Rectal Prolapse
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Direct answer
A complete rectal prolapse is a full-thickness circumferential intussusception of the rectum through the anal canal, recognised clinically by concentric mucosal folds and a deep sulcus between the prolapsed bowel and the anal verge; mucosal prolapse shows radial folds and involves mucosa only. Management in adults is essentially surgical: abdominal fixation — ventral rectopexy the modern standard — offers the lowest recurrence in fit patients, while perineal procedures (Delorme's mucosal sleeve resection, Altemeier's perineal rectosigmoidectomy) serve the unfit and the strangulated. In Indian children prolapse usually follows malnutrition, diarrhoea or worm infestation and resolves with treatment of the cause. Colonoscopy precedes any repair, because a rectal tumour can act as the lead point.
What you must remember
- Layer-based classification: mucosal prolapse (radial folds, no full-thickness component) versus complete prolapse (concentric rings, deep sulcus) versus internal intussusception, visible only on defecography.
- Support defects: diastasis of the levator ani, an abnormally deep pouch of Douglas, a redundant sigmoid mesocolon and lax anal sphincters form the classic anatomical tetrad.
- Assessment: colonoscopy to exclude a neoplastic lead point, defecography for internal prolapse and solitary rectal ulcer syndrome, anorectal manometry for sphincter function, and transit studies when constipation dominates.
- Abdominal route: suture or ventral mesh rectopexy, commonly laparoscopic, gives the lowest recurrence and the best functional result; adding sigmoid resection (the Frykman-Goldberg logic) suits the constipated patient.
- Ripstein caution: the anterior mesh sling famously converts recurrence into obstructed defaecation and constipation.
- Perineal route: Delorme (mucosal sleeve resection with muscular plication) for the unfit; Altemeier (perineal rectosigmoidectomy with levatorplasty) also suits strangulated or incarcerated prolapse.
- Paediatric practice: correct malnutrition, treat diarrhoea and deworm; the prolapse usually reduces spontaneously and surgery is exceptional.
Choosing between the operations
Picture a 70-year-old multipara with a 6 cm prolapse, chronic constipation and reasonable fitness for laparoscopy. Ventral rectopexy is the natural choice: it fixes the rectum to the sacral promontory along a single anterior mesh stripe, avoiding the posterolateral dissection that injures the pelvic autonomic nerves, and it corrects the associated internal intussusception and rectocele. Because she is constipated, some surgeons add a sigmoid resection to shorten the redundant colon. Now replace her with an 85-year-old with severe cardiorespiratory disease: a perineal procedure under spinal or regional anaesthesia — Delorme if the prolapse is mucosa-dominant and moderate, Altemeier if it is long and bulky — accepts a higher recurrence in exchange for operative safety. The strangulated, oedematous prolapse that will not reduce is an emergency: Altemeier resection at the same sitting deals with potentially gangrenous bowel without a laparotomy.
How the exam separates the prolapses
Examiners love the fold pattern: radial folds that do not involve the whole circumference mean mucosal prolapse (treat haemorrhoidal causes, consider mucosal sleeve excision), while concentric rings with a palpable double-groove mean complete prolapse (fixation surgery). The second discriminator is the soil, not the pipe: a young woman with tenesmus, mucus discharge and a rectal ulcer on proctoscopy has solitary rectal ulcer syndrome, the mucosal footprint of internal intussusception — diagnose it with defecography, and remember that rectopexy, not local ulcer surgery, is the definitive treatment. Third, rectopexy cures the prolapse but does not always cure incontinence: chronically stretched sphincters may not recover, and manometry before surgery predicts this. Finally, the childhood question: in an Indian paediatric outpatient department, prolapse with a worm burden and recurrent diarrhoea is treated medically — operating on such a child is the wrong answer.
Frequently asked questions
How is complete prolapse distinguished from mucosal prolapse on examination?
Complete prolapse shows concentric mucosal folds with a deep circumferential sulcus, whereas mucosal prolapse produces radial folds and prolapses only partial thickness, usually on straining.
Which operation suits an unfit elderly patient with rectal prolapse?
Delorme's mucosal sleeve resection with muscular plication, performed perineally under regional anaesthesia, accepts higher recurrence in exchange for far lower operative risk.
What is the Altemeier procedure and when is it the answer?
Perineal rectosigmoidectomy with levatorplasty — the chosen operation for strangulated or gangrenous prolapse and a reasonable option in high-risk patients with a long prolapse.
Why is colonoscopy mandatory before rectopexy?
A rectal or sigmoid tumour can serve as the lead point of the intussusception, and repairing the prolapse without excluding a neoplasm delays cancer diagnosis.
How is rectal prolapse managed in Indian children?
Conservatively — treat diarrhoea and worm infestation, improve nutrition and reduce the prolapse manually; the overwhelming majority resolve as the child grows.