Rectal prolapse
Rectal prolapse (rectal prolapse) is a pathology of the rectum, during the development of which this intestine exits out through the anus. The severity of the disease depends on how much the rectum falls out (only the mucous membrane or all the walls) and under what conditions. The main method of treatment of rectal prolapse is surgical. Rectal prolapse can affect everyone, regardless of gender and age, but in childhood and old age, this disease is much more common.
The content of the article:
Causes of rectal prolapse
Classification of types and degrees of rectal prolapse
Symptoms of rectal prolapse
Diagnosis of rectal prolapse
Treatment of rectal prolapse
Prognosis for rectal prolapse
Rectal prolapse
Causes of rectal prolapse
The main cause of rectal prolapse is the weakness of the pelvic floor muscles, the development of which is facilitated by a number of predisposing factors:
difficult delivery. Quite often, with improper straining, prolonged and severe childbirth, women have complications of labor in the form of rectal prolapse;
genetic predisposition. In patients who have a history of close relatives with this pathology, the risk of rectal prolapse increases significantly;
unconventional sex life. In conditions of non-traditional sexual acts, rectal injuries very often occur, which cause rectal prolapse;
neurological diseases that have a close connection with injuries or diseases of the spinal cord;
decreased tone of the sphincter and sprain of the ligaments supporting the rectum. Most often, such a cause of rectal prolapse occurs in the elderly;
general disorder of the functioning of the pelvic organs, acute and chronic diseases of the gastrointestinal tract;
the habit of straining hard during defecation, long sitting on the potty (children) or on the toilet (adults);
increased pressure inside the peritoneum;
vertical position of the sacrum and coccyx;
very deep rectal-uterine recess;
surgical interventions on the pelvic organs.
Very often, the cause of this pathology is not one factor, but several at the same time, which greatly complicates treatment.
The identification and elimination of predisposing factors is a very important point on the way to the correct therapy of this pathology.
Classification of types and degrees of rectal prolapse
As with most pathologies known to medicine, rectal prolapse does not have a single classification, but there is still a classification that doctors most often use in their practice. This classification is developed on the basis of the quantitative ratio of the rectal area that has fallen out, as well as the degree of inclusion in the process of the nearest parts of the colon or only the anus. This classification implies that each of the forms of rectal prolapse is a certain degree of a single pathological process. To date , four degrees of rectal prolapse have been identified:
partial prolapse of the rectum (mainly its mucous membrane);
complete prolapse of the colon with eversion of the dentate line (skin-mucosal border) of the anal canal;
prolapse of the rectum, as well as invagination of the above-located parts of the large intestine.
As for the typology of rectal prolapse, it is represented by two options:
the hernial type of rectal prolapse is caused by the displacement of the anterior wall of the rectum downwards and its exit through the anus;
the invagination type is characterized by the indentation of the sigmoid or rectum between the walls of the anus.
Symptoms of rectal prolapse
The symptoms of the disease depend on the nature of the pathology. The acute course of the disease is characterized by the sudden appearance of symptoms of rectal prolapse, which, as a rule, occurs after an increase in intraperitoneal pressure as a result of childbirth or heavy physical exertion, as well as in conditions of weakening of the anal sphincter and muscles of the bottom of the peritoneum, after sneezing, a sharp cough, etc. As a result of such episodes, the rectum may fall out for a considerable length (about 8-10 cm). The process of loss is accompanied by severe sharp pain, which often provokes a state of collapse or shock in the patient.
With a gradual (chronic) course of the process, a slow gradation of difficulty in defecation is carried out, which turns into a chronic process that minimizes the effectiveness of performing cleansing enemas and taking laxatives. At the same time, any defecation becomes painful for the patient, and intraperitoneal pressure is constantly increasing. Over time, the rectum falls out more and more, although at first it is possible to easily, even independently, set it for the anal canal. After some time, after acts of bowel movements, the intestine has to be adjusted manually. With the progression of the disease, the intestine begins to fall out not only during defecation, but also during sneezing, coughing, and even when getting out of bed or from a chair. With both variants of the development of the disease (acute and chronic), the main complaint of patients is precisely the prolapse of the rectum from the anus.
In 80% of patients with rectal prolapse, incontinence of intestinal contents is noted, which is especially common in the chronic course of this disease in women. Half of all patients develop various dysfunctional disorders of the rectum, the clinical manifestation of which may be chronic constipation, which forces patients to constantly use cleansing enemas or laxatives. Chronic diarrhea can also be a symptom of this disease, but they are much less common.
Pain syndrome has a pronounced severity in the case of acute illness, with chronic rectal prolapse, patients feel dull pain in the lower abdomen, which increases with significant physical exertion, walking or in the process of defecation. The pain may decrease or disappear after rectal reduction.
Also, with rectal prolapse, mucosal or bloody discharge often appears. Spotting can occur against the background of constant injury to small vessels of the rectum.
Patients often complain about the subjective sensation of a foreign body in the rectum and the presence of false urges to defecate. Rectal prolapse can be combined with uterine prolapse, while patients have the urge to urinate frequently, sometimes it can be intermittent.
Diagnosis of rectal prolapse
Diagnosis of this pathology begins with anamnesis and examination of the patient. When examining the patient’s anus, the anus is visualized, often a gaping anus, which indicates a weakening of the structures of the bottom of the peritoneum, responsible for maintaining the rectum and sphincter. During this examination, the nature of intestinal prolapse is determined, as well as the condition of the skin of the perianal region, thighs and perineum, very often the skin is inflamed.
Finger examination makes it possible to determine hypotension and weakness of sphincter contractions, as well as straightening of the anorectal angle. In this study, internal intussusception of the sigmoid or rectum can be diagnosed. If the patient has a concomitant pathology of an inflammatory nature (proctitis), during the finger examination, the patient will complain about the painfulness of the procedure, and the doctor determines the thickening of the walls of the anal canal.
The size and shape of the rectal prolapse, as well as the condition of its mucous membrane, should be determined when straining the patient over the tray, in a squatting position. The length of the falling fragment of the intestine can be different — from a slight inversion of its mucous membrane (1-2 cm) to complete loss of the rectum and part of the sigmoid colon. The fallen gut can have a different shape: spherical, cone-shaped, cylindrical, ovoid. Ovoid prolapse of the intestine indicates hypotension of the stretched intestinal wall.
Prolapse of the colon mucosa is most common in children. The fallen part of the intestine in this case has the shape of a roller or node. When the anus falls out, a circular protrusion of all the walls of the anus is visualized, it looks as if turned inside out, and the mucous membrane does not have a circular recess and passes into the skin of the anus. In the case of complete prolapse of the rectum, all its layers are turned outwards, accompanied by atony of the sphincter. The fallen gut is presented in the form of a cone or cylinder of different sizes, most often about 20 cm, the anal canal does not shift. The surface of the deformed part of the intestine can be smooth (if only the mucous membrane has fallen out) or folded (if all layers have fallen out). A feature of this form of prolapse is the presence of a circular groove (fold), the depth of which reaches from 1 to 6 cm, and it is localized between the skin of the anus and the wall of the rectum. Such a groove does not happen when the rectum falls out together with the anus. If there is a jagged line on the conglomerate, this is a sign of the loss of the walls of the anal canal.
In most cases, the anterior wall of the collapsed intestine is longer than the posterior wall and visually the entire intestine is facing slightly from behind, the opening of the rectum has the same direction. If the size of the dropped intestine is more than fifteen centimeters, there is a high probability that part of the sigmoid colon has also fallen out.
With a large size of the fallen intestine, it is possible to protrude into the peritoneal pocket of the small intestinal loop, according to the type of perineal hernia. The fallen area acquires a spherical shape, up to 30 cm long and about 30-40 cm in circumference. For the differential diagnosis of the conglomerate, palpatory examination, percussion, and X-ray contrast examination are performed.
Upon examination, the mucous membrane of the fallen intestine is edematous and hyperemic, under conditions of prolonged prolapse, significant changes occur on it, it can become dry, with fibrous-purulent overlays, extensive ulceration and profuse hemorrhage. At the initial stage, with the preserved tone of the muscles of the bottom of the peritoneum, the reduction of the intestine is very painful and requires the application of certain efforts. Over time, the muscles lose their tone and the rectification of the intestine is carried out by pulling the muscles or manually. Patients do this on their own, it is enough for them to lean forward, but sometimes the correction becomes possible only with outside help. The difficulty of reduction is caused by the development of edema of the intestinal walls.
At the beginning of the disease, infringements of the fallen rectum may occur, which are fraught with a violation of blood circulation in the affected area and necrosis of the tissues of the fallen intestine. In severe cases, in the absence of timely treatment, the patient may develop peritonitis. Sometimes the infringement of the rectum is complicated by the development of symptoms of intestinal obstruction (fecal vomiting, pain), which can provoke a fatal outcome.
Other complications of rectal prolapse include bleeding from the pathological site, as well as ulceration of the fallen intestine.
Treatment of rectal prolapse
Rectal prolapse requires timely treatment and how to perform it correctly is decided by a proctologist. The tactics of treatment of this pathology depends on the degree and form of rectal prolapse, as well as on the etiology of the disease. The main methods of therapy are conservative and surgical treatment.
Conservative therapy is appropriate during pregnancy in women and in the initial stages of the disease. In this case, the complex of therapeutic measures includes the exclusion of heavy physical exertion, drug elimination of constipation, and individual physical exercises are selected to strengthen the pelvic floor muscles. To date, almost all specialists are inclined to believe that the treatment of external rectal prolapse should be carried out only surgically (except for the presence of direct contraindications). And with internal prolapses (invaginations), a complex of therapeutic measures of a conservative nature should be carried out first. There are many approaches to the surgical treatment of this pathology, which differ in the technique of the operation, the choice of anesthesia and the features of the instruments involved. All operations to eliminate rectal prolapse can be divided into the following types:
rectal resection (removal of part of the rectum);
hemming of the rectum;
plastic surgery on the rectal canal and pelvic muscles;
a combination of several types of operations.
The most common operations for colon prolapse today are surgical interventions aimed at fixing the prolapsed intestine. They also have a number of variations. For example, the intestine can be sewn to the anterior longitudinal vertebral ligament or it is fixed to the sacrum with a special Teflon mesh. Plastic surgery is appropriate only at the second stage of surgery, after the intestine has already been fixed. Also, the use of laparoscopic surgery methods is actively included in modern medical practice, which can minimize the risk of complications and shorten the rehabilitation period.
Prognosis for rectal prolapse
The prognosis for the treatment of rectal prolapse is favorable in 75% of cases, success depends on many factors, among which the timeliness of diagnosis of the disease, elimination of the cause, the age of the patient and the presence of concomitant diseases is of particular importance. In order to prevent the disease, it is necessary to lead a healthy lifestyle, be attentive to your body and regularly undergo occupational examinations.
