Prolapse

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Rectal prolapse is a distressing condition for the patient. Approximately 50-75% of rectal prolapse patients suffer from associated anal incontinence, and the prolapse itself is socially embarrassing. Although the majority of patients are elderly women, prolapse can occur at all ages and is not infrequent in infants under the age of 2 years. Prolapse in infancy is usually precipitated by acute diarrhoeal illness or severe coughing; however, the association of rectal prolapse in infancy and cystic fibrosis makes a sweat test mandatory.

The cause of rectal prolapse in adulthood is unknown; however, rectal prolapse is thought to begin as an internal intussusception. A typical patient will have a lax pelvic floor and a floppy, redundant sigmoid colon. Patients usually present with complaint of a lump that prolapses at defaecation and either reduces spontaneously or has to be manually replaced. Incontinence and evacuatory difficulties are commonly associated. Occasionally, prolapse presents as an emergency and prolonged difficulty replacing the prolapse can lead to its strangulation. The best way to reduce an apparently irreducible prolapse is to raise the foot of the bed and coat the prolapse liberally with sugar; the osmotic effect reduces oedema and the prolapse can then be replaced.

The best way to confirm the diagnosis in the outpatient setting is to ask the patient to go to the clinic toilet and demonstrate the prolapse. Colonic investigation is recommended, although very elderly patients are unsuitable for colonoscopy and either CT colonography or flexible sigmoidoscopy is all that is required.

There have been many surgical approaches described for rectal prolapse, but they can be broken down into two main types: abdominal or perineal. Initial surgical attempts were perineal; Thiersch's anal encirclement operation was described in 1891 and Delorme's mucosal sleeve resection was described in 1900. The perineal approach may also involve rectosig-moidectomy (Altemeier operation). Abdominal approaches can be open or laparoscopic and surgeons may elect to remove redundant colon or not.

Abdominal approaches have lower recurrence rates than the perineal approaches, (in a major retrospective series from the University of Minnesota, the recurrence rate after abdominal procedures was 5% and 16% after perineal rec-tosigmoidectomy) but as the patients are often elderly and very frail; a perineal operation, which avoids the morbidity of abdominal surgery is attractive.

Solitary rectal ulcer syndrome (SRUS) is frequently, but not universally, associated with internal intussusception or full-thickness rectal prolapse. SRUS without full-thickness prolapse usually responds to dietary and biofeedback treatment; however, an abdominal procedure is usually indicated if there is associated full-thickness prolapse.

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