Rectal prolapse

Rectal prolapse (or rectal prolapse) means that all or part of the rectal wall slips out of its anatomical seat and emerges outward through the anus.

There are three types of rectal prolapse:

• Partial rectal prolapse (also called mucosal prolapse).
  The lining (mucous membrane) of the rectum sags from its natural position and protrudes from the anus.
  This can happen if the bowel movement is carried out with great effort. Partial prolapse is most common in children.
• Complete rectal prolapse. The entire rectal wall lowers and protrudes from the anus.
  At the initial stage, this can only be done during bowel movements (defecation).
  In later stages, this can also occur when the patient is standing or walking.
  In some cases, the leaked prolapse tissue can also remain permanently outside the body.
• Internal rectal prolapse (intussusception). Part of the wall of the colon (colon) or rectum can slip in or over another part, basically the parts slide over each other like a toy telescope.
  The rectum does not emerge from the anus.
  Intussusception is most common in children and affects adults less frequently.
  In children, the cause is usually unknown.
  In adults, this is usually associated with postoperative complications or another intestinal problem, such as tissue growth in the intestinal wall (for example, in a polyp or tumor).

In the more severe cases of rectal prolapse, a section of the colon sinks from its normal position as the tissues that normally hold it in place give way.
Typically, where the rectum begins, there is a sharp kink.
The rectal prolapse may straighten the kink and make it difficult to hold back the stool inside.
The result is fecal incontinence.

Rectal prolapse is most common in young children and the elderly, especially women.

Causes and risk factors of rectal prolapse

1. Chronic constipation or chronic diarrhea.
2. Age. The muscles and ligaments of the rectum and anus weaken with age. Other surrounding structures in the pelvic zone loosen up with age, increasing overall weakness in this area of the body.
3. Uterine prolapse. The uterus is a barrier that separates the bladder from the rectum and is very connected to these organs.
   A uterine prolapse (uterine prolapse) favors the prolapse of the rectum and bladder.
   Also, surgical removal of the uterus causes dilation of the bladder and rectum.
   The consequences are:
   • urinary problems,
   • poor functioning of the intestine,
   • Prolapse of the rectum and bladder.
4. Weakening of the sphincter. This is a sphincter that controls the exit of the faeces from the rectum.
5. Previous damage to the pelvis and anus.
6. Nerve damage. If the nerves that control the closing ability of the muscles of the rectum and anus are damaged, this can lead to rectal prolapse. Nerve damage can be caused by:
   • Pregnancy
   • vaginal birth,
   • paralysis of the sphincter,
   • spinal cord traumas,
   • back injuries,
   • Operations in the pelvic zone.
7. Other diseases, disorders and infections. Rectal prolapse can be the result of:
   • cystic fibrosis,
   • chronic obstructive pulmonary disease,
   • removal of the uterus (hysterectomy),
   • intestinal infection by parasites (for example, pinworms and whipworms,
   • colorectal tumor,
   • anorexia – according to proctologist Antonio Longo, anorexia causes a weakening of the intestinal retaining tissue,
   • Overweight – increases pressure in the abdomen and indirectly in the pelvis.

Symptoms of rectal prolapse

The signs and symptoms of rectal prolapse depend on its severity, among which can be found:

• pain in the abdomen and in the area of the sacrum;
• blood loss and mucus discharge from the anus;
• feeling of incomplete bowel emptying, the rectum never completely empties after defecation;
• difficulty emptying stool;
• protrusion of the rectum from the anus;
• feeling of heaviness at the level of the anus, which increases when standing and after defecation;
• Itch;
• episodes of constipation alternating with diarrhea;
• departure of liquid stool, especially after bowel movements;
• Fecal incontinence or decreased ability to control the bowel.

Rectal pain
Rectal prolapse can cause dull pain in the rectum, but this symptom does not apply in all cases and can vary from person to person.
The pain may also occur with a rectal ulcer (ulcer) that may have been caused by the rectal prolapse.
As a rule, ulceration occurs near the edge of the anus and may be accompanied by rectal bleeding.
Rectal pain should be closely examined by a doctor.

Diagnosis of rectal prolapse

The doctor diagnoses the rectal prolapse by analyzing the patient’s medical history and through special examinations.
In cases of complete prolapse, where the rectum returns to its position after defecation, the doctor asks the patient to squeeze as in bowel movements to demonstrate the prolapse and confirm the diagnosis.

If there is a suspicion of internal prolapse, diagnostic examinations include:

• Defecography – a radiological examination in which the doctor injects a contrast agent into the rectum, more precisely into the ampoula recti, to simulate the presence of feces. Then X-rays are taken of the seated patient while tensing the pelvic floor muscles.
• MRI defecography – An aqueous gel (about 180 cc) is inserted into the rectum via a rectal probe. The examination lasts 20-30 minutes and is divided into two phases:
  • Static phase – the patient remains calm.
  • Dynamic phase – the patient tenses the muscles and then presses as during bowel movements, but must hold the gel.
• Manorectal manometry (measurement of muscle activity).

If the patient has had rectal bleeding, the doctor may decide to conduct a series of examinations to check for the presence of another condition, such as colon cancer.

About 10% of children with cystic fibrosis have rectal prolapse.

Therapy for rectal prolapse

Treatment depends on many different factors, such as:

• age of the person,
• severity of prolapse,
• other pelvic abnormalities (such as bladder prolapse).

Diet and nutrition for rectal prolapse

Changes in diet and lifestyle to treat chronic constipation, for example, by consuming:

• Fruit – juicy fruit or almonds and nuts, without exaggeration,
• Vegetable.
• Legumes.

In addition, drink enough and exercise regularly.
These measures are usually sufficient for the successful treatment of rectal prolapse in young children.

Surgery for rectal prolapse

Sometimes surgery is performed to fix the rectum in its place and to remove the prolapsed part.
It can be performed through the abdomen or through the patient’s anus.

• Transabdominal rectopexy involves ligation of the rectum on the sacrum.
• Another transperineal or transabdominal surgery involves removing the prolapsed part of the rectum to restore almost normal bowel function.

Although abdominal surgery brings better results in the long run, surgeons in older people usually choose to work through the anus because recovery is faster with this method.

The different techniques of the procedure are:

• Laparotomy (open abdominal surgery) – The doctor performs a single, large abdominal incision.
  Then the surgeon carefully shifts the overlying organs.
  To prevent the rectum from sinking, he lifts it and sews it directly to the inner surface of the sacrum.
  It can be fastened with stitches (Frykman-Goldberg method) or with a mesh of synthetic material (Wells rectopexy).
  Sometimes a small part of the intestine can be removed.
• Laparoscopy (minimally invasive abdominal surgery) – Laparoscopy can only be performed in some cases.
  Thin instruments are inserted into the abdominal wall through a series of small incisions.
  The recovery time after laparoscopy is shorter than with open abdominal surgery.
• surgery – Under anesthesia, the surgeon carefully pulls the prolapse of the intestine through the anus.
  The prolapsed intestinal section is removed, then the damaged structures are restored.
  The latest techniques are rigid surgery (forklift-assisted trans-rectal resection) and longo method; a special staple suture device is used to remove part of the rectal mucosa and attach a suture.
  In the past, after surgery for prolapse or hemorrhoids, the patient had severe pain during bowel movements for several months, and the doctor prescribed pain-relieving opiates that led to constipation and hard stools. During defecation, the patient thus had even greater pain.

After surgery of rectal prolapse

After the operation of rectal prolapse, a number of steps are required until complete healing:

• Hospital nurses monitor and control temperature, pulse, breathing and blood pressure.
• An infusion is applied over the arm to replace fluid in the body.
• The doctor prescribes painkillers and antibiotics.
• The day after the procedure, the doctor prescribes laxatives to the patient to favor the first bowel movement.
  Defecation shortly after surgery can provoke pain and bleeding.
• You can get a bladder catheter for the day after until the bladder has emptied completely.
• You can walk again when the effect of the anesthetic wears off and you have control over your legs again.
• In perianal procedures, a bandage is inserted into the canal for hemostasis and it is removed the same day or the day after surgery.
• Hospitalization after transperineal surgery can last two to six days.
  For transabdominal interventions, hospitalization is 7-10 days.
  Check-ups are carried out by the doctor.

What is the success rate of the operation?
The abdominal procedure has a lower probability of recurrence than the procedure via the anus.
In most cases, however, the operation means a correction of the prolapse.

Prognosis and recovery time after rectal prolapse surgery

With timely and proper treatment, most people who undergo surgery have few or no symptoms associated with rectal prolapse after surgery.
However, several factors contribute to the quality and speed of the patient’s recovery, including:

• Age
• severity of prolapse,
• type of operation,
• general state of health.

Prevention of rectal prolapse

Recommendations to minimize deformations in rectal prolapse:

• Avoid constipation by good bowel movement technique;
• Reduce body weight to reduce pressure on prolapse.

Physical training

• strengthening the pelvic floor muscles through Kegel exercises along with exercises against rectal prolapse to support the rectum;
• use the pelvic floor muscles to block the increase in pressure in the abdomen when coughing or sneezing;
• stay in shape with prolapse problems through rehabilitation exercises.
• Avoid positions such as the low squat as they can make the situation worse.
• Avoid lifting heavy loads and standing for long periods.

Tips for hygiene and reducing faecal incontinence to a minimum:

• Maintaining a soft, well-formed stool texture – watery diarrhea could go off against the patient’s will.
• Alcohol-free wet wipes or wipes can help keep the anus clean. To finish cleaning, use a wet wipe.
• Avoid irritating substances such as caffeine and spicy foods as much as possible.
• Use a care cream around the area to avoid wounds.
• A regular cotton ball to remove eye makeup can act as a good barrier against foul odor and mucus leakage.

• External and internal hemorrhoids
• Pain and burning in the area
• rhagades