Rectal Prolapse

What is rectal prolapse?

A condition where in the rectum (distal most part of large intestine just above the anal canal) protrudes out of the anal opening due to stretching or disruption of its attachments to the posterior abdominal wall.

  • The primary cause of rectal prolapse remains unclear.
  • Predisposing factors include prolonged straining while passing stools (chronic constipation), multiple pregnancies, and neurological illnesses causing muscular weakness or connective tissue disorders (genetic predisposition).
  • In the elderly it is also caused due to aging that lead to weakening of the supporting ligaments and weak anal sphincter muscle.
rectal-prolapse

Rectal Prolapse

  • It is also due to a functional disturbance of the pelvic floor.
  • Weakness of the anal sphincter muscle is often associated with rectal prolapse, resulting in leakage of stool or mucus.
  • Diagnosis of rectal prolapse is made on history and physical examination.
  • In case of an internal rectal prolapse sometimes a defecography is required.
  • In most cases surgery is required to correct rectal prolapse in adults and in some children. The two major surgical treatments for rectal prolapse include perineal approach and abdominal approach.

Perineal Approach

  • Perineal approach includes three different methods and these methods can be used to surgically treat rectal prolapsed depending on the nature of the prolapse.
    • Minimally Invasive Procedure for Hemorrhoids (MIPH), this process is used only in cases of partial or mucosal prolapsed.
    • Altemeier procedure (also called a proctosigmoidectomy) involves removal of the prolapsed part of the rectum and suturing together the cut edges.
    • Thiersch wiring is a temporary procedure wherein the anal verge is wired to narrow the opening. The procedure is poorly tolerated.

Advantages of Perineal Approach

  • Decreased operative time
  • Less loss of blood
  • Less operative pain and faster recovery

Disadvantages of Perineal Approach

  • Anastomotic bleeding—pelvic sepsis from anastomotic leak. However, it can be mitigated through surgical expertise.
  • High recurrence rate

Abdominal Approach

What is it?

  • This approach includes two surgical processes for treating rectal prolapse.
    • Rectopexy- Surgical fixation of the rectosigmoid to the sacrum.
    • Anterior resection -The redundant part of the sigmoid is resected and removed. It may or may not be accompanied by rectopexy.

Advantages of this abdominal approach

  • Both procedures can be performed by Laparoscopic approach.
  • Laparoscopic surgical procedures for rectal prolapse are done under general anesthesia. In patients unfit for general anesthesia epidural or spinal anesthesia may be used; thereby, negating sensation of pain during the process.
  • Abdominal procedures give better results, of these Rectopexy is associated with a faster recovery.

Disadvantages of abdominal approach

  • Though this process is better than the perineal approach and does not have major disadvantages but it has certain limitations.
  • This process should be followed up with considerable amount of lifestyle change and dietary change for the best results.