Rectal prolapse is an uncommon condition (Figure 87-1). It was first described in the Bible (2 Chronicles 21). “You yourself will be very ill with a lingering disease of the bowels, until the disease causes your bowels to come out…. After all this, the Lord afflicted Jehoram with an incurable disease of the bowels. In the course of time, at the end of the second year, his bowels came out because of the disease, and he died in great pain.” The pathophysiology of a rectal prolapse has been evolving since 1543 when Vesalius described the detailed anatomy of the anorectum. Today, three types of rectal prolapse are recognized, and they represent three stages of a continuum.1
A patient with a rectal prolapse. (Used with permission from Knoop KJ, Stack LB, Storrow AB, Thurman RJ (eds): The Atlas of Emergency Medicine, 3rd ed. New York: McGraw-Hill; 2010. Photo contributor: Alan B. Storrow, MD.)
Rectal prolapse usually affects people at the extremes of age.2 It is most common in the very young and the elderly. The condition usually manifests itself in children within the first 4 years of life, with the highest incidence occurring in the first year.3 The gender incidence in children is equal but slightly weighted toward males.1 The peak incidence in the elderly is approximately between 60 and 70 years of age. It affects primarily elderly women, with a 6:1 ratio of females to males.4
ANATOMY AND PATHOPHYSIOLOGY
A rectal prolapse is classified into one of three stages (Figure 87-2). An internal prolapse is the prolapse of the upper rectum and sigmoid colon into the rectal ampulla (Figure 87-2A). It is also known as a hidden or occult prolapse. This type of prolapse does not emerge through the anus. Mucosal prolapse is more common in children. It results from the loose attachment of the mucosa to the submucosal layers and an associated weakness of the anal sphincter. A mucosal prolapse is diagnosed by the presence of radial folds and the absence of muscular wall.4
Types of rectal prolapse. A. Midsagittal view of the internal, hidden, or occult prolapse. B. Midsagittal view of the incomplete, mucosal, or partial prolapse. C. Posterior view of the incomplete, mucosal, or partial prolapse. D. Midsagittal view of the complete prolapse or procidentia. E. Posterior view of the complete prolapse or procidentia.
If the condition progresses, it leads to the protrusion of part or all layers of the rectum through the anal orifice. If only the mucosa is prolapsed, it is classified as an incomplete prolapse (Figures 87-2B and 87-2C). Synonyms include mucosal prolapse and partial prolapse. ...