A complete presentation on rectal prolapse

1. RECTAL PROLAPSE
MODERATOR
DR.NILUTPAL GOGOI
ASSISTANT PROFESSOR
DEPARTMENT OF GENERAL SURGERY,GMCH
PRESENTED BY
DR.ISHANDEEP BORAH
3RD YR PGT,GMCH
DEPARTMENT OF GENERAL SURGERY

2. Anatomy
• The rectum begins at the rectosigmoid junction and ends at the level of the anus.
• It is 15-20 cm in lenght.
• Rectum is divided into thirds based on its peritoneal relationships:
1) The upper rectum is covered by peritoneum anteriorly and laterally and it
extends approximately 10 cm above the dentate line.
2) The middle third is covered by peritoneum only anteriorly and extends from 5 to 10cm above the
dentate line.
3) The lower third of the rectum is totally extraperitoneal, extending from 1 to 5 cm above the
dentate line.

3. • The rectum has three lateral curves or valves of Houston, the proximal and distal valves fold to the
right and the middle to the left.
• Structurally, the rectum lacks taeniae coli, epiploic appendices and haustra.

4. Fascial relationships of the rectum
1) Fascia propria: It is a thin layer of investing fascia which coats the mesorectum posteriorly and lies
against presacral fascia.
2) Presacral fascia: It covers the anterior sacrum and coccyx. Dissection deep to the presacral fascia can
cause severe bleeding from the underlying presacral venous plexus.
3) Rectosacral fascia or Waldeyer fascia: It is a thick condensation of endopelvic fascia connecting the
presacral fascia to the fascia propria at th level of S4.
4) Denonvilliers fascia: It is located anterior to the rectum, is a membranous layer that is an extension of
the inferior peritoneal reflection and extends to the perineal body. This fascial layer separates the rectum
from the anterior structures.

6. Blood Supply
The blood supply to the rectum is derived from the superior, middle, and inferior rectal
(hemorrhoidal) arteries.
• The superior rectal artery is the end branch of the IMA.
• The middle rectal arteries are derived from the internal iliac arteries.
• The inferior rectal arteries are branches of the internal pudendal arteries.
Venous Supply
• Upper two thirds of the rectum: Drains into the superior rectal vein which further drains into the
IMV and portal system.
• Lower rectum: Drains into the middle and inferior rectal veins, which are connected to the internal
iliac and systemic circulation.

7. Lymphatic Drainage
• Upper two thirds of the rectum: Drains toward the inferior mesenteric and paraaortic nodes.
• Lower rectum drains in two directions, cephalad toward the inferior mesenteric nodes and laterally
and inferiorly toward the internal iliac nodes.

8. RECTAL PROLAPSE
• Rectal prolapse is a circumferential descent of the rectum through the anal canal.
• The degree of prolapse can vary from intrarectal or internal rectal prolapse to intra-anal prolapse to
external rectal prolapse.
• It occurs in 0.5% of the general population,with women older than 50 years 6 times more likely than men.
• Rectal prolapse usually has a progressive course.
• Starting from self-reducing prolapse during defecation, to prolapse requiring digital self-reduction.
• Prolapse may present with ulceration and even nonreducible, incarcerated prolapse with necrosis in the
most advanced and complicated cases.

9. Aetiology
• Rectal prolapse occurs due to sliding herniation of the pouch of Douglas through pelvic floor fascia
into the anterior aspect of the rectum.
• Decreased sacral curvature and anal canal tone are the probable causes in infants.
• Chronic constipation,Diarrhoea, cough,stricture urethra increases intra-abdominal pressure.
• Neurological(Hirschsprungs disease),fibrocystic disease of pancreas,cystic fibrosis.
• Diastasis of the levator ani, abnormally deep cul-de-sac,redundant sigmoid colon,patulous
sphincter,loss of rectal sacral support,lax and atonic pelvic floor musculature.

10. • Pudendal nerve damage causes pelvic floor and anal sphincter weakness.It may be due to obstetric
injury, diabetes or sacral nerve damage.
• Multiparous female due to repeated birth injuries to perineum leads to damage to the perineal nerve
supply.
• Psychiatric diseases such as autism or developmental delay and people taking constipation causing
medications.
• Fistula in ano surgery.
• Malnutrition reduces ischiorectal fossa fat.
• Solitary rectal ulcer syndrome.

11. CLINICAL FEATURES
• Primary presenting complaint is protuberance from anus often mistaken for hemorrhoidal disease.
• Feeling of incomplete evacuation of stool.
• Bleeding and mucus discharge.
• Urinary incontinence and pain.

12. TYPES OF RECTAL PROLAPSE
1.Partial Rectal Prolapse
2.Complete Prolapse(Procidentia)
3.Internal Intussusception(Internal rectal prolapse)

13. Partial Rectal Prolapse
• The mucosa and submucosa of the rectum descends for approx 1-4cm.
• There is no descent of the muscular layer.
• It is the commonest type of rectal prolapse.
Clinical features of partial rectal prolapse
• History of mass per anum, which can be observed when patient is allowed to strain in
squatting position.
• It is pink in colour and circumferential.

14. Complete Prolapse(Procidentia)
• Less common than partial prolapse.
• It is common in females (6 : 1 female : male).
• It is due to weakened levator ani and supporting pelvic tissues.
• The descent is always more than 4cm and commonly as much as 10-15cm in lenght,contains all
layers of the rectum (i.e.including muscular layer).

15. Clinical features of Total rectal prolapse
• It can mimic like intussusception of the rectum.
• Once complete prolapse is more than 5 cm, anteriorly it drags peritoneum as pouch which often
contains small intestine. On digital pushing it reduces with gurgling.
• Patulous anal sphincter is typical with mucus discharge and faecal incontinence(75%).
• Mucosa of the chronic rectal prolapse is thickened, ulcerated, bleeds, and often incarcerated below the
level of anal verge.

16. • Complete descent of rectum as mass per anum circumferentially which is red in colour.
• Mass is usually reducible and painless.
• Incarcerated or infected rectal prolapse is painful.
• It may be associated with uterine prolapse (uterine procidentia) in females.
• Sepsis, discharge, fever, anaemia .

17. Investigations
1).Digital rectal examination and proctoscopy.
 Differenciates true rectal prolapse from prolapsed rectal mucosa or prolapsed hemorrhoids.
 Can assess the sphincter tone.
2)Defecography:
 It reveals increased mobility of the rectum from sacral fixation point with redundant mesorectum and
funnel formation. It is a fluoroscopic procedure.
 It detects megarectum,incontinence,non relaxing puborectalis,abnormal perineal descent
(2.5cm),mucosal prolapse,solitary ulcer,rectocoele and enterocele.
DEFECOGRAPHIC GRADING OF RECTAL PROLAPSE
a) N-Normal rectal fixation and sphincter relaxation.
b) 1-nonrelaxed puborectalis.
c) 2-mild intussusception.
d) 3-moderate intussusception.
e) 4-severe intussusception.
f) 5-prolapse.
g) 6-rectocele.

18. 3)Cinedefecography, triple contrast cinedefecography,dynamic MRI
defecography,colpocystodefecography :
• These are helpful to delineate complex pelvic floor problem(Rectocele, cystocele,vaginal vault
prolapse, enterocele and sigmoidocele).

19. 4).Sigmoidoscopy or colonoscopy:
• It is used to detect the tumour in the intussuscepted prolapsed rectum.
5).Anal manometry:
• The resting (40 mmHg of internal sphincter) and squeeze (80 mmHg, external sphincter)
pressures at various points in anal canal.
6).Pudendal nerve latency study:
• It measures pudendal nerve terminal motor latency (PNTML) which is normally 1.8-2.2
msec. It is prolonged in pudendal nerve damage.

20. 7).Electromyography:
• Studies the puborectalis muscle tone.
8).Endoanal ultrasound:
• It usually shows a thickening of the internal anal sphincter.

21. 9).Colonic transit study.
• It is performed in patients with a lifelong history of constipation.
• It differentiates constipation due to obstructed defecation from constipation due to slow colonic
transit. The two frequently coexist.

22. Management of partial prolapse
• The nutrition of the patient is improved and digital repositioning is tried.
• Correction of constipation and fecal incontinence .
• Adequate fluid intake,fiber supplements, and stool softeners.
• Sugar or salt can be used topically to reduce rectal mucosal edema and facilitate reduction of the
prolapsed tissue.
• Enemas and suppositories may be helpful to assist in defecation.

23. • Submucosal injections:
If digital repositioning fails after 6wks,10 ml of 5% phenol in almond oil or ethanolamine oleate is
given into the apex of the prolapse under G/A so as to create an aseptic inflammation leading to
tethering of mucosa to the underlying muscular coat.
• Other alternatives includes tetracycline,oxytetracycline,hypertonic saline injection.
• Thiersch wiring alone is tried with good success rate in children.
• Goodsall's operation,Stapled transanal rectal resection surgery (STARR).
• Internal Delorme’s procedure.

24. Management of complete prolapse
• Surgery is required for full thickness rectal prolapse.
• It can be performed via perineal or abdominal approach.
• Abdominal operations can be done by open or laparoscopic approach.
• Recurrence rates vary between 13% and 31%.
• The choice of procedure is based upon the patient’s comorbidities, age,bowel function and
the surgeon’s preference.

25. TREATMENT OF COMPLETE PROLAPSE
• ABDOMINALAPPROACH
• Done in young patients.
• Low recurrence rate(2-5%).
• Methods:
1. Rectopexy:
a) Ripstein operation
b) Well's operation
c) Lahaut's operation
d) Frykman Goldberg resection rectopexy

26. 1) Laparoscopic Rectopexy
• It is an ideal and good approach to fix the rectum to sacrum.
• Laparoscopic posterior mesh rectopexy (LPMR) is the procedure of choice.
• Anterior mobilisation along the Denonvillier's fascia is done 5 cm below the peritoneal reflection.
• Polypropylene mesh is placed in the presacral space deep to rectum which is fixed to presacral fascia
along the sacrum and sacral promontory.
• Mesh is sutured to rectal wall also on both sides using interrupted polypropylene sutures.

27. 2) Ripstein operation
• After mobilisation of the rectum , 5 cm width Teflon mesh sling
is passed around the rectum to fix it behind the fascia 5 cm below
and in front of the sacral promontory. Sling is also fixed in front
and laterally to rectum.

28. 3) Well's operation
• Polyvinyl alcohol sponge is wrapped around the mobilized rectum and is fixed to sacrum.
• Infection, fistula formation is high.
• Polypropylene mesh is used as a modification now instead of polyvinyl sponge.
• Wrapping is partially done to reduce the incidence of constipation.

29. 4) Lahaut's operation
• Rectosigmoid is mobilised fully.
• Loop of rectosigmoid is passed infront through posterior rectus sheath behind the rectus
muscle.
• Extraperitonealisation is done to pull the rectus forward to prevent descent.

30. Perineal Approach
• Done in young and old patients.
• Recurrence is more (20-30%).
• Methods:
1. Thiersch Wiring.
2. Delorme’s Mucosectomy.
3. Altemier’s Perineal Procto Sigmoidectomy.
4. Perineal posterior fixation of the rectum of Lockhardt-Mummery.
5. Wyatt operation.
6. Mickulicz Miles perineal transanal rectosigmoidectomy/amputation of prolapse

31. Altemier’s Perineal Procto Sigmoidectomy
• Introduced by Mikulicz in 1899 and popularized by Altemeier et al.
• Patient is placed in lithotomy or jackknife position.
• Redundant rectum is externalized and anal canal is held open with a lone star retractor.
• Dentate line is identified and full thickness circumferential rectal incision made.
• Avascular intersphincteric plane is developed till pelvis.
• Redundant rectum and sigmoid colon are extracted and coloanal anastomosis done.
• Posterior rectopexy with postanal levatorplasty is done(improves anal continence).
• Recurrence rate is high(12-24%).

32. ANORECTAL MUCOSECTOMY WITH MUSCULAR
PLICATION(DELORME PROCEDURE)
• First described by Delorme in 1900.
• Advantage is that no full thickness bowel resection with anastomosis is required.
• Rest of the steps are same as Altemeier procedure.
• Submucosal dissection is performed without violating the muscular layer.
• Mucosectomy twice the length of prolapse is done.
• Longitudinal plicating sutures are placed in rows 1cm apart.
• Low morbidity of 9.5% and recurrence rate of 12-31%.

33. Thiersch Procedure
• It was introduced by Thiersch in 1891.He used silver wire.
• Encircled wire incites inflammatory reaction resulting in a circumferential band.It can be removed
after 12 months.
• It does not correct prolapse but acts as a mechanical support for sphincter.
• Subcutaneously connected two lateral perianal skin incisions are made 180 degree apart taking anus as
center.
• Polypropylene mesh or silicone roll is tunneled circumferentially around anus and fixed.
• Recurrence rate is 75%.
• Anal stenosis,fecal impaction,erosion of mesh can occur.

34. INTERNAL INTUSSUSCEPTION
(INTERNAL RECTAL PROLAPSE)
 It is internal telescoping of the rectum that does not protrude from anal canal.
 Rectocele is present in about 89% of the cases.
• Symptoms:
 Fecal incontinence
 incomplete evacuation
 straining
 digital assistance during defecation
 urge incontinence
 mucus discharge
• INVESTIGATION:
 DRE
 Anorectal manometry
 Anal ultrasound
 Defecography.

35. • Treatment:
 Conservative:
• Fiber supplements,
• laxatives,
• stool softeners,
• pelvic floor physiotherapy.
 Surgery:
• Stapled transanal rectal resection(STARR).
• Lapaaroscopic ventral mesh rectopexy.

36. Complications of Surgery
• Injury to hypogastric nerve causing impotence.
• Bladder dysfunction.
• Bleeding from sacral venous plexus.
• Injury to rectum and colon causing faecal fistula.
• Constipation after rectopexy.
• Recurrence of prolapse.
• Improper correction of continence occurs in 50% cases.
• Infection- proctitis,pelvic abscess, etc.

37. THANK YOU
Reference:
Sabiston Textbook of Surgery
Bailey & Love's Short Practice of Surgery
Shackelford's Surgery of the Alimentary Tract
SRB's Manual of Surgery