Herand Abcarian John H Pemberton

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Rectal prolapse is a relatively common condition. Appropriate management relies on the accuracy of diagnosis and a rational therapeutic plan. The following definitions should help clarify the various protrusions encountered in the anorectum. Mucosal prolapse is abnormal descent of the rectal mucosa ( Fig. 30-1 ).

Complete rectal prolapse or procidentia indicates intussusception of all layers of the rectal wall through the anus (see Fig. 30-1C ).

Occult rectal prolapse is incomplete rectal prolapse: the prolapse does not protrude though the anus and can be diagnosed reliably only through the use of defecating proctography.

Pouch-of-Douglas hernia ( Fig. 30-2 ) originates in the cul-de-sac of Douglas and protrudes through the anterior rectal wall and then out through the anus. The term sigmoidocele has been somewhat confusingly used to describe this type of prolapse. MUCOSAL PROLAPSE—HEMORRHOIDS Symptoms and Diagnosis

Mucosal prolapse protrudes from the anus and in the early stages is small, occurs only after defecation, and reduces spontaneously. Later, the protrusion occurs more frequently, becomes larger, and must be reduced manually. Over time, the mucosa protrudes with the slightest effort even with standing, remains irreducible, causes seepage of mucus, and stains the underclothes. Erosion and ulceration of the protruding mucosa lead to frequent bleeding. Continuous dilatation of the anal canal leads to varying degrees of incontinence. Severe pain is rare and occurs only if the prolapsed mucosa becomes strangulated or severely edematous.

The protruding mass has radiating furrows, which are often associated with internal hemorrhoids. These are located in the right posterior, right anterior, and left lateral positions ( Fig. 30-3^ ). This pattern helps distinguish it from a true procidentia, in which the protruding mass has circular furrows ( Fig. 30-35 ). Even in older individuals, rectal examination demonstrates good sphincter tone, and the size rarely exceeds 3 cm. The criteria that differentiate the two types of rectal prolapse are listed in Table 30-1 .

Palpation of the mucosal prolapse, with the index finger in the anal canal and the thumb gently squeezing the mass, reveals only the thickness of the doubled mucosal layer. The protrusion should be reduced gently, and anoscopic and proctosigmoidoscopy examination should be carried out to exclude the presence of tumor, polyps, intussusception, or procidentia before the appropriate treatment is determined.



The treatment of prolapse of the rectal mucosa includes the removal of or relief from any obvious contributing factor such as polyps, diarrhea, constipation, malnutrition, and obstructive uropathy. Next, the treatment of mucosal rectal prolapse depends on the age of the patient and the severity of the condition. Aggressive treatment with bulking agents (psyllium seed products) is key. Rubber Band Ligation

An effective method for the treatment of prolapsing hemorrhoids that are not responsive to medical management is rubber band ligation. With a McGivney or Barron hemorrhoidal ligator, a rubber band is placed at the apex of the prolapsing mucosa. Additional quadrants may be ligated in 1- to 2-week intervals until the prolapse is eliminated. For details of the technique and complications of the procedure, see Chapter 29 .


If anal sphincter function is adequate, simple hemorrhoidectomy yields excellent results. At the time of hemorrhoidectomy, the redundant rectal mucosa is excised, and the area is fixed to the internal sphincter with a running absorbable suture. With attention to technical detail, excellent functional results can be achieved, with no stricture, mucosal ectropion, or fecal incontinence (see Chapter 29 ). The results of hemorrhoidectomy in the presence of anorectal incontinence, however, are unsatisfactory. In patients with significant sphincter injury or in women with a traumatic cloaca, sphincteroplasty combined with the excision of prolapsing rectal mucosa may yield better results. PROCIDENTIA (COMPLETE RECTAL PROLAPSE)

Multiple series of patients with complete rectal prolapse document the disabling and therapeutically challenging

Figure 30-2 Rectal procidentia as conceived by Moschowitz. This is known as a pouch-of-Douglas hernia. (After Goldberg, S.M., and Gordon, P.H.: Clin. Gastroenterol., 4/490,1975.)

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