Rectal Prolapse

Rectal Prolapse

 

Parental concerns, appropriately, drive a lot of the traffic to our Emergency Departments.  Managing concerns and expectations is part of the art of what we do.  When a child develops Rectal Prolapse, there are often a lot of concerns, but it is important to keep some basic issues in mind.

 

Rectal Prolapse: Basics

  • Generally is a benign condition.
  • Often get sent to surgeons and GI specialists, but rarely require more than conservative management.
    • ~90% of kids 9 months to 3 years will not need additional therapy.
  • Most common under age 4 years!  Highest Incidence is <1 year of age.
    • The prognosis is more ominous in kids who develop it after age 4 years.
  • Mechanically, it is an intussusception of the rectum.
  • Classification of Prolapse: (Siafakas, 1999)
    • Mucosal Prolapse – Mucosa only; Generally < 2cm; Has radial folds
    • Complete Prolapse – Full Thickness; > 2cm, Has various Degrees/Severities based on length and whether the mucocutaneous junction is involved; Has circular folds
      • Third Degree actually is internal and does not pass through the anus.

 

Rectal Prolapse: Why it Happens

  • Anatomy Matter

    • More vertical course of the rectum along the sacrum.
    • Low position of the rectum and increased mobility of the sigmoid colon.
    • Lack of support by the levator ani muscle.
  •  Associated Conditions (Siafakas, 1999)

    • Increased intra-abdominal pressure
      • Chronic straining (constipation)
      • Attempts at toilet training at a developmentally inappropriate time.
      • Protracted coughing spells (Pertussis?)
      • Excessive vomiting
    • Diarrheal Illness
      • Acute or Chronic
      • Infectious diarrhea (ex, shigella, C.Diff)
      • Malaborption (ex, celiac, pancreatic insufficiency)
        • Cystic Fibrosis accounts for ~11% of rectal prolapse in the Western World, likely from multiple mechanisms.
        • Rectal Prolapse may be the presenting sign of Cystic Fibrosis in up to 33% of patients before other symptoms!
    • Parasitic Disease (ex, whipworms)
    • Neoplastic Disease (ex, polyps)
    • Malnutrition
      • Worldwide, likely most common condition associated with rectal prolapse.
      • Due to loss of fat leading to less perirectal support.
    • Neurologic Disorders (ex, Myelomeningoceles)
    • Misc: Congenital Hypothyroidism, Ehlers-Danlos Syndrome, Hirschsrpung’s.

 

Rectal Prolapse: Management

  • Most often the child with rectal prolapse will spontaneously reduce prior to your exam.
  • If it is still present, consider a few entities prior to simply reducing it. (Siafakas, 1999)
    • Ileocecal Intussusception
      • Can actually protrude from the rectum.
      • Distinguished from rectal prolapse by:
        • Child appears clinically ill and
        • Examiner’s finger can pass between prolapsed tissue and the anal sphincter.
    • Rectal Polyp that has Prolapsed
      • May appear during defecation and then reduce.
      • Does not involve the entire anal circumference.
  • Reduce it!
    • If it still is prolapsed, reduce it with steady pressure .
    • If it has been prolapsed for awhile, there may be swelling.
    • Firm, steady pressure with fingertips may be required for several minutes.
    • Many will talk about applying sugar to help lessen the edema, but I have not found any definitive literature on this.
  • Ask yourself why it happened!
    • See the above issues and consider whether any are the cause.
    • Unexplained rectal prolapse deserves follow-up for possible cystic fibrosis testing.

 

References

Flum AS1, Golladay ES, Teitelbaum DH. Recurrent rectal prolapse following primary surgical treatment. Pediatr Surg Int. 2010 Apr;26(4):427-31. PMID: 20238206. [PubMed] [Read by QxMD]

Siafakas C1, Vottler TP, Andersen JM. Rectal prolapse in pediatrics. Clin Pediatr (Phila). 1999 Feb;38(2):63-72. PMID: 10047938. [PubMed] [Read by QxMD]

Zempsky WT1, Rosenstein BJ. The cause of rectal prolapse in children. Am J Dis Child. 1988 Mar;142(3):338-9. PMID: 3344723. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. December 4, 2015

    […] can really help make your day go more smoothly in the ED. Knowing how to manage rectal prolapse, constipation, recurrent abdominal pain, or cerumen impaction may not be what got you motivated to […]

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