Generality
The rectal prolapse consists in the escape, through the anal canal, of a portion of the rectum. The precise causes are not yet known. However, it is suspected that at the origin there may be a general weakening of the pelvic muscles.
The symptoms are different and their appearance depends on the degree of rectal slipping. A serious prolapse of the rectum affects, to a considerable extent, the quality of life of those suffering from it.
The possibilities of treatment are numerous. There are both conservative and surgical treatments. The choice of the therapeutic path and its success are based on several factors, such as: severity of rectal prolapse, associated diseases, age and general state of health of the patient.
Short anatomical reference: the pelvic floor and the rectum
To understand what happens in the rectal prolapse, it is appropriate to make a brief anatomical review, concerning the pelvic floor and the rectum.
PELVIC FLOORING
The pelvic floor is the set of muscles, ligaments and connective tissue, located at the base of the abdominal cavity, in the so-called pelvic area . These structures cover a fundamental and indispensable function: they serve to support and maintain in their positions the urethra, the bladder, the rectum and, in women, the uterus.
THE RIGHT INTESTINE
The rectum (or rectal canal ) is the last portion of the intestinal canal. Approximately 13-15 cm long, it is placed between the sigma tract of the intestine and the anus (or anal canal). The walls of the rectal canal consist of three different layers of tissue:
- The mucosa, in direct contact with the lumen of the rectal canal
- A layer of muscle tissue
- A layer (outside) of adipose tissue, the mesorectum
The rectum is the stool collection point, before their evacuation; evacuation, which is controlled by the contraction of the muscles and ligaments of the pelvic floor.
What is rectal prolapse
The rectal prolapse is the sliding of the rectum downward, with the escape of its inner walls, or only of its mucosa, through the anus.
CLASSIFICATION OF RECTAL PROLASS
Sometimes, the rectal prolapse determines the protrusion of the walls, which constitute the rectal canal; in other cases, on the other hand, it causes the mucous membrane to escape or an internal failure, not visible on the outside.
In light of this, the following types of rectal prolapse can be distinguished:
- Complete rectal prolapse . Characteristics: the walls, which make up the rectal canal, come out completely from the anus.
- Rectal prolapse of the rectal mucosa (or partial prolapse ). Characteristics: the mucosa is the only part of the rectum that protrudes from the anus.
- Internal rectal intussusception . Characteristics: the rectum has slipped on itself, without, however, protruding from the anal canal.
This classification is the best known. However, it is fair to remember that each type of rectal prolapse can be subdivided into further subtypes, different for some clinical characteristics. In order not to complicate this text, we have chosen to report only the three main categories.
Epidemiology
The exact incidence of rectal prolapse is unknown. Certainly, the established cases are less than the real ones.
The subjects most affected are adults, especially those of advanced age (over fifty) and female. However, rectal prolapse can also occur in some young individuals (rare) and in children aged between one and three years.
Causes of rectal prolapse
The exact cause of rectal prolapse is not yet known. The most accepted hypothesis is that there is a weakening of the structures (muscles, ligaments and connective tissue) of the pelvic floor. Below we address the possible causes of this weakening.
RISK FACTORS
It appears that several risk factors are involved, which stretch and traumatize the muscles, ligaments and connective tissue of the pelvic area.
- Increased abdominal pressure due to:
- constipation
- diarrhea
- BPH
- pregnancy
- chronic bronchitis (e.g., chronic obstructive pulmonary disease and cystic fibrosis)
- Previous surgery on the pelvic organs
- Parasitic infections (for example, amoebiasis and schistosomiasis)
- Neurological diseases, such as:
- Spinal tumors
- Cauda equina syndrome
- Slipped disc
- Multiple sclerosis
- Lumbar area injury
It is very unlikely that the occurrence of only one of the aforementioned circumstances could result in a rectal prolapse. For example, a birth hardly causes a rectal prolapse.
However, the chances increase, in a remarkable way, when the single traumatic episodes are repeated, adding together one another (for example, more pregnancies, diarrhea or chronic constipation etc). This also explains why the elderly are the most affected subjects.
THE RISK FACTORS IN THE CHILD
It has been observed that rectal prolapse is linked to certain diseases in children. The associations concern Ehlers-Danlos syndrome, Hirschsprung's disease, congenital megacolon, malnutrition and rectal polyps.
Symptoms, signs and complications
The symptoms and signs of rectal prolapse depend on the severity and degree of progression of the prolapse itself. In fact, the more serious it is, the longer the symptoms are clear and obvious.
The patient may complain:
- The escape of a mass of tissue, the rectum, from the anus
- Ache
- Constipation and sense of failed intestinal emptying, after going to the body
- Fecal incontinence
- Mucus and blood from the anus
- Presence of mucosa rings around the anus
- Rectal ulcers
- A decreased tone (hypotonia) of the anal sphincter
THE MOST IMPORTANT SYMPTOM
The most characteristic symptom of rectal prolapse is the slipping of the rectum and its exit from the anus. This protrusion, at the beginning of the disturbance, appears only on certain occasions; while, it becomes a chronic presence in the most advanced stages of the disease.
Initial stage: rectal prolapse occurs when the patient goes to the body; as soon as the patient rises from the toilet, the rectum retracts and assumes the normal position.
Intermediate stage: the prolapse occurs more and more often, even after a trivial sneeze or a cough.
Final stage: the prolapse of the rectum becomes a constant condition, which affects the patient's standard of living. In fact, it can occur even without a specific reason (for example, during a walk). Those who suffer from it are forced, from time to time, to bring the rectum back into place, by digital pressure.
INCONTINENCE, BLOOD AND HYGIENE
Rectal prolapse is often the cause of fecal incontinence, bleeding and loss of mucus from the anus. Faced with these symptoms, the patient has difficulty managing his personal hygiene.
RECTAL ULCERS
Rectal ulcers are another classic symptom that affects the prolapsed area of the rectum (that is, an exit from the anus).
THE CLASSIC CLINICAL SIGN
Typical sign of rectal prolapse, which helps the doctor in the diagnosis, is the appearance of some rings of red mucous around the anus.
COMPLICATIONS
Complications of rectal prolapse are rare, but very serious. It is possible that part of the rectum that has escaped remains confined to the outside of the anus and excluded from blood circulation. As a result, this portion undergoes necrosis. This is a very painful circumstance, which requires urgent and careful therapeutic treatment.
ASSOCIATED DISEASES
The main associated diseases are cystocele, rectocele and uterine prolapse . These pathologies exclusively affect the female sex and share, with the rectal prolapse, the same triggering cause: the general weakening of the pelvic floor.
Diagnosis
The diagnosis of rectal prolapse may require several tests, as some symptoms resemble those of other diseases (for example, hemorrhoids). Therefore, the diagnostic path is also based on the differential diagnosis.
The doctor begins with a physical examination of the rectum ; after which he can rely on:
- proctoscopy
- Sigmoidoscopy
- Colonoscopy
- defecography
- Anorectal manometry
- Microscopic control of faeces and coproculture
PHYSICAL EXAMINATION OF THE RIGHT
The physical examination of the rectum provides numerous information, relating, for example, to the type of rectal prolapse or to the presence (or not) of blood, mucus, reddened mucosa and rectal ulcers.
The picture is completed with a pelvic exam (for women) and a survey related to the patient's medical history (medical history).
With a pelvic exam, it is ascertained whether a patient suffers from one of the diseases associated with rectal prolapse (uterine prolapse, cystocele or rectocele). The anamnesis, on the other hand, makes it possible to clarify whether, behind the sufferer, there is a history of constipation or fecal incontinence.
PROCTOSCOPY, SIGMOIDOSCOPIA AND COLONSCOPIA
Proctoscopy uses a metal tube ( proctoscope ), which, inserted into the rectal cavity, allows the analysis of its walls and mucosa. Before use, the patient must undergo an enema to clean the rectal walls. It is a very useful test, because it investigates not only the rectal prolapse, but also the presence of polyps and hemorrhoids .
Through the sigmoidoscopy, we observe the state of health of the rectal mucosa and the possible presence of rectal ulcers. To do this, a flexible probe, fitted with a camera, is inserted into the anal canal. It is also possible to take a tissue sample (biopsy), to be analyzed later in the laboratory.
Colonoscopy allows you to see, through the colonoscope, if there are any abnormal tissue or tumor lesions inside the colon (large intestine).
Exam | MICROdentistry |
proctoscopy | Requires the use of an enema; the insertion of the proctoscope can be annoying. In these cases, local anesthesia is used. |
Sigmoidoscopy | Inserting the probe can create discomfort. In these cases, tranquilizers are recommended. The patient may experience air movements (meteorism) or a feeling of pressure. |
Colonoscopy | Inserting the colonoscope can create discomfort. For this, the patient is given tranquilizers and painkillers. The risks of an injury due to the instrument are very low. |
defecography
Defecography is a radiographic examination, performed using a fluoroscope and put into practice when you come across gastrointestinal disorders.
To perform defecography, the patient is seated on a special toilet, connected to the radiographic instrument. During the examination, intestinal contractions, evacuation and the phase of emptying the rectum are observed on a monitor. The images show the positions of the anorectal tract and the type of rectal prolapse. In fact, in addition to distinguishing the internal rectal intussusception, the difference between a rectal prolapse of the mucosa and a mild form of complete rectal prolapse also emerges.
Defecography is an exhaustive but also invasive examination.
ANO-RECTAL MANOMETRY
Ano-rectal manometry is used to measure the contractility of the sphincter muscles of the anal and rectal canal. This is a very rare examination.
Therapy
Rectal prolapse therapy involves two types of treatment: conservative and surgical . The choice of one or the other depends on the type of rectal prolapse and its degree of severity.
CONSERVATIVE TREATMENT
Conservative treatment involves countermeasures, useful when the rectal prolapse is in its infancy. They are remedies aimed at mitigating the symptoms or causes of the prolapse itself, such as constipation or diarrhea.
The conservative approach varies depending on whether the patient is a child or an adult.
In children: the use of a lubricant allows the prolapsed rectum to be placed in a gentle way. To cope with constipation, on the other hand, a light laxative can be used and a diet rich in fiber and lots of water is recommended. Finally, another remedy involves the use of a sclerosing solution to stabilize the rectum.
In adults: also in this case, a diet rich in fiber is recommended, drink plenty of water and take laxatives. Furthermore, to some patients, a rubber ring is applied in the anal position. The latter is usually a temporary measure, pending surgery.
SURGICAL TREATMENT
Surgical treatment involves two possible operational approaches:
- Abdominal approach
- Perineal approach
For each approach, there are a large number of different intervention methods. The choice of the most appropriate method is made by the surgeon, based on the characteristics of the patient (age, sex, symptoms etc.) and the type of rectal prolapse.
Abdominal approach . Most of the procedures involve cutting ( resection ) of the prolapsed rectum tract, followed by fixation ( rectopexy ), by suturing, of the remaining rectal cavity. The rectopexy is usually performed at a sacral or pre-sacral level.
The abdominal approach is somewhat invasive. This is why it is usually performed on young adults and procedures are being perfected for resection and rectopexy by minimally invasive laparoscopy.
The main abdominal procedures:
- Front resection
- Plexus with Marlex prosthesis (or Ripstein procedure)
- Rectopexy with suture
- Repressive resected (or Frykman Goldberg procedure)
Perineal approach . Perineal procedures apply to older patients or when abdominal surgery may be risky. The perineal approach results in fewer complications and less pain. It can also be performed under local anesthesia.
The most used method is the so-called Delorme procedure . However, anal cerclage (or Thiersch thread ) and Altemeier perineal rectosigmoidectomy are also adopted .
SURGICAL TREATMENT IN CHILDREN
Surgery in children under the age of 4 becomes necessary when conservative treatments, lasting for at least a year, have not provided any benefit. Therefore, if the small patient still complains of pain, continuous rectal prolapse, ulcers and bleeding, the operation must be taken seriously.
As for adults, the operative approach can be abdominal or perineal and the choice of the most appropriate procedure depends on the case under consideration.
POST-OPERATIVE COMPLICATIONS
Like any surgical procedure, rectal prolapse operations are not without complications. Below is a table with the main post-operative complications.
Post-operative complications:
- Bleeding and dehiscence (ie reopening of the sutured wound)
- Ulcers of the rectal mucosa
- Necrosis of the rectal walls
- New rectal prolapse (15% of cases)
Prognosis and prevention
The prognosis of rectal prolapse depends on several factors and therefore deserves evaluations on a case by case basis.
In older patients, a rectal prolapse, if untreated, greatly affects the quality of life. However, the available treatments do not always ensure a positive prognosis. In fact, conservative treatments have a temporary effect and the success of the surgery depends on numerous factors, such as: age and general health of the patient, severity of rectal prolapse and associated diseases.
The prognosis is better for children. For these, the resolution of rectal prolapse can be spontaneous or need only conservative treatments (90% of cases).
