RECTAL PROLAPSE
From website http://www.uptodate.com
Overview of rectal procidentia (rectal prolapse)
Authors
Madhulika G Varma, MD
Scott R Steele, MD, FACS, FASCRS
Section Editor
Martin Weiser, MD
Deputy Editor
Rosemary B Duda, MD, MPH, FACS
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Apr 2012. | This topic last updated: Apr 5, 2012.
INTRODUCTION — Rectal procidentia, also called rectal prolapse, is a pelvic floor disorder that typically occurs in elderly women, but can occur in men and women of all ages [1,2]. Rectal prolapse results in local symptoms (eg, pain, bleeding, and seepage), bowel dysfunction (eg, constipation, incontinence), and a diminished and disabled quality of life.
An occult rectal prolapse involves intussusception, a “telescoping” of the bowel on itself internally, without protruding through the anal verge and is not a true rectal prolapse [1]. An occult prolapse (ie, intussusception) does not always lead to full thickness rectal prolapse, although patients may experience similar symptoms (eg, obstructed defecation, seepage) [5-7]. (See 'Clinical features' below.)
PELVIC FLOOR ANATOMY — The pelvic floor, also called the pelvic diaphragm, includes muscles (eg, levator ani, coccygeus) and fascia that support the pelvic organs of the lower abdominal cavity (eg, rectum, bladder, uterus) (figure 1 and figure 2). The pelvic floor separates the true pelvis from the perineum. The linked figures illustrate the pelvic anatomy for men (figure 3 and figure 4 and figure 5) and women (figure 6 and figure 7). The female pelvic anatomy is reviewed elsewhere.
DEFINITION — A complete rectal prolapse is the protrusion of all layers of the rectum through the anus, manifesting as concentric rings of rectal mucosa (picture 1). No standard method of classification has been widely accepted [3]. Complete rectal procidentia is a circumferential full thickness rectal wall prolapse beyond the anal canal [8,9]. Partial procidentia involves prolapse of the mucosa only.
EPIDEMIOLOGY AND RISK FACTORS — Rectal procidentia is uncommon, with an incidence between 0.25 to 0.42 percent in the adult population [2,10], and the prevalence is estimated at 1 percent in adults over age 65 years [3,10].
Factors that increase the risk of rectal procidentia include [11-13]:
• Age over 40 years
• Female gender
• Multiparity
• Vaginal delivery
• Prior pelvic surgery
• Chronic straining
• Chronic diarrhea
• Chronic constipation
• Cystic fibrosis
• Dementia
• Stroke
• Pelvic floor dysfunction (eg, paradoxical puborectalis contraction, nonrelaxing puborectalis muscle, abnormal perineal descent)
• Pelvic floor anatomic defects (eg, rectocele, cystocele, enterocele)
CLINICAL FEATURES
Patient presentation — Patients with rectal procidentia present with symptoms that include abdominal discomfort, incomplete bowel evacuation, and mucus and/or stool discharge associated with altered bowel habits, and a mass that has prolapsed through the anus [14,15]. Straining to initiate or complete defecation, incomplete evacuation, and a history of digital maneuvers to aid with defecation can occur as the prolapse progresses. Pain is not a typical presenting feature and suggests another diagnosis. (See 'Differential diagnosis' below and "An overview of the epidemiology, risk factors, clinical manifestations, and management of pelvic organ prolapse in women", section on 'Defecatory symptoms'.)
Physical examination — The diagnosis of rectal procidentia is typically made by the clinical evaluation. The most common sign is a full-thickness protrusion of the rectum, which may be intermittent [14,15]. The prolapse may be best identified with the patient in the squatting position or even sitting on the commode. A mirror can be used to assist in visualization of the perineum, or an enema may be required to facilitate prolapse occurrence. The concentric rings of the rectum protruding through the anus are the hallmark of rectal prolapse.
The digital rectal examination may detect anal sphincter weakness, attenuated sphincter tone, mass, and/or concomitant pelvic floor pathology (eg, rectocele, cystocele or uterine prolapse). The patient should be asked to tighten the anal sphincter as well as “bear down” as a simulation of defecation in order to assess proper contraction and relaxation of the pelvic floor muscles.
The perineum must be examined clinically. Strong consideration should be given to a radiographic evaluation, as patients with procidentia have an approximately 15 to 30 percent risk of concomitant pelvic floor disorder (eg, abnormal rectal evacuation, dyssynergia) [1,16-21]. (See 'Radiographic studies' below.) Pelvic floor abnormalities are discussed separately. (See "An overview of the epidemiology, risk factors, clinical manifestations, and management of pelvic organ prolapse in women" and "Pelvic organ prolapse in women: Diagnostic evaluation".)
DIAGNOSIS — The diagnosis of rectal procidentia is based on the observation of rectal protrusion on physical examination. (See 'Physical examination' above.)
A thorough review of bowel habits is essential, since as many as 75 percent of patients experience fecal incontinence, while constipation is reported in 15 to 65 percent of patients with rectal procidentia [14,15,22,23]. Additionally, a detailed review of diet, fiber intake, fluid intake, and use of both prescription and over-the-counter medications can often identify common causes of constipation.
DIFFERENTIAL DIAGNOSIS — A true rectal prolapse must be differentiated from several other common rectal and anal lesions, including [1]:
• Prolapsed internal hemorrhoids (picture 2). Internal hemorrhoids are swollen and/or inflamed veins present in the left lateral, right posterior, and right anterior walls of the anal canal. Grade IV hemorrhoids are prolapsed and cannot be reduced. The clinical features that distinguish rectal procidentia from prolapsed internal hemorrhoids include the presence of circumferential rings of mucosa (stacked coins) and a full-thickness protrusion with rectal prolapse (picture 1). (See "Overview of hemorrhoids" and "Treatment of hemorrhoids", section on 'Classification of internal hemorrhoids'.)
• Rectal mucosal prolapse (occult). An occult rectal prolapse involves intussusception, a “telescoping” of the bowel on itself internally, without protruding through the anal verge and is not a true rectal prolapse.
• Solitary rectal ulcer. This is an uncommon rectal disorder characterized by one or more mucosal ulcers or a polyp-like mass in the rectum. Patients present with bleeding, passage of mucus, straining during defecation, and a sense of incomplete evacuation. (See "Solitary rectal ulcer syndrome".)
POSTDIAGNOSTIC EVALUATIONS — Complex pelvic floor abnormalities, such as cystocele, vaginal vault prolapse, and enterocele, are frequently associated with rectal procidentia in women. Identification of additional abnormalities alters the surgical approach from procedures that address only the rectal procidentia to complex pelvic floor repairs. Pelvic organ prolapse and repair procedures in women are reviewed separately. (See "An overview of the epidemiology, risk factors, clinical manifestations, and management of pelvic organ prolapse in women".)
Radiographic studies — Complex pelvic floor abnormalities are assessed by dynamic pelvic MRI and cystocolpoproctography [24]. In patients for whom the prolapse cannot be reproduced on physical examination, or when symptoms are present suggestive of additional pelvic floor disorders, functional imaging is useful [20,21,25]. Defecography, either via traditional fluoroscopy or dynamic MRI, can reveal defects associated with rectal prolapse in up to 80 percent of patients with obstructive defecation symptoms [13].
Pelvic physiology studies — Anorectal physiology studies including manometry, electromyography (EMG), and pudendal nerve terminal motor latency (PNTML) testing have been commonly used in patients with fecal incontinence secondary to obstetrical injuries, although their use in patients with procidentia with incontinence has been less extensively studied. Evaluation of fecal incontinence and pelvic organ prolapse is discussed separately. (See "Fecal incontinence in adults", section on 'Diagnostic procedures' and "Pelvic organ prolapse in women: Diagnostic evaluation", section on 'Neuromuscular examination'.)
Anal manometry serves as a useful baseline assessment of sphincter function, as the internal anal sphincter muscle weakens from chronic dilation and can demonstrate low resting pressures. These findings may predict continence following repair and the potential need for postoperative biofeedback, though the studies rarely change the operative approach [26-28].
While the sphincter function can recover after treatment of prolapse with restoration of manometric pressures, these results do not correlate well with actual functional changes [29]. Regardless of manometry or ultrasound findings that demonstrate sphincter defects, most patients are treated for the prolapse and followed postoperatively to evaluate functional outcome and the need for any further treatment if fecal incontinence persists. Treatment of fecal incontinence is discussed elsewhere. (See "Fecal incontinence in adults", section on 'Treatment'.)
Pudendal nerve terminal motor latency (PNTML) involves stimulation of the pudendal nerves, generally using a specialized Saint Mark’s glove, at the level of the ischial spines. This stimulation evokes contraction of the external sphincter muscle, and allows individual nerve measurement (normal latency 2.0 + 0.2 msec). While there are some data to suggest that prolonged PNTML preoperatively is associated with worse postoperative continence, most authors have failed to demonstrate an association of PNTML or manometry with postoperative functional outcome via either perineal or abdominal approaches [24,25]. These studies are routinely done at baseline so that preoperative counseling can be provided to patients regarding potential persistent bowel dysfunction.
Colonoscopy — Colonoscopy should be up to date on all patients age 50 years or older, and should be performed on a selective basis for younger patients or those with new symptoms since their last colonoscopy. Very rarely does colonoscopy provide information that may lead to a change in management directly related to a rectal prolapse. However, other pathology (eg, malignancy) may be detected and warrant specific treatment. (See "Screening for colorectal cancer: Strategies in patients at average risk", section on 'Average risk screening'.)
Colonic transit study — A colonic transit study is performed for operative candidates that have a severe or life-long history of constipation to determine if a sigmoid colectomy is indicated to treat the rectal prolapse. (See 'Indications for surgical management' below and "Etiology and evaluation of chronic constipation in adults", section on 'Colon transit studies'.)
MEDICAL MANAGEMENT — Medical management is offered to minimize symptoms prior to a surgical repair, for those with comorbid illnesses that preclude a surgical repair, and for those who refuse a surgical repair. Medical management strategies are determined by the patient’s symptoms, degree of prolapse, and the magnitude of the adverse effect on the patient’s quality of life.
Initial medical management for all patients includes ensuring adequate fluid and fiber intake. High fiber foods, fiber supplement (total 25 to 30 grams per day), and 1 to 2 liters per day of water and other fluids are used to regulate bowel movements and attempt to control seepage and/or constipation [30]. Enemas and suppositories may be required for patients with severe constipation and difficulty evacuating the colon. (See "Management of chronic constipation in adults".)
Patients with concomitant nonrelaxing or paradoxical puborectalis often benefit from pelvic floor exercises and biofeedback, with subjective improvement in 40 to 80 percent of patients [31,32]. Patients are instructed to perform pelvic floor muscle exercises (such as Kegel-type exercises for both men and women). Improvement is assessed using perianal or transanal EMG, ultrasound or manometric monitoring. (See "Treatment of urinary incontinence", section on 'Pelvic muscle exercises'.)
Although limited data are available on biofeedback for rectal prolapse specifically, based on retrospective studies, success rates of biofeedback for patients with fecal incontinence or obstructed defecation range between 30 and 90 percent when a full course of therapy is completed [33,34]. The least ideal option includes taping the buttock or placing a wadded up pad against the perineum to reduce or prevent protrusion. This is reserved for very elderly, bedbound, or debilitated patients who cannot tolerate any operative procedure. This is a palliative measure only for symptoms and does not treat the prolapse.
INDICATIONS FOR SURGICAL MANAGEMENT - Rectal procidentia is typically managed surgically for patients who can tolerate an operative procedure. The primary indications for repair of rectal procidentia include the sensation of a mass from the prolapsed bowel, fecal incontinence, and/or constipation. Although not routinely performed, symptomatic patients with an internal or hidden intussusception with obstructive defecation symptoms may benefit from a stapled transanal rectal resection (STARR procedure) [35]. NO WAY
The presence of rectal prolapse is an indication for surgical repair because of the eventual progression of symptoms, weakening of the sphincter complex, and risk of incarceration, although the optimal surgical approach has not been elucidated [4]. In general, patients with procidentia should undergo a surgical consultation to determine operative eligibility.
Surgical management of rectal procidentia and the outcomes are discussed separately.
SUMMARY AND RECOMMENDATIONS — Rectal procidentia (rectal prolapse), and intussusception (occult rectal prolapse) are pelvic floor disorders that typically occur in elderly women.
• The symptoms of rectal procidentia include a history of abdominal discomfort, incomplete bowel evacuation, rectal mass, and mucus and/or stool discharge associated with altered bowel habits. The most common sign is a full-thickness protrusion of the rectum though the anus, which may be intermittent (See 'Clinical features' above.)
• Diagnostic evaluations to detect associated pelvic floor disorders include physical examination, colonoscopy as per screening guidelines, defecography, and anorectal physiology studies. (See 'Postdiagnostic evaluations' above and "Screening for colorectal cancer: Strategies in patients at average risk", section on 'Average risk screening'.)
• Surgical repair is the mainstay of therapy; however, for patients with comorbid illnesses that preclude an operation, we suggest medical management to minimize symptoms of constipation that includes fluid and fiber intake maximized, and pelvic floor exercises and biofeedback (Grade 2C). (See 'Medical management' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Felt-Bersma RJ, Tiersma ES, Stella MT, Cuesta MA. Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele. Gastroenterol Clin North Am 2008; 37:645.
2. Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg 2005; 94:207.
3. Stein EA, Stein DE. Rectal procidentia: diagnosis and management. Gastrointest Endosc Clin N Am 2006; 16:189.
4. Tou S, Brown SR, Malik AI, Nelson RL. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev 2008; :CD001758.
5. Felt-Bersma RJ, Cuesta MA. Rectal prolapse, rectal intussusception, rectocele
6. Mellgren A, Schultz I, Johansson C, Dolk A. Internal rectal intussusception seldom develops into total rectal prolapse. Dis Colon Rectum 1997; 40:817.
7. Wijffels NA, Collinson R, Cunningham C, Lindsey I. What is the natural history of internal rectal prolapse? Colorectal Dis 2010; 12:822.
8. Lowry AC, Simmang CL, Boulos P, et al. Consensus statement of definitions for anorectal physiology and rectal cancer Report of the Tripartite Consensus. 1999. fascrs.org/physicians/practice_parameters/definition_consesus_statement_anorectal_physiology_rectal_cancer/.
9. Kumar AS. Prolapse: What is that hanging outside of me? whcenter.org/documents/cme/Kumar_Prolapse_WhatIsThat.pdf (Accessed on January 04, 2012).
10. Patel SM, Lembo AJ. Constipation: Rectal prolapse and solitary rectal ulcer syndrome. In: Sleisenger and Fordtan's Gastrointestinal and Liver Disease, 8th, Feldman M. (Ed), Saunders Elsevier, Philadelphia 2006. Vol 1, p.230.
11. Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg 2005; 140:63.
12. Marceau C, Parc Y, Debroux E, et al. Complete rectal prolapse in young patients: psychiatric disease a risk factor of poor outcome. Colorectal Dis 2005; 7:360.
13. Mellgren A, Bremmer S, Johansson C, et al. Defecography. Results of investigations in 2,816 patients. Dis Colon Rectum 1994; 37:1133.
14. Hiltunen KM, Matikainen M, Auvinen O, Hietanen P. Clinical and manometric evaluation of anal sphincter function in patients with rectal prolapse. Am J Surg 1986; 151:489.
15. Keighley MR, Fielding JW, Alexander-Williams J. Results of Marlex mesh abdominal rectopexy for rectal prolapse in 100 consecutive patients. Br J Surg 1983; 70:229.
16. Moschvowitz AV. The pathogenesis, anatomy and cure of prolapse of the rectum. Surg Gynecol Obstet 1912; 15:7.
17. Broden B, Snellman B. Procidentia of the rectum: studies with cineradiography.
18. Kuijpers HC. Treatment of complete rectal prolapse: to narrow, to wrap, to suspend,
19. Nicholls RJ. Rectal prolapse and the solitary ulcer syndrome. Ann Ital Chir 1994;
20. Okamoto N, Maeda K, Kato R, et al. Dynamic pelvic three-dimensional computed tomography for investigation of pelvic abnormalities in patients with rectocele and rectal prolapse. J Gastroenterol 2006; 41:802.
21. Hecht EM, Lee VS, Tanpitukpongse TP, et al. MRI of pelvic floor dysfunction: dynamic true fast imaging with steady-state precession versus HASTE. AJR Am J Roentgenol 2008; 191:352.
22. Madoff RD, Mellgren A. One hundred years of rectal prolapse surgery. Dis Colon Rectum 1999; 42:441.
23. Kim DS, Tsang CB, Wong WD, et al. Complete rectal prolapse: evolution of management and results. Dis Colon Rectum 1999; 42:460.
24. Kaufman HS, Buller JL, Thompson JR, et al. Dynamic pelvic magnetic resonance imaging and cystocolpoproctography alter surgical management of pelvic floor disorders. Dis Colon Rectum 2001; 44:1575.
25. Maglinte DD, Bartram CI, Hale DA, et al. Functional imaging of the pelvic floor. Radiology 2011; 258:23.
26. Glasgow SC, Birnbaum EH, Kodner IJ, et al. Preoperative anal manometry predicts continence after perineal proctectomy for rectal prolapse. Dis Colon Rectum 2006; 49:1052.
27. Williams JG, Wong WD, Jensen L, et al. Incontinence and rectal prolapse: a prospective manometric study. Dis Colon Rectum 1991; 34:209.
28. Woods R, Voyvodic F, Schloithe AC, et al. Anal sphincter tears in patients with rectal prolapse and faecal incontinence. Colorectal Dis 2003; 5:544.
29. Ris F, Colin JF, Chilcott M, et al. Altemeier's procedure for rectal prolapse: analysis of long-term outcome in 60 patients. Colorectal Dis 2011.
30. Ternent CA, Bastawrous AL, Morin NA, et al. Practice parameters for the evaluation and management of constipation. Dis Colon Rectum 2007; 50:2013.
31. Rao SS. The technical aspects of biofeedback therapy for defecation disorders. Gastroenterologist 1998; 6:96.
32. Hart SL, Lee JW, Berian J, et al. A randomized controlled trial of anorectal biofeedback for constipation. Int J Colorectal Dis 2012; 27:459.
33. Jorge JM, Habr-Gama A, Wexner SD. Biofeedback therapy in the colon and rectal practice. Appl Psychophysiol Biofeedback 2003; 28:47.
34. Khaikin M, Wexner SD. Treatment strategies in obstructed defecation and fecal incontinence. World J Gastroenterol 2006; 12:3168.
35. Patel CB, Ragupathi M, Bhoot NH, et al. Patient satisfaction and symptomatic outcomes following stapled transanal rectal resection for obstructed defecation syndrome. J Surg Res 2011; 165:e15.