Rectal Prolapse and Solitary Rectal Ulcer Syndrome
Rectal prolapse involves the protrusion of the rectum through the anal orifice with procidentia or complete prolapse, which is the common scenario, where all layers of the rectum visibly descend through the anal canal (19). Rectal prolapse can be occult where internal intussusception of the rectal tissue occurs without visible protrusion (2). In mucosal prolapse, the distal rectal tissues and not the entire rectal circumference protrude through the anal orifice.
In adults, rectal prolapse occurs 3 to 10 times more frequently in women, usually in the sixth and seventh decades of life, and is not associated with multiparity. It is often associated with chronic straining of stool, poor tone of the pelvic muscles, fecal incontinence, and occasionally neurologic disease or traumatic damage to the pelvis. Protrusion of the rectal tissue is a striking clinical sign of complete procidentia heralded by the presence of concentric, red, mucosal folds with a palpable double thickness to the rectal wall tissue. Accompanying symptoms include straining with defecation and tenesmus. The rectum may protrude extensively with the lumen tip pointing slightly posteriorly.
Flexible sigmoidoscopy is generally performed to rule out other mucosal lesions such as malignancy or associated solitary rectal ulcer syndrome (SRUS). Video defecography is the best way to identify occult prolapse and may show failure of relaxation of the puborectalis muscle, changes in the anorectal angle, and mucosal abnormalities with internal prolapse.
Complete procidentia should be surgically corrected to avoid complications and ongoing damage to the pelvic floor and anal sphincter muscles.
Conservative management with perineal muscle exercises, buttock strapping, and biofeedback training may offer palliation in patients who are unable or refuse to undergo surgery. Surgical management involves the replacement of the rectum into the sacral hollow with or without resection of redundant rectosigmoid colon, which can be carried out with a Ripstein procedure (anterior sling rectopexy).
Figure 3. Endoscopic appearance of solitary rectal ulcer in a patient with rectal prolapse. Reprinted with permission from Gopal DV, Young C, Katon RM.
Solitary rectal ulcer syndrome presenting with rectal prolapse, severe mucorrhea and eroded polypoid hyperplasia: case report and review of the literature. Can J Gastroenterol. 2001;15:479 - 483.
This common procedure involves mobilization of the rectum to the tip of the coccyx and attachment of the rectum to the presacral fascia by a nonabsorbable plastic mesh.
SRUS is a benign condition that affects the rectum and usually presents in women during the third and fourth decades of life (19,20). SRUS pursues a chronic course of constipation, mucorrhea-associated rectal prolapse, rectal bleeding, and tenesmus. The etiology of this syndrome is thought to be associated with either overt rectal prolapse or internal intussusception. During defecation, excessive straining forces the anterior rectal mucosa downward against the unyielding pelvic floor, causing trauma and focal ischemia to the mucosa.
Approximately one quarter of all patients with SRUS are incorrectly diagnosed at the initial assessment, proving that this syndrome can be easily missed if specific details of medical history, clinical course, and physical examination are not noted.
Once clinical symptoms are elucidated and flexible sigmoidoscopy is performed (Figure 3), other investigations are rarely required and have a limited value in confirming SRUS.
Figure 4A. Intact internal anal sphincters (IAS) and external anal sphincters (EAS).
Occasionally, a barium enema may show nodularity of the rectal mucosa and thickening of the first valve of Houston, but ulceration is not often demonstrated, and in 40% to 50% of cases the study is normal.
Management of SRUS is based on the presence of symptoms. Usually conservative therapy with bulk laxatives and bowel retraining is attempted before considering surgical options for intractable or worsening symptoms. Medical management can include the application of local steroids or 5-acetylsalicylic acid (ASA) products.
Figure 4B. Anterior IAS and EAS anal sphincter injury. Reprinted with permission from Gopal DV, Faigel DO. Rectal endoscopic ultrasound - a review of clinical applications. Endoscopic ultrasonography and therapeutic indications. Series #2. Pract Gastroenterol. 2000;24:24 - 34.
Although these have been unsuccessful in treating the underlying defecatory disorder, macroscopic healing does occur. Dietary treatment with fiber and bulk-forming agents is often recommended, but there is little evidence to support this approach. Because some patients may have a predominant behavioral disorder of excessive straining with defecation, biofeedback and retraining may show some benefit. Biofeedback typically includes correction of the pelvic floor defecatory behavior; regulation of toilet habits; encouragement to stop the use of laxatives, suppositories, and enemas; and discussion of any psychosocial factors that may contribute to the behavior.
It is often used in adjunct with surgery and has demonstrated successful results in case series with limited long-term follow-up.
Deepak V. Gopal, MD, FRCP (C)
Assistant Professor of Medicine
Division of Gastroenterology
Oregon Health & Science University
Portland VA Medical Center
Portland, Oregon
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