Rectal Prolapse
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Basics

Protrusion of the rectum through the anus

Description

  • Partial prolapse:
    • Involves only mucosa
    • Frequently follows anal operative procedures (radial rectal folds prolapsed through anus)
  • Complete prolapse:
    • Involves the entire rectal wall (procidentia)
    • Occurs most commonly as:
      • A spontaneous event in children
      • A complication of other disorders in the elderly (concentric rectal folds prolapsed through anus)
  • System(s) affected: Gastrointestinal

Epidemiology


Incidence
  • Predominant age: <3 years in children, 5th decade in adults
  • Predominant sex: Female > Male in adults; females represent 80–90% of adult patients; Male = Female in children (1)[B]
  • 4.2/1,000 overall; 10/1,000 >65 years of age

Geriatric Considerations
Common problem in the elderly

Pediatric Considerations
Idiopathic type most common in children

Risk Factors

  • Myelomeningocele
  • Exstrophy of the bladder
  • Cystic fibrosis (CF)
  • Chronic constipation or diarrhea
  • Imperforate anus (2)[C]
  • Multiple sclerosis
  • Stroke/Paralysis
  • Autism, developmental delay, psychiatric comorbidities requiring multiple medications (3)[B]

Genetics
Unknown

General Prevention

Avoid constipation and diarrhea.

Pathophysiology

The anatomic basis for rectal prolapse is a deficient pelvic floor through which the rectum herniates.

Etiology

  • Children:
    • Idiopathic (most common)
    • Abnormal innervation of levator ani muscle complex or puborectalis or anal sphincter, or abnormal anatomic relationships of these muscle groups
  • Adults:
    • Diastasis of levator ani
    • Loose endopelvic fascia
    • Loss of normal horizontal position of rectum
    • Weak anal sphincter
    • Pudendal neuropathy
    • Redundant sigmoid colon
    • Loss of rectal-sacral attachments

Commonly Associated Conditions

  • CF
  • Myelomeningocele
  • Exstrophy of the bladder
  • Chronic constipation (25–50%) or diarrhea
  • Imperforate anus
  • Paraplegia
  • Stroke
  • Fecal incontinence (50–75%)
  • Vaginal vault or uterine prolapse (13–30%) (3)[B]
  • Mental retardation
  • Marfan syndrome
  • Ehlers-Danlos disease
  • Urinary incontinence (may be found in 25–35% of patients with rectal prolapse) (3)[B]
  • Bladder stones
  • Nutritional disorders
  • Progressive systemic sclerosis

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