Rectal Prolapse and Procidentia
(See also Evaluation of Anorectal Disorders.)
Transient, minor prolapse of just the rectal mucosa often occurs in otherwise normal infants. Mucosal prolapse in adults persists and may progressively worsen.
Procidentia is complete prolapse of the entire thickness of the rectum. The primary cause of procidentia is unclear. Most patients are women > 60.
To determine the full extent of the prolapse, the clinician should examine the patient while the patient is standing or squatting and straining. Rectal procidentia can be distinguished from hemorrhoids by the presence of circumferential mucosal folds. Anal sphincter tone is usually diminished. Sigmoidoscopy, colonoscopy, or barium enema x-rays of the colon must be done to search for other disease. Primary neurologic disorders (eg, spinal cord tumors) must be ruled out.
In infants and children, conservative treatment is most satisfactory. Causes of straining should be eliminated. Firmly strapping the buttocks together with tape between bowel movements usually facilitates spontaneous resolution of the prolapse.
For simple mucosal prolapse in adults, the excess mucosa can be excised.
For procidentia, rectopexy, in which the rectum is mobilized and fixed to the sacrum, may be required in patients who can tolerate a laparotomy. In patients who cannot tolerate a laparotomy, perineal operations (eg, Delorme or Altemeier procedure) can be considered. (See also the American Society of Colon and Rectal Surgeons' clinical practice guidelines for the treatment of rectal prolapse.)