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Although considered an anal condition a cylindrical prolapse at the anal margin is known as a rectal prolapse because it is the rectum that is able to descend through the open anal canal to be seen outside.
The rectum turns itself inside out “like a sleeve of a jumper” and appears as a lump in the anal area affecting its whole circumference. It is this circumferential appearance that characterises the rectal prolapse and distinguishes it from conditions with which it is often confused (prolapsed haemorrhoids, polyps, skin tags, mucosal prolapse).
The condition affects women much more commonly than men and is most common in the seventh and eighth decades of life.
Causes of Rectal Prolapse
Chronic constipation (and straining at stool), pelvic floor weakness (often as a result of pregnancy) and anal sphincter weakness are all thought to contribute to the development of the condition as is a lengthy (redundant), thin walled (atonic) colon. Neurological conditions and rare genetic conditions that cause weakness in the body’s conective tissues are occasionally to blame.
- Mucous Discharge
- Strangulation and Gangrene
Surgery is the only practical solution to this problem. A huge number of surgical techniques have been described to treat rectal prolapse. They all have particular benefits and drawbacks none is entirely satisfactory.
Success is measured in terms of the percentage chance of the prolapse recurring over a defined period (recurrence). Prolapse repairs are divided into two types, abdominal procedures and those carried out from below around the anal margin, perineal operations.
These techniques may be performed in an open or laparoscopic fashion. They involve fixation of the prolapsing segment of bowel (sigmoid colon and rectum) by the use of stitches or mesh. Occasionally a bowel resection is performed at the same time.
The surgery is performed under a general anaesthetic and depending upon the nature of the surgery and well being of the patient may be performed as a day case or with a one or two day hospital stay.
The commonly performed procedures in the UK are sutured and mesh rectopexy fixation. Recurrence rates may be as high as 20% over long term follow-up and evacuatory problems (constipation) are frequently encountered.
Two procedures are commonly performed in the UK. They are:
- Delorme’s procedure, the lining (mucosa) of the rectum and sigmoid colon are stripped from the prolapsing segment and the under-lying muscular wall of the bowel is bunched-up (plicated) with stitches to fix the rectum back above the anal sphincters.
- Altmeier’s procedure, the prolapsing segment of bowel is completely divided above the anal sphincters, pulled out through the anal canal and removed. The bowel is then rejoined with stitches to restore bowel continuity.
The advantage of these procedures, which have a high recurrence rate (perhaps up top 50% at 2 years), is that they can be performed without the need for general anaesthetic and are largely pain free after operation.
They can be performed as a day-case or with short hospital stays and easily repeated if failure should occur. They are therefore very useful in the treatment of very elderly and infirmed individuals.