Rectal Prolapse:

Abd El Aziz Mahmoud Abd El Aal

•• Rectal prolapse is a circum4erential descent of thebowel with or without protrusion thro~gh the an~s. It may beneT tiel (Mu.oeel) or complete ( Procidentia).The cause of the prolapse is often obscure •- The mechanism that normally stabilizes the rectum is complex,and the importonce of the pelvic floor in this process is notfully recognized.- The aetiological points upon which the many methods devisedfor its treatment are founded may be classified under 5 headingsl-Inflammation of the mucous membrane.2-In8ufficiency of pelvic floor.J-InsLlfficienc:/ of ne t uraI support of the rectum.4-The otructLlreof Douglas-cul-de-sac.5-1088 of muscular tone •2 - Bleeding and discharge.J - Partisl or complete faecal incDntinence •- The prolapse is liable to he cumplicoted by1 - Irreducibility and gangrene.2 - Ulceration and haemorrhage.J - Rup t ure of the prolapse.- Managment of rectal prolapse.General mea aureas- It is essential to coirect any eXisting pathologic processor .ne chanical conditions which may aggravate the protr uai.cn ,- Cunstipation and diarrhea shoLlld controlled •- Diet shoLlld be regLllated carefLllly.~ I’tifecation:• Avoid prolonged sitting on toilet •• Stool rendered soft by aperients •- Improving sphincter tone.- Constitutional treatment: sLlitable tonics and good hygienicmeasures •• Management of prolapse in children- The majority of cases of rectal prolapse in infancy recoverspontaneously without treatment.- Recovery may be aided by:1- submucosal iDjection of 5% phenol in almond oil or.2- Alternatively in severe eases by means of a Thiersch,~type of operation using cat gLlt instead of silver wire.~ - In older children with more severe prolapse. linear cauterization1L is uaua LLy effective • If this ahou’ld fail in an older child. rect-I”) al fixation or exciaim wOLlld be indicated.~ - Abdominal operstiohs are absolLltely contraindicated.- Only very rarely it is necessary to perform rectosigmoidectomyfor irredLlcible gangrenous prolapse.- In those cases of rectal prolapse that are complete or !-,ersist;’{ r, after infancy in association with lax sphincter there may be , ,ei ther a congenital neurological defect of the Jnegarecturn type.l!1:;!I,’, , If’lAttempts at operative correotion in these patients withoutthe.most careful investigation and assessment are to bestrongly deprecated and they are lIuoh better managed inspecial centres.~anagment of procidentia in Ad~lt andpld patients._ Therapy varies according to the demands of patients aswell as to the severity at the pxooident:laChoioe,. vary fromconservative managment to major operations with severalmodali ties in beheen • However, opera.tion is not indicatedfor so-called internal intussusception. Consequently, therspychc uld be limited to patients w~o haVl! protrusion of the normalrectum through the anua ,- Operations that attempt to repair the puborectalis muscleby simple suture have been ineffective because the muscle isususlly too attenuated. Fixation operations using a Teflon ormersilene graft sutured to the rectum and at t ached to the uppersacr um are popular now in Uni ted states •_ Asimilar operation (Well”, operation) is widely used now in Britian- While lot times, sacral fixation,issdvisllble still it lacksthe important objective of providing pelvic support.- .APPl:ic.ation of the puborectalis sling, provides betterfiJ::taion and at the aa.ne time a feilling of pelvic support.-Summary of choice of therapy,-A - Poor risk elderly patients.The severely incapRcitated 01 v~ry old person witha short life expectancy should usually’ treated conservatively.....,-17e..It the prolaps~8 ia too tro~bl.some to manage, a Thiersch loopshould be placed to constrict the an~s so as to prevent prolapseOr alternatively Delorm’s operation oan be ~sed.B Acceptable risk elderly patients.Elderly patients who have a limited s~gical risk andrelatively short life expeotancy can be treated effectively.There are multiple proced~es that sho~ld be considered and the choicedepends on the experience of the s~geon than any other tactorI - Ripstein operation is the most widely ~sed now in theUnited states. 2 - Well’. operation is the most widely usednow in England •Complications specific to these operations include obstruction,bleeding, infection, and desachment of the graft. P’ortunately,they are not co~non. J. Delorm’s operation.4°_ perineal rectope.y.C Good risk patients._ Adults in the younger age groups and even up to GOY or sorequire the best possible reconstruction, one that will lastfor decades._ There are several choices depending more on the experience of thes~geon and so~ewhat less on the patient’s charaoteristics.1- Ivalon, polyvinyl sponge (wells operation is the most ,widelyused in Great Britian.2- The Teflon sling operation (Ripstein)is the most widely ~sedin United state.----- ---The irritant prober ties of polyvinyl alcohol spong helpto fix the rectWll firmly but a180 predispose it to infectionor rejection. The inert polypropylene mesh fixation fixation.., front of the rectWll has been.associated with acute kinkingof the bnel or if too tight with 1nie.UnaJ. obstructionI!:,,ii,”3 - Marlex mesh abdominal rectopexy. Excellent results havebeen reported during the past loY. The monofilament knittedpolypropylene (Marlex) mesh is inert and seems to berelatively free from infection.4 - Repair of Rectal prolapse by llsing·a puborectal sling procedure.- He,re, the graft, unfortunately, is not movable and it cannotLeng t nen to allow easier defecation •- Its advantage over sacral fixation is that it provides a muchbetter feeling of pelvic support, and often improves bladderfunction.- This procedllre can.be used for treatment of procidentia withrectopexy •This involves a series of horizontal nonabsorbable purse.: 1 string slltures placed between the poeterior 1J of the circWllferenceof the rectum and sacr~~.The procedue seems to be effective and avo t ds the cOllplicationsthat have been reported with the Teflon sling and Ivalon sponeprocedure.I,I!’~,”6) Treatment by GraciloplastYIMay be an effective single procedure for the control of c’Jlpleterectal prolapse _cl ~b. %e.~OI’.~iOD of good pelvic’floor function.Therapy of partial prolapse• It can be treated bYI,”1 - injection of scle~osing 80lLitions ,2 - Rubbar band ligation.J - Ligation and excision.4 - Oryo eurgery.Operations for rectal prolapse either perineal, sacral orabdominal Are infrequently liable to variable complications •General complications inclade, pulmonary, cardiac complication,or pulmonary embolism,- Local complica t Lon s IncLuda , Haemorrhage, infection, const Lp-,a tion and faecal impaction.lluinary retention, recurrence eitherpartial or complete, and incontinence,- Incontince is managed betterly bypostanal repair.- This’ essay also gives informations about speCial proplemsot rectal prolapse such as occult rectal prolapse, prolapsein cystic fibrosis, sigmoidorectal intussusception and the syndromeof the dEscendinG perineum.