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Join for FREE Log in My subscriptions Videos I like My playlists. The different kinds of rectal prolapse can be difficult to grasp, as different definitions are used and some recognize some subtypes and others do not.
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Essentially, rectal prolapses may be. External complete rectal prolapse rectal procidentia, full thickness rectal prolapse, external rectal prolapse is a full thickness, circumferential, true intussusception of the rectal wall which protrudes from the anus and is visible externally.
Internal rectal intussusception occult rectal prolapse, internal procidentia can be defined as a funnel shaped infolding of the upper rectal or lower sigmoid wall that can occur during defecation. However, a publication by the American Society of Colon and Rectal Surgeons stated that internal rectal intussusception involved the mucosal and submucosal layers separating from the underlying muscularis mucosa layer attachments, resulting in the separated portion of rectal lining "sliding" down.
Mucosal prolapse partial rectal mucosal prolapse  refers to prolapse of the loosening of the submucosal attachments to the muscularis propria of the distal rectummucosal layer of the rectal wall.
Most sources define mucosal prolapse as an external, segmental prolapse which is easily confused with prolapsed 3rd or 4th degree hemorrhoids piles.
Internal mucosal prolapse rectal internal mucosal prolapse, RIMP refers to prolapse of the mucosal layer of the rectal wall which does not protrude externally. There is some controversy surrounding this condition as to its relationship with hemorrhoidal disease, or whether it is a separate entity. Solitary rectal ulcer syndrome SRUS, solitary rectal ulcer, SRU occurs with internal rectal intussusception and is part of the spectrum of rectal prolapse conditions.
Mucosal prolapse syndrome MPS is recognized by some. It includes solitary rectal ulcer syndrome, rectal prolapse, proctitis cystica profunda, and inflammatory polyps. Rectal prolapse and internal rectal intussusception has been classified according to the size of the prolapsed section of rectum, a function of rectal mobility from the sacrum and infolding of the rectum.
This classification also takes into account sphincter relaxation: . Rectal internal mucosal prolapse has been graded according to the level of descent of the intussusceptum, which was predictive of symptom severity: .
The height of intussusception from the anal canal is usually estimated by defecography. Recto-rectal high intussusception intra-rectal intussusception is where the intussusception starts in the rectum, does not protrude into the anal canal, but stays within the rectum.
the intussusceptum originates in the rectum and does not extend into the anal canal. The intussuscipiens includes rectal lumen distal to the intussusceptum only. These are usually intussusceptions that originate in the upper rectum or lower sigmoid. Recto-anal low intussusception intra-anal intussusception is where the intussusception starts in the rectum and protrudes into the anal canal i.
the intussusceptum originates in the rectum, and the intussuscipiens includes part of the anal canal.
An Anatomico-Functional Classification of internal rectal intussusception has been described,  with the argument that other factors apart from the height of intussusception above the anal canal appear to be important to predict symptomology.
The parameters of this classification are anatomic descent, diameter of intussuscepted bowel, associated rectal hyposensitivity and associated delayed colonic transit:. Patients may have associated gynecological conditions which may require multidisciplinary management.
Fecal incontinence may also influence the choice of management. Rectal prolapse may be confused easily with prolapsing hemorrhoids. In full thickness rectal prolapse, these folds run circumferential. In mucosal prolapse, these folds are radially.
Furthermore, in rectal prolapse, there is a sulcus present between the prolapsed bowel and the anal verge, whereas in hemorrhoidal disease there is no sulcus. The prolapse may be obvious, or it may require straining and squatting to produce it.
Altemeier Procedure for Complete Rectal Prolapse
The perianal skin may be macerated softening and whitening of skin that is kept constantly wet and show excoriation. In addition, patients are frequently elderly and therefore have increased incidence of colorectal cancer. Full length colonoscopy is usually carried out in adults prior to any surgical intervention.
This investigation is used to diagnose internal intussusception, or demonstrate a suspected external prolapse that could not be produced during the examination.
Colonic transit studies may be used to rule out colonic inertia if there is a history of severe constipation. This investigation objectively documents the functional status of the sphincters.
However, the clinical significance of the findings are disputed by some. STARRand these patients may benefit from post-operative biofeedback therapy. Decreased squeeze and resting pressures are usually the findings, and this may predate the development of the prolapse. It may be used to evaluate incontinence, but there is disagreement about what relevance the results may show, as rarely do they mandate a change of surgical plan.
Rectal prolapse is a "falling down" of the rectum so that it is visible externally. The appearance is of a reddened, proboscis-like object through the anal sphincters. Patients find the condition embarrassing.
The true incidence of rectal prolapse is unknown, but it is thought to be uncommon.
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As most sufferers are elderly, the condition is generally under-reported. It is rare in men over 45 and in women under Anatomical differences such as the wider pelvic outlet in females may explain the skewed gender distribution.
Associated conditions, especially in younger patients include autism, developmental delay syndromes and psychiatric conditions requiring several medications.
Initially, the mass may protrude through the anal canal only during defecation and straining, and spontaneously return afterwards.
Later, the mass may have to be pushed back in following defecation. This may progress to a chronically prolapsed and severe condition, defined as spontaneous prolapse that is difficult to keep inside, and occurs with walking, prolonged standing,  coughing or sneezing Valsalva maneuvers.
If the prolapse becomes trapped externally outside the anal sphincters, it may become strangulated and there is a risk of perforation. The precise cause is unknown,    and has been much debated.
This theory was based on the observation that rectal prolapse patients have a mobile and unsupported pelvic floor, and a hernia sac of peritoneum from the Pouch of Douglas and rectal wall can be seen. Shortly after the invention of defecographyIn Broden and Snellman used cinedefecography to show that rectal prolapse begins as a circumferential intussusception of the rectum,   which slowly increases over time. Since most patients with rectal prolapse have a long history of constipation,  it is thought that prolonged, excessive and repetitive straining during defecation may predispose to rectal prolapse.
obstructed defecation and anatomical factors:  . Some authors question whether these abnormalities are the cause, or secondary to the prolapse. Some authors suggest that pudendal nerve damage is the cause for pelvic floor and anal sphincter weakening, and may be the underlying cause of a spectrum of pelvic floor disorders. Sphincter function in rectal prolapse is almost always reduced.
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Alternatively, the intussuscepting rectum may lead to chronic stimulation of the rectoanal inhibitory reflex RAIR - contraction of the external anal sphincter in response to stool in the rectum. The RAIR was shown to be absent or blunted. Squeeze maximum voluntary contraction pressures may be affected as well as the resting tone.
This is most likely a denervation injury to the external anal sphincter. The assumed mechanism of fecal incontinence in rectal prolapse is by the chronic stretch and trauma to the anal sphincters and the presence of a direct conduit the intussusceptum connecting rectum to the external environment which is not guarded by the sphincters.
The assumed mechanism of obstructed defecation is by disruption to the rectum and anal canal's ability to contract and fully evacuate rectal contents. The intussusceptum itself may mechanically obstruct the rectoanal lumencreating a blockage that straining, anismus and colonic dysmotility exacerbate. Some believe that internal rectal intussusception represents the initial form of a progressive spectrum of disorders the extreme of which is external rectal prolapse.
The intermediary stages would be gradually increasing sizes of intussusception. However, internal intussusception rarely progresses to external rectal prolapse. Surgery is thought to be the only option to potentially cure a complete rectal prolapse.
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Dietary adjustments, including increasing dietary fiber may be beneficial to reduce constipation, and thereby reduce straining. psyllium or stool softener can also reduce constipation.
Surgery is often required to prevent further damage to the anal sphincters. The goals of surgery are to restore the normal anatomy and to minimize symptoms. There is no globally agreed consensus as to which procedures are more effective,  and there have been over 50 different operations described. Surgical approaches in rectal prolapse can be either perineal or abdominal.
A perineal approach or trans-perineal refers to surgical access to the rectum and sigmoid colon via an incision around the anus and perineum the area between the genitals and the anus.
Procedures for rectal prolapse may involve fixation of the bowel rectopexyor resection a portion remove or both. The abdominal approach carries a small risk of impotence in males e. Laparoscopic procedures Recovery time following laparoscopic surgery is shorter and less painful than following traditional abdominal surgery.
The perineal approach generally results in less post-operative pain and complications, and a reduced length of hospital stay.
These procedures generally carry a higher recurrence rate and poorer functional outcome. The goal of Perineal rectosigmoidectomy is to resect or remove the redundant bowel. This is done through the perineum. The lower rectum is anchored to the sacrum through fibrosis in order to prevent future prolapse.
Redundant rectal and sigmoid wall is removed and the new edge of colon is reconnected anastomosed with the anal canal with stitches or staples. This is a modification of the perineal rectosigmoidectomy, differing in that only the mucosa and submucosa are excised from the prolapsed segment, rather than full thickness resection.
The muscle layer that is left is plicated folded and placed as a buttress above the pelvic floor. This procedure can be carried out under local anaesthetic. After reduction of the prolapse, a subcutaneous suture a stich under the skin or other material is placed encircling the anus, which is then made taut to prevent further prolapse.
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Complications include breakage of the encirclement material, fecal impaction, sepsis, and erosion into the skin or anal canal. Recurrence rates are higher than the other perineal procedures. This procedure is most often used for people who have a severe condition or who have a high risk of adverse effects from general anesthetic,  and who may not tolerate other perineal procedures. Internal rectal intussusception rectal intussusception, internal intussusception, internal rectal prolapse, occult rectal prolapse, internal rectal procidentia and rectal invagination is a medical condition defined as a funnel shaped infolding of the rectal wall that can occur during defecation.
This phenomenon was first described in the late s when defecography was first developed and became widespread. Internal intussusception may be asymptomaticbut common symptoms include: .
Recto-rectal intussusceptions may be asymptomaticapart from mild obstructed defecation.