Rosen & Barkin's 5-Minute Emergency Medicine Consult (601 page)

• 099.3 Reiter’s disease
  
• 372.33 Conjunctivitis in mucocutaneous disease
  
• 711.10 Arthropathy associated with Reiter’s disease and nonspecific urethritis, site unspecified
  

BASICS

• Full-thickness evagination of the rectal wall outside the anal opening
  
• 3 types of rectal prolapse:
  
  • Full-thickness prolapse:
    
    • Protrusion of the rectal wall through the anal canal; the most common
      
  • Partial thickness or mucosal prolapse:
    
    • Only mucosal layer protrudes through anus
      
  • Occult (internal) prolapse or rectal intussusception:
    
    • Rectal wall prolapse without protrusion through the anus
      
    • May be difficult to diagnose
      

• Cause unclear and multifactorial:
  
  • Chronic constipation/excessive straining
    
  • Laxity of sphincter:
    
    • Pelvic floor trauma/weakness; childbearing
      
    • Neurologic disease
      
• More common in women, peak in 7th decade
  

• Very rare after age 4 yr
  
• True rectal prolapse unusual in children; more likely partial or intussusception
  
• Consider chronic diarrhea, parasites, cystic fibrosis (CF), malnutrition as contributing causes
  

DIAGNOSIS

• Dark red mass protrudes from the rectum
  
• Possible mucous or bloody discharge
  
• Sensation of rectal mass
  
• Tenesmus
  
• Constipation or incontinence
  

• History with emphasis on bowel obstruction and duration of prolapse
  
• Often progressive symptoms over time with self-reducing prolapse initially
  

• Rectal exam must differentiate prolapse from polyps, hemorrhoids, and intussusception.
  
• True prolapse shows dark red mass at the anal verge with or without mucus; circumferential circular folds in beefy mucosa of protruding rectum.
  
• Mucosal prolapse rarely greater than a few centimeters of protrusion; will not contain circular folds of muscular layer
  
• Internal hemorrhoids identified by folds of mucosa radiating out like spokes in wheel
  
• Prolapsed polyps and hemorrhoids do not involve the entire rectal mucosa and do not have a hole in the center.
  
• Intussusception identified by complaints of intermittent, severe abdominal pain; may appear more ill:
  
  • Examiner’s finger can be passed between the apex of the prolapsed bowel and the anal sphincter; whereas, in rectal prolapse the protruding mucosa is continuous with the perianal skin
    

Careful physical exam

• No lab test necessary for uncomplicated prolapse
  
• Preoperative testing for incarcerated rectal prolapse, going to OR
  

No imaging is necessary for uncomplicated prolapse

• Prolapsed internal hemorrhoids
  
• Prolapsed rectal polyp
  
• Intussusception
  
• Other rectal mass
  

TREATMENT

• Position of comfort
  
• Prevent mucosal desiccation with moist gauze
  
• Avoid trauma to mucosa
  

• Stabilization generally not needed in simple prolapse
  
• Incarcerated or ischemic prolapse:
  
  • NPO
    
  • IV fluids
    
  • Prepare for surgery
    

Manual reduction of rectal prolapse:

• Place in knee-chest position
  
• Apply gentle steady pressure for 5–15 min
  
• Invert mucosa through lumen from distal
  
• Sedation as needed to relax sphincter
  
• Finger may be placed in rectum to guide reversal of prolapse
  
• Prolapse very large or difficult to reduce:
  
  • Apply 1/2–1 cup sugar to reduce swelling and assist manual reduction
    
• Prolapse recurs immediately after reduction:
  
  • Apply pressure dressing with lubricant, gauze, tape; buttock may be taped together for several hours
    
• If prolapse incarcerated or ischemic, or if manual reduction fails or prolapse frequently recurs:
  
  • Admission for emergent surgical correction
    

Sedation and pain medication only as needed

FOLLOW-UP

• Necrotic or ischemic mucosa
  
• Inability to reduce acute prolapse or frequently recurs
  

• Reduced rectal prolapse
  
• Stable and tolerating PO
  
• Instructions to treat the presumed underlying cause:
  
  • Correct constipation:
    
    • Stool softeners
      
    • Increase fluid intake
      
    • Increase dietary fiber
      
• Avoid prolonged sitting or straining
  

Refer for workup including:

• Search for leading lesion
  
• Refer for definitive surgical repair of recurrent prolapse
  
• Testing for CF in children
  

Colorectal follow-up

• Perform careful physical exam to differential rectal prolapse from polyps, hemorrhoids, and intussuscepted bowel
  
• For large or difficult to reduce rectal prolapse, apply sugar to reduce swelling and assist in manual reduction
  

• Demirel AH, Ongoren AU, Kapan M, et al. Sugar application in reduction of incarcerated prolapsed rectum.
  Indian J Gastroenterol
  . 2007;26(4):196–197.
  
• Gourgiotis S, Baratsis S. Rectal prolapse.
  Int J Colorectal Dis
  . 2007;22(3):231–243.
  
• Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse.
  Scand J Surg
  . 2005;94(3):207–210.
  
• Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse.
  Arch Surg
  . 2005;140(1):63–73.
  
• Melton GB, Kwaan MR. Rectal prolapse.
  Surg Clin North Am
  . 2013;93(1):187–198.
  

See Also (Topic, Algorithm, Electronic Media Element)

Hemorrhoid

CODES

569.1 Rectal prolapse

BASICS