Rectal prolapse

Diagnosis

To diagnose rectal prolapse, the doctor will review the patient’s medical history and conduct an examination of the rectum. The patient may be asked to contract their muscles as if they were having a bowel movement. Sometimes, it can be challenging to distinguish between rectal prolapse and hemorrhoids. Therefore, additional tests may be necessary to help identify rectal prolapse and rule out other potential causes:

• Digital rectal examination: The lower rectum and anus are examined during a digital rectal examination (DRE). To evaluate for any abnormalities, the doctor will slide a gloved, lubricated finger into the rectum through the anus. This also helps in assessing the strength of the sphincter muscles.
• Colonoscopy: During this procedure, a colonoscope is sent through the anus and rectum into the colon. It provides images of the inside of the large intestine including the colon, rectum, and anus. A colonoscopy may be performed to rule out other diseases, such as polyps or colon cancer.
• Anal manometry: This test is used to evaluate the functioning of the rectum and anal sphincters in removing stool (feces). It involves inserting a short, flexible tube with a balloon on the end through the anal opening and into the rectum, beyond the ring of muscles known as the anal sphincter. The balloon at the tip of the catheter is then progressively inflated, causing the nerves and muscles of the rectum and anus to contract.
• Defecography: This is a radiological exam that allows doctors to observe the muscles and organs during defecation. Defecography can reveal anatomical changes in and around the lower gastrointestinal tract. The procedure involves using a contrast agent, typically a barium paste, along with an imaging test such as a detailed fluoroscopic X-ray or magnetic resonance imaging (MRI).
• Electromyography (EMG): This examination assesses whether nerve damage is the underlying cause of impaired functionality in the anal sphincters, as well as evaluates the coordination of the muscles involved.

Treatment

Rectal prolapse can be treated through a combination of constipation medication and surgery. Medications such as stool softeners and suppositories may be prescribed to manage constipation. If surgery is necessary, the appropriate approach will depend on the patient’s age and physical condition.

There are two main surgical approaches for rectal prolapse:

• Abdominal approach: also called rectopexy, which involves attaching the rectum to the back wall of the pelvis with permanent stitches and mesh. This reinforces the rectum and allows scar tissue to develop, helping to keep it in place. Rectopexy has a high success rate in the long-term.
• Rectal approach: If abdominal surgery is not a suitable option for rectal prolapse treatment, the surgeon may opt for a different approach through the anus, also known as the perineal approach. Unlike abdominal surgery, rectal surgery through the perineal approach may not always require general anesthesia and can sometimes be performed with epidural anesthesia. This approach may be a better choice for individuals with minor prolapse or if their rectum is stuck on the outside (incarcerated).

There are two common procedures used with the perineal approach:

• Altemeier procedure: During this operation, the prolapsed rectum is extracted through the anus by the surgeon and excised. If the prolapse involves the sigmoid colon, the lower section of the colon may also be removed, a procedure known as proctosigmoidectomy. The surgeon then reconnects the two ends of the large intestine, which are the remaining colon and the anus, by suturing them together. As a result, the newly attached end of the colon takes over the function of the rectum.
• Delorme procedure: In cases where the prolapse is limited to the mucosal layer or a small external area, a less invasive surgical option may be recommended by the surgeon. The Delorme procedure involves the removal of the prolapsed mucosal lining of the rectum and then folding the rectal muscle wall onto itself. The muscle wall is then stitched together inside the anal canal, creating a double muscle layer that reinforces the rectum.