Rectal Prolapse

What is Rectal Prolapse (Breech - Bowel Prolapse)?

Rectal prolapse, also known as prolapse of the large intestine, is the protrusion or prolapse of the last part of the large intestine out of the anus. In the early stages of the disease, patients experience changes in their defecation habits. Again, discharge from the rectum during this period causes discomfort in patients. In the later stages of the disease, the intestine protrudes from the anus. Both the protrusion of the large intestine out of the anus and the protrusion of the large intestine out of the anus during defecation and then back in causes damage to the muscles that control the anus. Damage to these muscles that control the anus can have consequences, including difficulty in passing stool.

Prolapse of the large intestine, which is more common in women and the elderly, is also a common condition accompanied by bladder and uterine prolapse. Men who suffer from long-term constipation and use medication for this are also frequently affected by rectal prolapse. The part of the large intestine that comes out in the early stages can spontaneously go back in. However, in the later stages of the disease, patients may have to remove this protruding part by hand.

Causes of Rectal Prolapse

There are many causes of rectal prolapse. The most common causes are prolonged constipation, excessive straining habits and straining during childbirth. In some cases, there is a genetic predisposition. In addition, some physical conditions that develop due to the aging of patients trigger rectal prolapse. With age, the muscles in the pelvis and the muscles that control the anus relax. Prolapse of the large intestine can occur due to relaxation of both muscle groups.

Another factor causing rectal prolapse is nerve damage. When the nerves that send messages to the muscles in the anus are damaged for various reasons, patients experience some problems both in holding the stool and in defecation. These problems can develop rectal prolapse. Factors that can cause damage to the nerves around the anus include pregnancy or normal vaginal births, surgical operations in the pelvic area, spinal injuries and spinal fractures. Rectal prolapse is usually caused by a combination of several causes rather than one cause.

Symptoms of Rectal Prolapse

The symptoms usually encountered in large bowel prolapse are as follows:

• A constant feeling of straining,
• Sensation of wetness in the anus,
• Difficulty during defecation,
• Fecal incontinence
• Urinary incontinence
• Chronic constipation,
• Involuntary gas leakage,
• Involuntary fecal incontinence,
• Stains on laundry,
• Diarrhea
• Rectal bleeding
• Itching in the anus,
• Negative sensation when walking or sitting,
• Ulceration in the anus,
• Bad odor from the rectum,
• Pain in the anus,
• Tissue necrosis of the protruding rectal fragment,

Rectal Prolapse Tests

Clinical examination is usually sufficient to diagnose rectal prolapse. In some cases, patients may be asked to push in order to make a diagnosis.

Video Defecography

In some patients, prolapse of the large intestine is hidden in the anus. In these patients, rectal prolapse can be diagnosed by video defecography, a special X-ray film taken during defecation. In this technique, radiographs can be taken while the bowel movements of the patients are taking place and treatment plans can be made at this stage.

Anorectal manometry

Another test for prolapse of the large intestine is anorectal manometry. This test examines the function of the muscles around the anus and the coordination between the anus and rectum.

Endoscopic Examination

Another diagnostic method used in the diagnosis of large bowel prolapse is endoscopic examination. Anoscopy, rectosigmoidoscopy, rectoscopy and colonoscopy methods are applied by determining the appropriate one for the patient.

Rectal Prolapse Treatment Methods

For the treatment of rectal prolapse, the prolapse of the large intestine cannot be reversed, even if the causes of constipation that cause patients to constantly strain are eliminated. For this reason, surgical procedures are the only option for the treatment of rectal prolapse. There are two different surgical methods that can be used to treat rectal prolapse.

Abdominal

In this method, colon prolapse surgery is performed by entering through the abdomen.

Perineal

In perineal surgeries, procedures are performed by entering through the anus. Which method will be more efficient for the patient is determined by the general health status of the patients as well as the indicators of the test results.

About rectal prolapse surgery

Surgery is the only treatment option for rectal prolapse. Two different surgical methods are used for this. The method to be used is determined by the patient's general health condition, age, results of radiological tests and the type of disease. However, the aim of both methods is to pull the intestine up.

Repair by abdominal route

Laparoscopic surgeries, one of the most frequently performed surgeries in recent years, can be performed through 3 to 4 small incisions in the abdomen. In this procedure called ventral mesh rectopexy, it is possible to treat rectal prolapse as well as vaginal hernia.

In the abdominal route, an artificial patch is used to elevate the intestine. This patch is called a mesh. Since it is placed between the vagina and rectum in women, vaginal hernia is also treated in case of vaginal hernia. In addition, other health problems such as uterine and bladder prolapse, which often accompany rectal prolapse in women, are also treated.

Repair by anal route

Six different methods are used in the anal repair technique. In the first method called STARR, excess rectal mucosa hanging from the anus is removed. This method, which stands for stapler transanal rectal resection, is only suitable for patients with rectal intussusception and mucosal peolapsus. It is known that after STARR operations, 5-10% of patients develop a constant feeling of straining due to stenosis in the ximba line.

The other anal repair technique is perineal resection. In these operations, the rectum segment that hangs out of the anus is cut out. Afterwards, the intestine is reconnected by sewing it to the anus. Perineal resection is a method for abdominal repair in elderly patients and those at high risk of general anesthesia. The recurrence rate after surgery with this technique is 8%, while the chance of developing complications is 3%.

Rectal mucopexy surgeries are another surgical method performed through the anus. It is the process of folding the anus and lifting it upwards. The possibility of recurrence after surgeries performed with this technique is 10%. In addition, problems such as bleeding can be seen in 5% to 10% of patients and painful defecation in 10%.

In Mikulicz surgeries, a stapler called a stapler is often used. The rectum is shortened with this instrument and then sutured to strengthen the puborectal muscle. The likelihood of complications and recurrence after surgery with this method is 8%.

The process of fixing the rectum to the sacrum with sutures is called transsacral rectopexy. In patients treated with this method, the possibility of relapse is 2%, while the possibility of losing the patient is very rare.

In the Goldberg-Freykman technique, the sigmoid canal is removed after the sutures are fixed to the rectum. Patients treated with this technique have a 3% chance of relapse and a 4% chance of losing the patient.

What are the risks of rectal prolapse surgery?

Regardless of the method to be preferred in the treatment of rectal prolapse, there is a possibility of some complications during and after surgery. These complications include the following:

• Bleeding occurs in 6% of patients after surgery. In addition to this bleeding inside the rectum, ulceration can also be seen.
  
  
• Approximately 20% of patients experience urgent defecation after surgery. This complaint is known to resolve spontaneously over time.
  
  
• Diverticulum formation in the intestines.
  
  
• The condition in which the rectum, the last part of the large intestine, opens a hole in the vaginal canal in women and the feces come through this channel is called rectovaginal fistula. The probability of this condition occurring after surgery is 5%.
  
  
• Intestinal knotting
  
  
• Wound healing problems are observed in 5% of patients.

Dietary Changes

Especially for patients diagnosed with partial rectal prolapse, a diet is created with easily digestible foods that will not cause constipation. Patients should pay attention to this diet and avoid overeating.

Use of laxatives

Laxatives are also used to treat patients with severe constipation. These medicines help patients to defecate more easily. However, long-term use of medicines is not recommended. Because long-term use of laxatives may affect bowel movements in the opposite direction, as well as reduce absorption of nutrients and cause vitamin and mineral deficiency in patients.

Complications of rectal prolapse

If rectal prolapse is not treated, some complications are possible in patients. These complications include the following:

• There is compression of the small intestine between the part of the intestine hanging from the anus. this can also lead to intestinal rot.
• The part of the intestine that hangs from the anus can be perforated due to friction. In patients who have undergone surgery, there is a possibility of leakage at the suture site.
• Mucosal prolapse
• Fecal incontinence
• Gas leakage
• Cancer risk
• Presacral nerve injury
• Breech pain
• Rectal fistula
• Rectal abscess

How is rectal prolapse classified?

The classification used today is the one defined by Altemeier in 1971. Accordingly, rectal prolapse is divided into 3 different classes.

Type 1

It is also called type 1 false prolapse or rectal mucosal prolapse and is usually associated with hemorrhoids.

Type 2

In type 2, which usually causes problems such as gas and fecal incontinence, there is no prolapse of the rectum out of the anus. Instead, the organ of the rectum is intertwined 7 to 8 cm upwards inside the rectal canal. This is called intussusception.

Type 3

It is the most common type of rectal prolapse. In type 3, the anus prolapses completely outwards.

Rectal prolapse in children

Rectal prolapse is a health problem that develops in children younger than 5 years of age. Rectal prolapse, which occurs equally in both girls and boys, may be associated with rectal bleeding in some children. In children, rectal prolapse is first seen during defecation. Afterwards, he comes in on his own. However, over time, it starts to come out with increased intra-abdominal pressure such as sneezing or straining. After 5 years of age, it usually resolves spontaneously.

Symptoms in children

Symptoms that can be seen in case of rectal prolapse in children include the following:

• Prolapse of the anus during defecation
• At first, the outward prolapse is small. However, in the later stages, up to 15-20 cm of intestine may come out.
• Ulcer formation can be seen
• Bleeding may occur

Treatment of rectal prolapse in children

The treatment of rectal prolapse in children is primarily medical. If medical treatment fails, injections and surgery can be used.

Injection

In cases where medical treatment is not a solution, injections are used. Solutions with different properties are used in injection, which is a procedure performed under general anesthesia:

• 55 phenol and glycerin with the least likelihood of complications
• 10-30% hypertonic NaCl solution with the highest probability of complications
• 25-50% glucose solutions

Surgery

Surgery is used when other treatments are not successful. The rectal surgeries performed in children are similar to the techniques used in adults.