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Emergency And Acute Medicine – Rectal Prolapse
Rectal prolapse is a full-thickness evagination of the rectal wall outside the anal opening. Three types are recognized: full-thickness prolapse, which is the most common and involves protrusion of the rectal wall through the anal canal; partial thickness (mucosal) prolapse, where only mucosa protrudes; and occult (internal) prolapse or rectal intussusception, where prolapse occurs without external protrusion and may be difficult to diagnose.
The cause is unclear and likely multifactorial. Contributing factors include chronic constipation and excessive straining, laxity or weakness of the pelvic floor and sphincter (often related to pelvic floor trauma or childbearing), and neurologic disease. It is more common in women, with a peak incidence in the seventh decade. In children, true rectal prolapse is unusual after age four; pediatric cases should prompt consideration of contributing conditions such as chronic diarrhea, parasitic infection, cystic fibrosis, or malnutrition.
Patients typically present with a dark red mass protruding from the rectum, sometimes with mucous or bloody discharge. They may report a sensation of rectal fullness or mass, tenesmus, constipation, or fecal incontinence. History should focus on duration, progression, and any evidence of bowel obstruction. Early prolapse may reduce spontaneously but often becomes progressively more frequent and persistent.
Diagnosis is clinical and relies on careful physical examination. True rectal prolapse appears as a dark red mass at the anal verge with circumferential circular folds in the beefy mucosa. Mucosal prolapse is usually only a few centimeters and lacks the circular folds of the muscular layer. Internal hemorrhoids have folds that radiate like spokes rather than circular rings. Prolapsed hemorrhoids and polyps do not involve the entire rectal mucosa and do not have a central lumen-like opening. Intussusception may present with intermittent severe abdominal pain and a more ill-appearing patient; on exam, a finger can be passed between the apex of the prolapsed bowel and the anal sphincter, whereas in rectal prolapse the protruding mucosa is continuous with perianal skin.
No laboratory tests or imaging are required for uncomplicated prolapse. Preoperative evaluation may be needed if the prolapse is incarcerated and the patient is heading to the operating room.
Prehospital care includes placing the patient in a position of comfort, preventing mucosal drying with moist gauze, and avoiding trauma to the exposed tissue. Most simple prolapse does not require extensive stabilization. If the prolapse is incarcerated or ischemic, keep the patient NPO, provide IV fluids, and prepare for possible surgery.
Emergency department management focuses on manual reduction. Position the patient in a knee-chest position and apply gentle, steady pressure for 5–15 minutes, inverting the mucosa back through the lumen from distal to proximal. Sedation can be used if needed to relax the sphincter, and a finger in the rectum can help guide reduction. For large or difficult reductions, applying about one-half to one cup of sugar to the prolapsed tissue can reduce edema and facilitate reduction. If the prolapse immediately recurs after reduction, a pressure dressing with lubricant, gauze, and tape can be applied, and the buttocks may be taped together for several hours. If the prolapse is ischemic or incarcerated, if reduction fails, or if prolapse frequently recurs, admission for emergent surgical management is indicated.
A key danger is constriction of blood flow by the anal sphincter, which can cause ischemia, venous obstruction, thrombosis, and full-thickness necrosis with potential loss of bowel. Timely reduction decreases risk, and ischemic mucosa requires surgical intervention. Common complications after reduction include localized pain and self-limited mucosal bleeding.
Patients can be discharged if the prolapse is reduced, they are stable and tolerating oral intake, and they receive instructions to address contributing factors, especially constipation management with stool softeners, increased fluids, higher dietary fiber, and avoiding prolonged sitting or straining. Follow-up with colorectal surgery is recommended, especially for recurrent prolapse or evaluation for a possible leading lesion. In children, evaluation for cystic fibrosis should be considered as part of follow-up.
Rectal prolapse is a full-thickness evagination of the rectal wall outside the anal opening. Three types are recognized: full-thickness prolapse, which is the most common and involves protrusion of the rectal wall through the anal canal; partial thickness (mucosal) prolapse, where only mucosa protrudes; and occult (internal) prolapse or rectal intussusception, where prolapse occurs without external protrusion and may be difficult to diagnose.
The cause is unclear and likely multifactorial. Contributing factors include chronic constipation and excessive straining, laxity or weakness of the pelvic floor and sphincter (often related to pelvic floor trauma or childbearing), and neurologic disease. It is more common in women, with a peak incidence in the seventh decade. In children, true rectal prolapse is unusual after age four; pediatric cases should prompt consideration of contributing conditions such as chronic diarrhea, parasitic infection, cystic fibrosis, or malnutrition.
Patients typically present with a dark red mass protruding from the rectum, sometimes with mucous or bloody discharge. They may report a sensation of rectal fullness or mass, tenesmus, constipation, or fecal incontinence. History should focus on duration, progression, and any evidence of bowel obstruction. Early prolapse may reduce spontaneously but often becomes progressively more frequent and persistent.
Diagnosis is clinical and relies on careful physical examination. True rectal prolapse appears as a dark red mass at the anal verge with circumferential circular folds in the beefy mucosa. Mucosal prolapse is usually only a few centimeters and lacks the circular folds of the muscular layer. Internal hemorrhoids have folds that radiate like spokes rather than circular rings. Prolapsed hemorrhoids and polyps do not involve the entire rectal mucosa and do not have a central lumen-like opening. Intussusception may present with intermittent severe abdominal pain and a more ill-appearing patient; on exam, a finger can be passed between the apex of the prolapsed bowel and the anal sphincter, whereas in rectal prolapse the protruding mucosa is continuous with perianal skin.
No laboratory tests or imaging are required for uncomplicated prolapse. Preoperative evaluation may be needed if the prolapse is incarcerated and the patient is heading to the operating room.
Prehospital care includes placing the patient in a position of comfort, preventing mucosal drying with moist gauze, and avoiding trauma to the exposed tissue. Most simple prolapse does not require extensive stabilization. If the prolapse is incarcerated or ischemic, keep the patient NPO, provide IV fluids, and prepare for possible surgery.
Emergency department management focuses on manual reduction. Position the patient in a knee-chest position and apply gentle, steady pressure for 5–15 minutes, inverting the mucosa back through the lumen from distal to proximal. Sedation can be used if needed to relax the sphincter, and a finger in the rectum can help guide reduction. For large or difficult reductions, applying about one-half to one cup of sugar to the prolapsed tissue can reduce edema and facilitate reduction. If the prolapse immediately recurs after reduction, a pressure dressing with lubricant, gauze, and tape can be applied, and the buttocks may be taped together for several hours. If the prolapse is ischemic or incarcerated, if reduction fails, or if prolapse frequently recurs, admission for emergent surgical management is indicated.
A key danger is constriction of blood flow by the anal sphincter, which can cause ischemia, venous obstruction, thrombosis, and full-thickness necrosis with potential loss of bowel. Timely reduction decreases risk, and ischemic mucosa requires surgical intervention. Common complications after reduction include localized pain and self-limited mucosal bleeding.
Patients can be discharged if the prolapse is reduced, they are stable and tolerating oral intake, and they receive instructions to address contributing factors, especially constipation management with stool softeners, increased fluids, higher dietary fiber, and avoiding prolonged sitting or straining. Follow-up with colorectal surgery is recommended, especially for recurrent prolapse or evaluation for a possible leading lesion. In children, evaluation for cystic fibrosis should be considered as part of follow-up.
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