Rectal prolapse

Specialty: Gastrointestinal.

• Protrusion of the rectal mucosa
• complete rectal prolapse
• rectal origin

Why it occurs

• Weakness of the muscular structures supporting the pelvic floor and rectal fixation fascia due to senility, multiparity or previous pelvic operations
• Chronic defecatory straining secondary to persistent constipation or anal dyssynergia
• Persistent increase in intra-abdominal pressure (chronic cough in COPD, tense ascites, morbid obesity)
• Pudendal nerve neuropathy or cauda equina lesions with pelvic denervation.

Initial workup

Detailed anorectal physical examination at rest and under Valsalva maneuver (ask the patient to push up from a squatting position to observe the complete circumferential protrusion and differentiate it from prolapsed hemorrhoids that show radial grooves) | Magnetic resonance defecography (to evaluate pelvic multicompartment prolapse) | Anorectal manometry (frequent associated anal sphincter hypotonia) | Colonoscopy (mandatory before any attempt at surgical repair to rule out proximal colonic masses as a triggering factor).

Standard management

• Osmotic laxatives — polyethylene glycol 17 g per day to ensure soft stools and avoid excessive straining that exacerbates prolapse
• Soluble fiber — psyllium 5-10 g per day to optimize fecal consistency
• Topical anesthetics with low-dose corticosteroids — lidocaine cream with hydrocortisone to temporarily reduce inflammation of manually reduced prolapsed mucosa
• Topical application of emergency granulated sugar (acts as a local dehydrating osmotic agent to reduce edema of the prolapsed mucosa and facilitate its manual reduction).