of colon Extra peritoneum resected and reapproximated Modified version incorporated levator plication anterior to rectum

Altemeier Procedure Low anastomotic leak rate Often used for elderly, poor surgical candidates Recurrence rate of about 20%, less if modified version used

Sling Repair/Fixation Ripstein Operation Lower midline incision Mobilization of rectosigmoid down to levators Mesh secured to sacrum, rectum and then sacrum again while rectum under tension

Ripstein Operation Low recurrence rate of ~3 — 8% Complications Wound infection Fecal impaction Rectal stricture