Rectal ProlapseRectal Prolapse

Basic ScienceBasic Science

September 28, 2005September 28, 2005

Which of the following are Which of the following are risk factors for rectal risk factors for rectal

prolapse?prolapse?1.1. Chronic constipationChronic constipation

2.2. Chronic diarrheaChronic diarrhea

3.3. Mental retardationMental retardation

4.4. Prior history of intussusceptionPrior history of intussusception

5.5. Female sexFemale sex

Which of the following are Which of the following are risk factors for rectal risk factors for rectal

prolapse?prolapse?1.1. Chronic constipationChronic constipation

TrueTrue2.2. Chronic diarrheaChronic diarrhea

TrueTrue3.3. Mental retardationMental retardation

TrueTrue4.4. Prior history of intussusceptionPrior history of intussusception

False- Rectal prolapse is thought of as a type of False- Rectal prolapse is thought of as a type of intussusception- having intussusception at an intussusception- having intussusception at an anatomically distant location doesn’t increase risk, but anatomically distant location doesn’t increase risk, but rectal prolapse does tend to recur and progress.rectal prolapse does tend to recur and progress.

5.5. Female sexFemale sexTrue- but childbearing is only part of the reason- half of True- but childbearing is only part of the reason- half of

patients are men or nulliparous womenpatients are men or nulliparous women

All of the following are anatomic All of the following are anatomic abnormalities seen in patients abnormalities seen in patients

with rectal prolapse except:with rectal prolapse except:

1.1. Deep rectovaginal or rectovesical Deep rectovaginal or rectovesical pouchpouch

2.2. Lax pelvic floor musculatureLax pelvic floor musculature

3.3. Failure of normal relaxation of the Failure of normal relaxation of the external sphincterexternal sphincter

4.4. Foreshortened mesorectumForeshortened mesorectum

5.5. Redundant sigmoidsRedundant sigmoids

All of the following are anatomic All of the following are anatomic abnormalities seen in patients abnormalities seen in patients

with rectal prolapse except:with rectal prolapse except:

1.1. Deep rectovaginal or rectovesical Deep rectovaginal or rectovesical pouchpouch

2.2. Lax pelvic floor musculatureLax pelvic floor musculature

3.3. Failure of normal relaxation of the Failure of normal relaxation of the external sphincterexternal sphincter

4.4. Foreshortened mesorectumForeshortened mesorectum

5.5. Redundant sigmoidsRedundant sigmoids

Classification of rectal Classification of rectal prolapse:prolapse:

Partial:Partial: Complete:Complete: Grade 1:Grade 1: Grade 2:Grade 2: Grade 3:Grade 3:

Classification of rectal Classification of rectal prolapse:prolapse:

Partial: prolapse of rectal mucosa Partial: prolapse of rectal mucosa onlyonly

Complete: prolapse with all layersComplete: prolapse with all layers Grade 1: occult prolapseGrade 1: occult prolapse Grade 2: prolapse to but not through Grade 2: prolapse to but not through

anusanus Grade 3: any protrusion through Grade 3: any protrusion through

anusanus

True or False:True or False:

Urinary incontinence is associated Urinary incontinence is associated with prolapsewith prolapse

Colonoscopy is useful for the Colonoscopy is useful for the diagnosis of prolapsediagnosis of prolapse

In grade 3 prolapse, rectal prolapse In grade 3 prolapse, rectal prolapse is easily confused with hemorrhoids is easily confused with hemorrhoids

True or False:True or False:

Urinary incontinence is associated Urinary incontinence is associated with prolapsewith prolapse TrueTrue

Colonoscopy is useful for the diagnosis Colonoscopy is useful for the diagnosis of prolapseof prolapse FalseFalse

In a grade 3 prolapse, rectal prolapse In a grade 3 prolapse, rectal prolapse is easily confused with hemorrhoidsis easily confused with hemorrhoids False- grade 2 prolapse can be confused False- grade 2 prolapse can be confused

with prolapsing hemorrhoidswith prolapsing hemorrhoids

Complications of Complications of prolapse include:prolapse include:

Complications of prolapse Complications of prolapse include:include:

UlcerationUlceration StrangulationStrangulation Urinary and fecal incontinenceUrinary and fecal incontinence Spontaneous rupture with Spontaneous rupture with

eviscerationevisceration

Perineal Perineal rectosigmoidectomy is rectosigmoidectomy is

appropriate for:appropriate for:1.1. Younger patients who want to Younger patients who want to

minimize recurrenceminimize recurrence

2.2. Patients with a grade 3 prolapse Patients with a grade 3 prolapse protruding at least 3 cmprotruding at least 3 cm

3.3. Patients who are poor candidates Patients who are poor candidates for trans abdominal surgery for trans abdominal surgery

Perineal Perineal rectosigmoidectomy is rectosigmoidectomy is

appropriate for:appropriate for:1.1. Younger patients who want to minimize Younger patients who want to minimize

recurrencerecurrence False- better suited for elderly patients that are False- better suited for elderly patients that are

poor candidates for abd surgery due to high poor candidates for abd surgery due to high recurrence raterecurrence rate

2.2. Patients with a grade 3 prolapse Patients with a grade 3 prolapse protruding at least 3 cmprotruding at least 3 cm

TrueTrue

3.3. Patients who are poor candidates for trans Patients who are poor candidates for trans abdominal surgeryabdominal surgery

TrueTrue

Transabdominal approaches to rectal Transabdominal approaches to rectal prolapse repair (ie transabdominal prolapse repair (ie transabdominal

rectopexy):rectopexy):

1.1. Are associated with problems with Are associated with problems with defecation and constipationdefecation and constipation

2.2. Have a lower recurrence rate than Have a lower recurrence rate than transperineal approachestransperineal approaches

3.3. Require resection of the redundant Require resection of the redundant sigmoidsigmoid

Transabdominal approaches to Transabdominal approaches to rectal prolapse repair (ie rectal prolapse repair (ie

transabdominal rectopexy):transabdominal rectopexy):1.1. Are associated with problems with Are associated with problems with

defecation and constipationdefecation and constipation truetrue

2.2. Have a lower recurrence rate than Have a lower recurrence rate than transperineal approachestransperineal approaches

truetrue

3.3. Require resection of the redundant Require resection of the redundant sigmoidsigmoid

not necessarilynot necessarily

Fecal incontinence is Fecal incontinence is corrected by surgical repair corrected by surgical repair

of prolapse in:of prolapse in:1.1. 90% of patients90% of patients

2.2. 70%70%

3.3. 50%50%

4.4. 30%30%

5.5. 10%10%

Fecal incontinence is Fecal incontinence is corrected by surgical repair corrected by surgical repair

of prolapse in:of prolapse in:1.1. 90% of patients90% of patients

2.2. 70%- return of continence may 70%- return of continence may take as long as 1 yeartake as long as 1 year

3.3. 50%50%

4.4. 30%30%

5.5. 10%10%

1) Rectal prolapse-1) Rectal prolapse-

A)A) is due to sliding herniation through pouch of is due to sliding herniation through pouch of Douglas through pelvic floor fascia into anterior Douglas through pelvic floor fascia into anterior aspect of rectumaspect of rectum

B)B) Is a full thickness rectal intusseception starting Is a full thickness rectal intusseception starting ~3inches above dentate line and extending beyond ~3inches above dentate line and extending beyond anal vergeanal verge

C)C) Is six times more common in males than femalesIs six times more common in males than females

D)D) Peak incidence in the 7Peak incidence in the 7thth decade of life decade of life

E)E) Young male patients tend to have psychiatric Young male patients tend to have psychiatric disordersdisorders

1) Rectal prolapse-1) Rectal prolapse-

B) Is a full thickness rectal intusseception B) Is a full thickness rectal intusseception starting ~3inches above dentate line and starting ~3inches above dentate line and extending beyond anal vergeextending beyond anal verge

D) Peak incidence in the 7D) Peak incidence in the 7thth decade of life decade of life

E) Young male patients tend to have E) Young male patients tend to have psychiatric disorderspsychiatric disorders

2) Chronic or lifelong constipation w/ component of straining has 2) Chronic or lifelong constipation w/ component of straining has been found to be present in ~what percentage of patients w/ been found to be present in ~what percentage of patients w/ prolapse?prolapse?

A)A)15%15%

B)B)35%35%

C)C)100%100%

D)D)50%50%

E)E)5%5%

2) Chronic or lifelong constipation w/ component of straining has been 2) Chronic or lifelong constipation w/ component of straining has been found to be present in ~what percentage of patients w/ prolapse?found to be present in ~what percentage of patients w/ prolapse?

D) Present in over 50% of patients D) Present in over 50% of patients according to case reviews aimed at according to case reviews aimed at elucidating predisposing factors other elucidating predisposing factors other than the frequently found anatomic than the frequently found anatomic characteristics- ex. diasthesis of levator characteristics- ex. diasthesis of levator ani; abnormally deep cul-de-sac; ani; abnormally deep cul-de-sac; redundant sigmoid colon; patulous anal redundant sigmoid colon; patulous anal sphincter; loss of rectal sacral sphincter; loss of rectal sacral attachments attachments

3) Rectal prolapse can be distinguished 3) Rectal prolapse can be distinguished from prolapsed incarcerated internal from prolapsed incarcerated internal hemorroids by the characteristic hemorroids by the characteristic _______ (invaginated/concentric) folds _______ (invaginated/concentric) folds of rectal prolapse and by the _______ of rectal prolapse and by the _______ (painful/painless) reduction if not (painful/painless) reduction if not incarcerated.incarcerated.

3) Rectal prolapse can be 3) Rectal prolapse can be distinguished from prolapsed distinguished from prolapsed incarcerated internal hemorroids incarcerated internal hemorroids by the characteristic by the characteristic concentricconcentric folds of rectal prolapse and by the folds of rectal prolapse and by the painlesspainless reduction if not reduction if not incarcerated.incarcerated.

4) Two predominant approaches, 4) Two predominant approaches, ________ and _________, are ________ and _________, are considered in operative repair of considered in operative repair of rectal prolapse. Generally believed rectal prolapse. Generally believed that the _______ approach results in that the _______ approach results in less perioperative morbidity and less perioperative morbidity and pain an reduced length of hospital pain an reduced length of hospital stay. stay.

4) Two predominant approaches, 4) Two predominant approaches, abdominalabdominal and and perinealperineal, are , are considered in operative repair of considered in operative repair of rectal prolapse. Generally believed rectal prolapse. Generally believed that the that the perinealperineal approach results approach results in less perioperative morbidity and in less perioperative morbidity and pain an reduced length of hospital pain an reduced length of hospital stay. stay.

5) Solitary rectal ulcer syndrome (SRUS)-5) Solitary rectal ulcer syndrome (SRUS)-

A)A)Gross pathology always demonstrates Gross pathology always demonstrates the typical crater like ulcer with the typical crater like ulcer with fibrinous central depressionfibrinous central depression

B)B)Typical patient is young and female w/ Typical patient is young and female w/ history of straining and difficult history of straining and difficult evacuationevacuation

C)C)Most located on posterior aspect of Most located on posterior aspect of rectum 4-12 cm from anal vergerectum 4-12 cm from anal verge

D)D)Diagnostic evaluation by defecography Diagnostic evaluation by defecography is radiologic procedure of choiceis radiologic procedure of choice

5) Solitary rectal ulcer syndrome (SRUS)-5) Solitary rectal ulcer syndrome (SRUS)-

C) Typical patient is young and female w/ C) Typical patient is young and female w/ history of straining and difficult history of straining and difficult evacuationevacuation

D) Diagnostic evaluation by D) Diagnostic evaluation by defecography is radiologic procedure of defecography is radiologic procedure of choicechoice

* Always located on anterior aspect of * Always located on anterior aspect of rectum. Gross pathology can range rectum. Gross pathology can range from typical ulcer to polypoid lesion.from typical ulcer to polypoid lesion.

6) Rectocele is abnormal sac like 6) Rectocele is abnormal sac like projection of anterior rectum that projection of anterior rectum that extends from distal rectum to distal extends from distal rectum to distal anal canal. Usually begins just _____ anal canal. Usually begins just _____ (above/below) the sphincter (above/below) the sphincter complex. Rectal pressures are complex. Rectal pressures are ______ (higher/lower) than in the ______ (higher/lower) than in the vagina. Major symptom of rectocele vagina. Major symptom of rectocele is ________ ( diarrhea/stool trapping).is ________ ( diarrhea/stool trapping).

6) Rectocele is abnormal sac like 6) Rectocele is abnormal sac like projection of anterior rectum that projection of anterior rectum that extends from distal rectum to distal extends from distal rectum to distal anal canal. Usually begins just anal canal. Usually begins just aboveabove the sphincter complex. the sphincter complex. Rectal pressures are Rectal pressures are higherhigher than in than in the vagina. Major symptom of the vagina. Major symptom of rectocele is rectocele is stool trappingstool trapping..

7) It is rare that a rectocele less than 7) It is rare that a rectocele less than ____ is symptomatic.____ is symptomatic.

A)A)0.5cm0.5cm

B)B)1cm1cm

C)C)2cm2cm

D)D)3cm3cm

E)E)5cm5cm

7) It is rare that a rectocele less than 7) It is rare that a rectocele less than ____ is symptomatic.____ is symptomatic.

C) 2cm; although small rectoceles are C) 2cm; although small rectoceles are common. Criteria for operative common. Criteria for operative intervention include symptomatic stool intervention include symptomatic stool trapping requiring digital evacuation trapping requiring digital evacuation or vaginal support and large or vaginal support and large protruding rectoceles pushing vaginal protruding rectoceles pushing vaginal mucosa past introitus producing mucosa past introitus producing dryness, ulceration and discomfortdryness, ulceration and discomfort

8) Colonic inertia8) Colonic inertia

A) Estimated that 10% of population suffers A) Estimated that 10% of population suffers from chronic, unremitting functional from chronic, unremitting functional constipationconstipationB) Majority of patients are female w/ mean B) Majority of patients are female w/ mean age older than 50.age older than 50.C) Delay in gastric emptying and small bowel C) Delay in gastric emptying and small bowel follow through has been noted in these follow through has been noted in these patients implying global motility problempatients implying global motility problemD) Barium enema is useful initial examinationD) Barium enema is useful initial examination

8) Colonic inertia8) Colonic inertia C) Delay in gastric emptying and small bowel C) Delay in gastric emptying and small bowel

follow through has been noted in these follow through has been noted in these patients implying global motility problempatients implying global motility problemD) Barium enema is useful initial examinationD) Barium enema is useful initial examination

* Estimated that 2% of population suffers from * Estimated that 2% of population suffers from chronic functional constipation. Majority of chronic functional constipation. Majority of patients female with mean age younger than patients female with mean age younger than 30. Abdominal pain, bloating and nausea 30. Abdominal pain, bloating and nausea usually accompany the constipation. usually accompany the constipation.

9) Neurologic constipation9) Neurologic constipation

A)A)As a group 50% of these patients are As a group 50% of these patients are malemale

B)B)Responds well to medical managementResponds well to medical management

C)C)Commonly presents as slow transit Commonly presents as slow transit constipation in presence of dilated colonconstipation in presence of dilated colon

D)D)Includes adult Hirschsprung’s disease, Includes adult Hirschsprung’s disease, Chagas’ disease and neuronal intestinal Chagas’ disease and neuronal intestinal dysplasiadysplasia

9) Neurologic constipation9) Neurologic constipation

A) As a group 50% of these patients A) As a group 50% of these patients are maleare male

C) Commonly presents as slow transit C) Commonly presents as slow transit constipation in presence of dilated constipation in presence of dilated coloncolon

D) Includes adult Hirschsprung’s D) Includes adult Hirschsprung’s disease, Chagas’ disease and disease, Chagas’ disease and neuronal intestinal dysplasianeuronal intestinal dysplasia

10) Laparoscopic colon resection-10) Laparoscopic colon resection-

A)A) Benefits similar to those mentioned for lap Benefits similar to those mentioned for lap cholecystectomy- shorter hospital stay; less post op cholecystectomy- shorter hospital stay; less post op pain; earlier return of bowel functionpain; earlier return of bowel function

B)B) Most colon and rectal diseases are amenable to lap Most colon and rectal diseases are amenable to lap approach except can not do for sigmoid resection for approach except can not do for sigmoid resection for diverticulitis diverticulitis

C)C) Port site recurrence appears equivalent to recurrence Port site recurrence appears equivalent to recurrence of cancer in incision of patients treated by of cancer in incision of patients treated by conventional operation conventional operation

D)D) Post operative recovery of lap colectomy is prolonged Post operative recovery of lap colectomy is prolonged on average if hand assisted techniques are used or if on average if hand assisted techniques are used or if anastamosis has to be performed extracorporeallyanastamosis has to be performed extracorporeally

10) Laparoscopic colon resection-10) Laparoscopic colon resection-

A) Benefits similar to those mentioned A) Benefits similar to those mentioned for lap cholecystectomy- shorter for lap cholecystectomy- shorter hospital stay; less post op pain; earlier hospital stay; less post op pain; earlier return of bowel functionreturn of bowel function

C) Port site recurrence appears C) Port site recurrence appears equivalent to recurrence of cancer in equivalent to recurrence of cancer in incision of patients treated by incision of patients treated by conventional operation according to conventional operation according to SabistonSabiston