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Rectal Prolapse

Rectal prolapse — the way out of all layers of the rectum through the anus. Sometimes there is a so-called internal rectal prolapse, which is based on intrarectally direct or intussusception of the sigmoid colon with no way out.

When rectal prolapse is a constant compression of the vessels in the submucosal layer, therefore, the greatest modifications being made to the mucous membrane of the drop-down area. Due to stasis and plethora of the vessels of the mucosa looks swollen, erythematous, but retains a characteristic luster. When compression of the feeding vessels, it acquires a bluish tint, and prolonged severe compression, the walls of the anal canal may Microtiterwells. Depending on the tone and contractility of individual groups of muscle fibers the drop-down portion of the rectum may be in the form of a cylinder, cone or sphere. After reposition of the intestine the blood flow is restored the mucosa becomes normal.

For internal loss of the rectum characterized by the development of a solitary ulcer that is formed in the front wall of the rectum just above the dentate line. The ulcer has a polygonal shape, the size usually does not exceed 2-3 cm in diameter. The edges of ulcers are even, not have the characteristic granulation of the shaft; the bottom is shallow, in some areas covered by fibrin. Instead of ulcers on the anterior wall of the rectum may develop focal swelling and redness.

Causes

All cases of rectal prolapse cannot be explained by any one cause. Almost always a combination of adverse circumstances that contribute to the development of the disease. However, most patients you can still identify leading etiological factor that is very important to select adequate treatment method. Various circumstances can only predispose to the development of the pathological process, and may directly cause rectal prolapse. By the predisposing causes include: hereditary factors, features of the Constitution of the body and structure of the rectum, acquired degenerative changes in the muscles of the sphincter apparatus and the wall of the rectum. Direct causes of rectal prolapse may be acute and chronic gastrointestinal diseases, heavy physical labor, exhaustion, blunt abdominal trauma, a difficult birth. In 12-13 % of observations identified a relatively rare cause of disease — mutilation, homosexuality, operations on the pelvic organs, etc.

The main cause predisposing to rectal loss are considered constitutional-the anatomical features of an organism that determine its “readiness” to prolapse. These include: congenital weakness of ligaments, the deep pelvic peritoneal pocket, dolichosigma, excessive mobility of the sigmoid and rectum etc.

Contribute to the development of the disease and factors such as bowel dysfunction (particularly constipation), female, infertility, neurological changes (spinal cord injury, cauda equina injury, senile changes).

There are two main options for the development of rectal prolapse: 1) the type of sliding hernia; 2) the type of intussusception.

When Grajewo version permanent increase in intra-abdominal pressure and weakening of the pelvic floor muscles lead to the fact that peritoneal Douglas pocket gradually moves down, grabbing a front wall of the rectum. Formation of Douglas deep space accompanied by the separation of the muscles of levatores, especially when increased intra-abdominal pressure. In the future, with an increase in the adverse circumstances, there is a prolapse of the anterior wall of the rectum through the anal canal to the outside. With time zone displacement of the rectal wall increases and becomes circular. To adverse circumstances is getting an increasing number of loops of small bowel in shifting down Douglas pocket (enterocele). Sometimes content prijepodneva Douglas pocket is modified sigmoid colon (Sigmatel).

The definition of the pathogenesis of rectal prolapse in each case greatly facilitates the choice of optimal method of surgical correction.

Symptoms

The appearance of the disease occurs in two main variants. The first is sudden onset, often after a sharp increase in intra-abdominal pressure caused by heavy physical exertion, childbirth or the weakening of the pelvic floor muscles and the anal sphincter, after a sharp coughing, sneezing, etc. Right after or during a similar episode in the rectum falls to a considerable extent (8-10 cm or more). This is often a severe pain in the abdomen, which is associated with the tension of the peritoneum and mesentery of the colon. The pain may be so strong that it leads the patient into a state of shock or collapse.

The second option is more common — gradual slow increase in difficulty of bowel movement, acquiring a chronic character, when laxatives and cleansing enemas are becoming less effective. Each defecation in these patients becomes a painful process, accompanied by a significant increase in intra-abdominal pressure. Gradually, during the next straining rectum begins to fall, but the first is pretty easy almost on their own for reduce anal canal. After some time the rectum after stool have to fix by hand. With continued disease rectal prolapse occurs not only during defecation, but also by coughing, sneezing, or even when making the vertical position of the body. And the first and second variant of the disease the main complaint of patients is a prolapsed anus from the anus.

The second symptom is incontinence of various components of the intestinal contents, observed in almost 80 % of patients. Very often the leaking of intestinal contents is observed in the second variant of development of the disease in women.

Weakness of sphincters of rectum and insufficiency of the pelvic floor muscles are an integral part of the pathogenesis of the disease. More than 50% of the patients observed various violations of function of the colon, often in the form of chronic constipation, leading to constant use of laxatives or cleansing enemas. More rarely the disease develops on the background of chronic diarrhea.

Pain syndrome patients, as a rule, is not expressed, the pain often occurs when there is a sudden prolapse of the rectum. Still about 50% of patients report pain in the lower abdomen, aggravated by defecation, a significant physical activity even when walking. When reduction colon abdominal pain either decreases or is at all.

Typical complaints are abnormal discharge from the anus, often in the form of mucus, but there may be spotting due to the modified injury of small blood vessels in loose and edematous mucosa the drop-down part of the rectum.

Often patients complain of foreign body sensation in the rectum and false desires on a defecation. At long existence of rectal prolapse, especially combined with uterine prolapse, the patients indicate different dysuric disorders, such as frequent urination or intermittent urination.

Classification and types

Over a long period of study of rectal prolapse proposed many classifications of the disease. Among them the greatest practical interest is the differentiation of three degrees of prolapse:

  • Grade I — the rectum appears only during defecation.
  • Grade II — prolapse of the rectum occurs not only during defecation, but also during exercise.
  • Grade III — the rectum falls when walking and even when taking vertical position.

In addition, important clinical criterion is the ability to self-reposition of the prolapsed part of the intestine, which indirectly indicates the degree of compensation of the pelvic floor muscles. If the muscles can not only shrink, but also to maintain tone, such a state is characterized as compensated and Vice versa. Thus, if the intestine alone reduce, the muscles of the pelvic floor, especially lavatory are in the stage of compensation. The need for manual manuals to reposition the rectal evidence of decompensation of the pelvic floor muscles that should be taken into consideration when choosing the method of treatment. You should also determine the degree of insufficiency of the anal sphincter, which is characteristic for most patients with rectal prolapse.

Complications

From complications of the disease should first be noted the infringement of the prolapsed part of the rectum. It can occur in almost every patient, if time does not reduce a prolapsed part or if the attempt at reposition was done roughly. Rapidly increasing swelling not only prevents the reduction, but also impairs blood supply to the intestine, which leads to necrotic areas and ulcers.

Especially dangerous is the denial of the simultaneous appearance of loops of small bowel in a peritoneal pocket between the walls of the rectum. In these cases, may develop acute intestinal obstruction and peritonitis.

Diagnostics

Apparent ease of detection of rectal prolapse is valid only partly, when patients come to the doctor with a “real” diagnosis. Even the appearance of the rectum from the anus under light or straining in the upright position is not the end of the diagnosis, but only its beginning. In those cases, when a patient comes with complaints of foreign body sensation or tenesmus, it is necessary to use special methods of inspection, especially in the squatting position. And in this case helps the straining of the patient. Then the patient should be placed on the viewing stool and perform a finger examination of the rectum. You should pay attention to the condition of hemorrhoids, tone and volitional contraction of the sphincter, the presence of any pathologies, such as polyps.

During the inspection the drop down part of the rectum evaluated its shape and size, condition of mucosa, the presence of dentate (ANO-rectal) line.

At loss only of the rectum detected by the circular space between the wall of the rectum and the anal canal, this space disappears if there is a loss of not only the rectum but the anal canal. The long length of the prolapsed intestine (more than 12-15 cm) evidence of involvement in the pathological process of the sigmoid colon.

Spherical or ovoid shape drop-down part marked by severe loss of tone of the intestinal wall, and in the presence of loops of intestine between its walls.

The presence of loops of small bowel can be determined by palpation of the prolapsed part of the rectum. When it is compacted loops of the small bowel with a characteristic rumbling are pushed into the abdominal cavity, and she dropped the part is significantly reduced in size, there is a good folding of the mucosa.

In the case of internal of rectal prolapse (intussusception) large role in the diagnosis belongs pallavolo study and sigmoidoscopy. When digital examination is a pathological formation of a smooth, elastic consistency, easily movable relative to the walls of the rectum, which may disappear in the knee-elbow position, and Vice versa, increasing straining and coughing. Sigmoidoscopy in these cases helps to determine the nature discovered of education and confirm the presence of invaginata.

In addition, with these methods, determined by the presence of the so-called solitary ulcer located usually on the front wall nijneangarsk of the rectum.

Further examination of patients should be aimed at identifying the causes and pathogenesis of rectal prolapse.

Endoscopic examination of the colon is necessary to detect tumors, diverticulosis and other pathological formations of the colon.

An important element of diagnosis is the x-ray examination (including defecography), which are determined not only anatomical {the presence of invaginata, loops of small bowel in the prolapsed peritoneal pocket) but also functional (the severity and length of colostasis, as a compensation of pelvic floor muscles) changes.

You must also performing physiological studies aimed at assessing functional status zamechatelnogo apparatus of the rectum, motor-evacuation ability of the colon and the activity of the pelvic floor muscles.

Differential diagnosis. Rectal prolapse should be differentiated from loss of hemorrhoids. The difference is the lobular structure of hemorrhoids, with folds of mucous membrane located along, but not in the transverse direction as in the mucosa of the rectum.

For rectal prolapse is sometimes treated loss of large polyps or villous tumors. Finger examination is able to quickly refute the erroneous diagnosis.

Great difficulties arise in the presence of internal loss and a solitary ulcer. In the latter case it should be differentiated from endophytic tumors using morphological methods (Cytology, biopsy).

Sometimes there is a need to differentiate the internal from intussusception and rectocele. The characteristic of the differential characteristic is the method of manual AIDS, which are forced to resort to the patient. When rectocele at manual guide they fix the crotch in the front or side from the anus and insert the finger into the vagina for fixation of the anterior wall of the rectum. Patients with internal prolapse introduce the finger into the rectum, trying to shift invaginate and release the exit from the rectum.

All the same differential diagnosis in such cases should be based on radiological survey data. Especially valuable in such situations is videodesexogratis.

Treatment

Currently, for the treatment of external of rectal prolapse uses only surgical methods. At the same time, the treatment of all patients with internal prolapse (intussusception) should begin with obligatory carrying out a complex of conservative therapy. More than one-third of patients conservative treatment provides a positive effect. The best results of conservative treatment observed in young and middle-age, not having advanced forms of the disease, anamnesis of disease not more than 3 years.

Surgical treatment of rectal prolapse has a long history Dating back to antiquity. Offered over 200 different operations, different from each other sometimes radically, but often only in minor details. All methods of surgical treatment are classified according to their fundamental characteristics at the five main options:

  1. the impact on the prolapsed part of the rectum;
  2. plastic anal canal and pelvic floor;
  3. intra-abdominal resection of the colon;
  4. fixation of the distal colon;
  5. combination methods.

Surgery the prolapsed part of the rectum. Cauterization of the prolapsed part of the rectum in a variety of ways, including electric, used until the mid-XX century At the present time practically not used.

Resection of the prolapsed part of the rectum for certain indications used in some patients, especially in elderly with severe comorbidities.

Most widely:

  • operation Mikulic — circular amputation of the prolapsed rectum;
  • operation of Nelaton — the so called patchwork cut off the drop down part of the colon;
  • operation delarme’s — amputation of the mucous membrane of the prolapsed part of the rectum with the imposition borivali stitches in the muscle wall in the form of a roller, motorization placed over the anal canal.

The last operation is currently the most widespread, primarily because it is technically simple to implement, gives the smallest rate of postoperative complications and a small percentage of recurrence of prolapse. Although, of course, is pathogenetically justified method this method include only a very limited number of patients.

Plastic the anal canal and pelvic floor. A typical operation of this kind is the narrowing of the anus copper (silver) wire on Tirso (1891). Instead of a wire was proposed and other materials (silver and steel chains, silk and Mylar threads, the various strips of autoplastic and synthetic materials, etc.). All of these proposals in practice proved to be untenable due to the large frequency of postoperative complications and a high percentage of recurrence of rectal prolapse. In fact, this type of surgical benefits should also include the operation of a harmful separation and twisting of the distal rectum and anal canal, having now only a historic interest.

Despite the large number of proposed options for narrowing of the anus (over 40), they all suffer from one significant drawback — too mechanically and primitively trying to resolve a complex pathological process. So they are doomed to failure, especially in adult patients.

Plastic pelvic floor by suturing the edges of elevatorov suturing with or without podseleniya to the rectum, on the contrary, gives good results, but not as a standalone operation, but only when it complements other surgical intervention aimed at elimination of rectal prolapse.

Intra-abdominal resection of the distal colon, including direct, radical cure for her loss. But it is unlikely that this method of treatment, i.e. removal of the organ is physiologically and pathogenetically justified in most patients. Therefore, resection of the sigmoid and rectum are not widely spread among Russian surgeons as a treatment of rectal prolapse.

At the same time, completely abandon the execution of such operations should not be, because in some patients the inert rectum or dolichosigma may be the cause of hair loss. Application in other similar cases, such as locking, transactions can only aggravate the condition of patients, leading not only to constipation but also to a complete loss of self-defecation. Resulting chronic colonic stasis, followed by a constant increase in intra-abdominal pressure, in turn, leads to the inevitable recurrence of the loss.

Resection of the sigmoid and rectum with loss of the latter must be pathogenetically substantiated and not be performed as a separate operation and in combination with other surgical benefits (e.g., commits), eliminating the pathogenetic links of the pathological process.

The locking operation is aimed at keeping the rectum to its normal anatomical and physiological conditions.

The most logical, from the point of view of the essence of the disease, methods of elimination of rectal prolapse have been used for over 100 years. Among the numerous methods proposed for this period, currently the most widely:

  • method Terenina—Kümmel — fixation of the rectum to the anterior longitudinal ligament of the spine in the region of the Cape a separate host seams;
  • method of Epstein — fixation of the rectum to promontorium with Teflon mesh;
  • modification of the method of Epstein — sanaathana fixation of the rectum to the sacrum using a synthetic mesh.

Operation Terenina—Kümmel, as experience has shown, providing a reliable fixation of the rectum, however, in some patients leads to constipation. Therefore, this method of fixation it is advisable to use in patients under the age of 35 years with a history of illness less than 3 years.

In other cases, shown sanaathana fixation of the rectum to the sacrum using a Teflon mesh. This technique allows to keep intact the anterior wall of the rectum, without breaking thus its evacuation function.

In recent years, increasingly laparoscopic method of surgical treatment of type zagrebelsky fixation of rectum using Teflon mesh. This method, along with reliable fixation of the rectum, has a very important quality — low-traumatic intervention, which allows to reduce inpatient postoperative period to 4-5 days.

Combined methods. The complexity of the pathogenesis of rectal prolapse is often forced to resort to combined methods of surgical treatment. Apply combination (combination) various methods of fixation, plastics and even resection of the distal colon.

An example of such operations can serve as a method Venglovskii R. I. (1902), combines cutting off the prolapsed part of the rectum with levatoroplasty, the method of A. V. Vishnevsky (1922) — narrowing of the anal canal, fixation of the rectum to the lower edge of the sacral ligaments and intra-abdominal fixation of the rectum to the uterus (bladder).

A number of patients suffering from rectal prolapse on the background of long-term constipation, it is advisable to use a combination of fixation of the rectum with resection of nonfunctioning of the left departments of the colon or dolichosigma. The indication for such surgical intervention is the delay of the passage on the left parts of the colon over 72 h (according to radiographic or scintigraphic studies).

Concluding a brief review of surgical treatment of rectal prolapse, it should be emphasized the importance of studying the pathogenesis of the disease in each particular patient. Modern survey methods allow this in the majority of patients.

In the presence of patients with internal rectal intussusception (internal prolapse), accompanied by the formation of a solitary ulcer, the most appropriate time of resection of the distal colon by type the anterior or abdominal-anal resection.

In patients of elderly and senile age with severe comorbidities that prevent performing abdominal surgery, the operation is delarme’s. This operation is recommended when the length of the drop-down segment of the intestine is not more than 7-8 cm.

Forecast. In the treatment of rectal prolapse a differentiated choice of method of surgical treatment depending on the patient’s age, duration of anamnesis, rectal prolapse, intestinal transit character and other factors. With the right choice of method of surgical intervention the prognosis for surgical treatment is usually favorable. From 72-75 % of operated manage to eliminate rectal prolapse and to improve the evacuation function of the colon.

For a lasting effect of the surgical method need to not only its compliance with the pathogenesis of the disease, but also the correct behavior of patients in the postoperative period, both in the near and distant. The necessary elimination of the factors that contribute to disease, normalization of the gastrointestinal tract and the elimination of heavy physical exertion.

Reviewed by the QSota Medical Advisory Board