1. Rectal Prolapse
By: John N. Afthinos, M.D.

2. Definition
Descent of mucosa or the entire thickness of the rectum through the anus

3. Etiology Poor bowel habits, especially constipation Female gender
Nulliparity
Redundant rectosigmoid
Deep pouch of Douglas

4. Etiology Patulous anus Diastasis of levator ani
Lack of fixation of rectum to sacrum
Intussusception
Tumor can be lead point
Prior colorectal surgery

5. Clinical Features Peak at 6th decade of life
Most common complaint: protrusion (3/4)
Worsens with time because sphincters weakened by dilation
Occurs on Valsalva
Incontinence and problems with bowel regulation
½ with constipation

6. Clinical Features Preceive obstruction or incomplete evacuation
May need to apply manual pressure to fully defecate
Mucous discharge from protrusion
Hemorrhage only if massive or irreducible

7. Differential Diagnosis
Large thrombosed hemorrhoids
Prolapsing polypoid mass
Ectropion—mucosal prolapse
Rectocele
Enterocele

8. Evaluation H&P DRE Proctosigmoidoscopy Cinedefecography Examine tone
Degree of prolapse
Proctosigmoidoscopy
Evaluate mucosa and for mass
Cinedefecography

10. Treatment If active prolapse—must reduce
Manually
Put sugar on it to decrease swelling
Manually under anesthesia
If irreducible, emergent resection may be needed

11. Treatment Non-operative Correction of constipation
Perineal strengthening exercises
Adhesive strapping of buttocks
Injection of sclerosing agent

12. Treatment
Operative goals are to accomplish 2 or more of the following:
Narrow anal orifice
Obliterate Pouch of Douglas
Restore pelvic floor
Resect redundant bowel
Suspend or fix the rectum

13. Narrowing the Anal Orifice
Thiersch Repair
Placement of a material around anus, subcutaneously to narrow it
Suture material, silastic tubing, mesh, fascia lata, etc
Size opening with No. 16 or 18 Hegar dilator
Can be done on older, high-risk patients

15. Narrowing the Orifice Complications: Silastic material may be best
Fecal impaction: can be relieved only under anesthesia
Wound infection must remove prosthesis
Can prolapse post-procedure
May be irreducible
Silastic material may be best

16. Obliteration of Pouch of Douglas
Serial purse string sutures placed in a cephalad direction into pelvic floor
About 1/2 recur when done as a stand alone treatment

17. Restoration of Pelvic Floor
Plication of levators anterior to rectum to strengthen the floor
Often falls apart

18. Bowel Resection Anterior resection Removes redundant bowel
Dissect to lateral ligaments of rectum
Anastomosis near sacral promontory
Rectum can be sutured to sacral periosteum
Recurrence rate of about 7-10%
Anastomotic leak, incisional hernia, obstruction are complications

20. Altemeier Procedure Perineal resection of redundant sigmoid
Entry into peritoneal cavity and delivery of colon
Extra peritoneum resected and reapproximated
Modified version incorporated levator plication anterior to rectum

21. Altemeier Procedure Low anastomotic leak rate
Often used for elderly, poor surgical candidates
Recurrence rate of about 20%, less if modified version used

24. Sling Repair/Fixation
Ripstein Operation
Lower midline incision
Mobilization of rectosigmoid down to levators
Mesh secured to sacrum, rectum and then sacrum again while rectum under tension

26. Ripstein Operation Low recurrence rate of ~3 — 8% Complications
Wound infection
Fecal impaction
Rectal stricture