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 M. Fox
Sean M. 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 renowned 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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