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