Basic Science September 28, 2005 Rectal Prolapse Basic Science September 28, 2005

Which of the following are risk factors for rectal prolapse? Chronic constipation Chronic diarrhea Mental retardation Prior history of intussusception Female sex

Which of the following are risk factors for rectal prolapse? Chronic constipation True Chronic diarrhea Mental retardation Prior history of intussusception False- Rectal prolapse is thought of as a type of intussusception- having intussusception at an anatomically distant location doesn’t increase risk, but rectal prolapse does tend to recur and progress. Female sex True- but childbearing is only part of the reason- half of patients are men or nulliparous women

All of the following are anatomic abnormalities seen in patients with rectal prolapse except: Deep rectovaginal or rectovesical pouch Lax pelvic floor musculature Failure of normal relaxation of the external sphincter Foreshortened mesorectum Redundant sigmoids

All of the following are anatomic abnormalities seen in patients with rectal prolapse except: Deep rectovaginal or rectovesical pouch Lax pelvic floor musculature Failure of normal relaxation of the external sphincter Foreshortened mesorectum Redundant sigmoids

Classification of rectal prolapse: Partial: Complete: Grade 1: Grade 2: Grade 3:

Classification of rectal prolapse: Partial: prolapse of rectal mucosa only Complete: prolapse with all layers Grade 1: occult prolapse Grade 2: prolapse to but not through anus Grade 3: any protrusion through anus

True or False: Urinary incontinence is associated with prolapse Colonoscopy is useful for the diagnosis of prolapse In grade 3 prolapse, rectal prolapse is easily confused with hemorrhoids

True or False: Urinary incontinence is associated with prolapse Colonoscopy is useful for the diagnosis of prolapse False In a grade 3 prolapse, rectal prolapse is easily confused with hemorrhoids False- grade 2 prolapse can be confused with prolapsing hemorrhoids

Complications of prolapse include:

Complications of prolapse include: Ulceration Strangulation Urinary and fecal incontinence Spontaneous rupture with evisceration

Perineal rectosigmoidectomy is appropriate for: Younger patients who want to minimize recurrence Patients with a grade 3 prolapse protruding at least 3 cm Patients who are poor candidates for trans abdominal surgery

Perineal rectosigmoidectomy is appropriate for: Younger patients who want to minimize recurrence False- better suited for elderly patients that are poor candidates for abd surgery due to high recurrence rate Patients with a grade 3 prolapse protruding at least 3 cm True Patients who are poor candidates for trans abdominal surgery

Are associated with problems with defecation and constipation Transabdominal approaches to rectal prolapse repair (ie transabdominal rectopexy): Are associated with problems with defecation and constipation Have a lower recurrence rate than transperineal approaches Require resection of the redundant sigmoid

Are associated with problems with defecation and constipation Transabdominal approaches to rectal prolapse repair (ie transabdominal rectopexy): Are associated with problems with defecation and constipation true Have a lower recurrence rate than transperineal approaches Require resection of the redundant sigmoid not necessarily

Fecal incontinence is corrected by surgical repair of prolapse in: 90% of patients 70% 50% 30% 10%

Fecal incontinence is corrected by surgical repair of prolapse in: 90% of patients 70%- return of continence may take as long as 1 year 50% 30% 10%

1) Rectal prolapse- is due to sliding herniation through pouch of Douglas through pelvic floor fascia into anterior aspect of rectum Is a full thickness rectal intusseception starting ~3inches above dentate line and extending beyond anal verge Is six times more common in males than females Peak incidence in the 7th decade of life Young male patients tend to have psychiatric disorders

1) Rectal prolapse- B) Is a full thickness rectal intusseception starting ~3inches above dentate line and extending beyond anal verge D) Peak incidence in the 7th decade of life E) Young male patients tend to have psychiatric disorders

2) Chronic or lifelong constipation w/ component of straining has been found to be present in ~what percentage of patients w/ prolapse? 15% 35% 100% 50% 5%

2) Chronic or lifelong constipation w/ component of straining has been found to be present in ~what percentage of patients w/ prolapse? D) Present in over 50% of patients according to case reviews aimed at elucidating predisposing factors other than the frequently found anatomic characteristics- ex. diasthesis of levator ani; abnormally deep cul-de-sac; redundant sigmoid colon; patulous anal sphincter; loss of rectal sacral attachments

3) Rectal prolapse can be distinguished from prolapsed incarcerated internal hemorroids by the characteristic _______ (invaginated/concentric) folds of rectal prolapse and by the _______ (painful/painless) reduction if not incarcerated.

3) Rectal prolapse can be distinguished from prolapsed incarcerated internal hemorroids by the characteristic concentric folds of rectal prolapse and by the painless reduction if not incarcerated.

4) Two predominant approaches, ________ and _________, are considered in operative repair of rectal prolapse. Generally believed that the _______ approach results in less perioperative morbidity and pain an reduced length of hospital stay.

4) Two predominant approaches, abdominal and perineal, are considered in operative repair of rectal prolapse. Generally believed that the perineal approach results in less perioperative morbidity and pain an reduced length of hospital stay.

Most located on posterior aspect of rectum 4-12 cm from anal verge 5) Solitary rectal ulcer syndrome (SRUS)- Gross pathology always demonstrates the typical crater like ulcer with fibrinous central depression Typical patient is young and female w/ history of straining and difficult evacuation Most located on posterior aspect of rectum 4-12 cm from anal verge Diagnostic evaluation by defecography is radiologic procedure of choice

5) Solitary rectal ulcer syndrome (SRUS)- C) Typical patient is young and female w/ history of straining and difficult evacuation D) Diagnostic evaluation by defecography is radiologic procedure of choice * Always located on anterior aspect of rectum. Gross pathology can range from typical ulcer to polypoid lesion.

6) Rectocele is abnormal sac like projection of anterior rectum that extends from distal rectum to distal anal canal. Usually begins just _____ (above/below) the sphincter complex. Rectal pressures are ______ (higher/lower) than in the vagina. Major symptom of rectocele is ________ ( diarrhea/stool trapping).

6) Rectocele is abnormal sac like projection of anterior rectum that extends from distal rectum to distal anal canal. Usually begins just above the sphincter complex. Rectal pressures are higher than in the vagina. Major symptom of rectocele is stool trapping.

7) It is rare that a rectocele less than ____ is symptomatic. 0.5cm 1cm 2cm 3cm 5cm

7) It is rare that a rectocele less than ____ is symptomatic. C) 2cm; although small rectoceles are common. Criteria for operative intervention include symptomatic stool trapping requiring digital evacuation or vaginal support and large protruding rectoceles pushing vaginal mucosa past introitus producing dryness, ulceration and discomfort

8) Colonic inertia A) Estimated that 10% of population suffers from chronic, unremitting functional constipation B) Majority of patients are female w/ mean age older than 50. C) Delay in gastric emptying and small bowel follow through has been noted in these patients implying global motility problem D) Barium enema is useful initial examination

8) Colonic inertia C) Delay in gastric emptying and small bowel follow through has been noted in these patients implying global motility problem D) Barium enema is useful initial examination * Estimated that 2% of population suffers from chronic functional constipation. Majority of patients female with mean age younger than 30. Abdominal pain, bloating and nausea usually accompany the constipation.

9) Neurologic constipation As a group 50% of these patients are male Responds well to medical management Commonly presents as slow transit constipation in presence of dilated colon Includes adult Hirschsprung’s disease, Chagas’ disease and neuronal intestinal dysplasia

9) Neurologic constipation A) As a group 50% of these patients are male C) Commonly presents as slow transit constipation in presence of dilated colon D) Includes adult Hirschsprung’s disease, Chagas’ disease and neuronal intestinal dysplasia

10) Laparoscopic colon resection- Benefits similar to those mentioned for lap cholecystectomy- shorter hospital stay; less post op pain; earlier return of bowel function Most colon and rectal diseases are amenable to lap approach except can not do for sigmoid resection for diverticulitis Port site recurrence appears equivalent to recurrence of cancer in incision of patients treated by conventional operation Post operative recovery of lap colectomy is prolonged on average if hand assisted techniques are used or if anastamosis has to be performed extracorporeally

10) Laparoscopic colon resection- A) Benefits similar to those mentioned for lap cholecystectomy- shorter hospital stay; less post op pain; earlier return of bowel function C) Port site recurrence appears equivalent to recurrence of cancer in incision of patients treated by conventional operation according to Sabiston