Prolapsus rectal | Clinique Omicron Québec

Classification and types of rectal prolapse

Risk factors and pathogenesis

• Female gender and multiparity : obstetrical trauma → pudendal nerve injury + pelvic floor muscle rupture + progressive denervation + multiparity (≥ 2 vaginal deliveries) multiplies the risk by 3 to 5 + prolonged deliveries + forceps + fetal macrosomia
• Chronic constipation and defecation flare-ups: repeated pushing → increased intra-abdominal pressure → gradual perineal descent → stretching of the pudendal nerves → denervation of the external sphincter → incontinence + worsening of the prolapse
• Advanced age : loss of pelvic ligament elasticity + pelvic floor muscle atrophy + menopause (estrogen deficiency → atrophy of pelvigenital structures)
• Neuromuscular disorders : multiple sclerosis + myelomeningocele + spinal cord injury + cauda equina syndrome → pelvic floor denervation → prolapse
• Rectal prolapse in children: special form before age 3 + often benign and transient + associated with cystic fibrosis (cystic fibrosis) - systematic screening - + intestinal parasitosis + malnutrition + conservative treatment in 80 % of cases + surgery rarely necessary

Diagnosis

• Clinical examination in the squatting or bowel position: have the patient push as if to defecate → the prolapse appears → assess its size + color (pink or purplish mucosa if ischemia) + reducibility + circular folds (complete) vs radial folds (mucous) + palpation of the apex (wall splitting = complete) + rectal touch: sphincter tone often diminished
• Rigid or flexible rectoscopy: evaluation of the mucosa + search for solitary ulceration of the rectum (lesion often associated with internal prolapse + pearly white appearance on the anterior surface of the rectum 7-10 cm from the anus)
• Dynamic defecography (or dynamic MRI of the pelvic floor): gold standard for internal prolapses + visualizes perineal descent + intussusception + elytrocele + cystocele + associated rectocele + indispensable before any surgical decision to map all pelvic floor disorders
• Anorectal manometry : evaluates resting and contracting sphincter pressure + rectal sensitivity + inhibitory recto-anal reflex (IRAR) + essential before surgery to assess basal continence and predict post-operative functional outcome
• EMG of the anal sphincter: assesses pudental denervation + useful if severe incontinence or obstetrical history

Treatment

• Conservative measures (treatment of constipation + rehabilitation): first-line treatment for mildly symptomatic prolapse or in patients at high surgical risk + transit regulation (dietary fiber 25-30 g/day + hydration + avoidance of pushing efforts + osmotic laxatives) + perineal re-education with biofeedback + pelvic floor electrostimulation + work on the levator ani muscles + may improve associated incontinence but does NOT cure complete structural prolapse → stand-by or adjuvant treatment
• Abdominal approach - rectopexy (laparotomy or laparoscopy) : gold-standard surgical treatment of complete rectal prolapse in operable patients + mobilization of the rectum to the pelvic floor + fixation of the mesorectum to the anterior face of the sacral promontory (prosthetic rectopexy with mesh - Orr-Loygue technique + or sutured rectopexy - Wells technique) + ± concomitant sigmoid resection if associated severe constipation (Frykman-Goldberg technique) + recurrence rate : 2-5 % + continence improvement in 50-75 % of cases + morbidity: dyspareunia + anastomotic stenosis + micturition disorders (nerve floor dissection)
• Perineal approach - perineal resection-anastomosis (Altemeier operation) : resection of the prolapsed rectum using a purely perineal approach + manual transanal colorectal anastomosis + indicated in elderly patients + comorbid patients + at high risk of anaesthesia + or if the abdominal approach is refused + higher recurrence rate (10-15 %) than the abdominal approach + but lower perioperative morbidity + less well tolerated in terms of long-term continence.
• Perineal approach - Delorme proctopexy : resection of the prolapsed mucosa + plication of the muscularis + mucosal anastomosis + preservation of the rectum + indicated for short prolapses (< 5 cm) + or frail patients + intermediate recurrence rate (5-10 %)
• Emergency manual reduction (irreducible or strangulated prolapse) : if the prolapse is incarcerated (irreducible + edematous + painful) → application of powdered sugar or osmotic solutions to the mucosa to reduce edema → gentle manual reduction + analgesia + if necrosis begins (blackish + necrotic mucosa) → urgent surgery

Consult at Clinique Omicron

Clinique Omicron's specialized physicians and nurse practitioners (NPs) assess symptoms suggestive of rectal prolapse (externalized perineal mass + fecal incontinence + rectal discharge + dyschezia), distinguish complete rectal prolapse from hemorrhoidal prolapse, prescribe perineal re-education as first-line conservative treatment, refer to proctology or colorectal surgery for endoscopic evaluation, defecography and surgical decision, and treat underlying constipation which aggravates the prolapse. Consultations are available at several points of service in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.

The contents of this page are provided for information purposes only and do not replace the advice of a physician, proctologist or colorectal surgeon. Complete rectal prolapse requires specialized evaluation including dynamic defecography and anorectal manometry before any surgical decision is taken - the surgical route and technique must be tailored to the patient's individual profile.