II. Definitions
- Rectal Prolapse
- Protrusion of all or some layers of the Rectum via the anus with straining
- Intussception of the bowel through the anus
III. Epidemiology
- Bimodal distribution: Pediatric and Elderly patients
IV. Pathophysiology
- Weak pelvic support
V. Types
- Full thickness Rectal Prolapse
- Internal prolapse (Internal Intussusception
- Prolapse not visible outside the anal canal
- Mucosal prolapse
- Progression of Hemorrhoids more than a pelvic support disorder
VI. Risk Factors
- Chronic Constipation
- Conditions predisposing to straining at stool (e.g. Multiple pregnancies)
- Increasing Age (esp. women)
VII. Symptoms
- Mass protruding from the anus
- Onset often after straining to stool
- Associated symptoms
- Rectal Pain
- Anal Discharge
- Rectal Bleeding
VIII. Associated Conditions
- Pelvic Organ Prolapse (e.g. Rectocele, Cystocele)
- Hemorrhoids (especially with mucosal prolapse)
IX. Complications
- Incarcerated Hernia (rare)
- Tissue breakdown and necrosis of incarcerated bowel
X. Management: Manual Reduction
- Contraindications
- Tissue necrosis
- Adjuncts
- Technique
- Avoid delays due to risks of prolonged prolapse with tissue breakdown and necrosis risk
- Patient lies in lateral decubitus position or prone position
- Apply granulated sugar or gauze soaked in sugar water over prolapsed mucosa for 10 to 20 minutes
- Assistant retracts the buttock cheeks
- Examiner applies both thumbs against the central opening, and other fingers resting against the buttocks
- Thumbs apply constant gentle pressure
- Fingers apply circumferential pressure, rotating the hands clockwise and counterclockwise
- Maintain over several minutes as the prolapse reduces
- Apply a pressure dressing against the anus to prevent a short-term recurrence
- First layer against the anus may be Vaseline Gauze
XI. Management: Other Measures
- Surgery Indications
- Failed reduction
- Incarcerated Hernia
- Disposition
- Follow-up for evaluation for malignancy (nidus for prolapse)
XII. Prevention
- Pelvic Floor Exercises
- Avoid straining at stool
- Follow bowel regimen to maintain soft stools
XIII. Resources
XIV. References
- Warrington (2022) Crit Dec Emerg Med 36(7): 15
- Cohee (2020) Am Fam Physician 101(1):24-33 [PubMed]
- Jones (2011) BMJ 342:c7099 [PubMed]