Rectal prolapse

aesculapian condition
aesculapian conditionRectal prolapseOther namesComplete rectal prolapse, external rectal prolapseFull thickness rectal prolapse & mucosal prolapse..jpgA. full thickness external rectal prolapse, and B. mucosal prolapse. Note circumferential arrangement of folds in full thickness prolapse compared to radial folds in mucosal prolapse.[1]SpecialtyGeneral surgery
Rectal prolapse is when the rectal walls have prolapsed to a degree where they protrude out the anus and are visible outside the torso. [ 2 ] however, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on if the prolapse department is visible outwardly, and if the fully or only fond thickness of the rectal wall is involved. [ 3 ] [ 4 ] rectal prolapse may occur without any symptoms, but depending upon the nature of the prolapse there may be mucous drop ( mucus coming from the anus ), rectal shed blood, degrees of faecal dissoluteness and obstruct defecation symptoms. [ 5 ]

Reading: Rectal prolapse

rectal prolapse is broadly more common in aged women, although it may occur at any long time and in either sex. It is very rarely dangerous, but the symptoms can be debilitating if left untreated. [ 5 ] Most external prolapse cases can be treated successfully, often with a surgical procedure. inner prolapses are traditionally harder to treat and operation may not be suitable for many patients .

categorization [edit ]

A. Internal rectal intussusception. B. External (complete) rectal prolapse. Internal rectal intussusception.. External ( complete ) rectal prolapse The different kinds of rectal prolapse can be difficult to grasp, as unlike definitions are used and some recognize some subtypes and others do not. basically, rectal prolapses may be

  • full thickness (complete), where all the layers of the rectal wall prolapse, or involve the mucosal layer only (partial)
  • external if they protrude from the anus and are visible externally, or internal if they do not
  • circumferential, where the whole circumference of the rectal wall prolapse, or segmental if only parts of the circumference of the rectal wall prolapse
  • present at rest, or occurring during straining.

External (complete) rectal prolapse ( rectal procidentia, broad thickness rectal prolapse, external rectal prolapse ) is a full thickness, circumferential, dependable invagination of the rectal rampart which protrudes from the anus and is visible outwardly. [ 6 ] [ 7 ] Internal rectal intussusception ( occult rectal prolapse, inner procidentia ) can be defined as a funnel shaped invagination of the upper rectal ( or lower sigmoid ) rampart that can occur during defecation. [ 8 ] This invagination is possibly well visualised as folding a sock inside out, [ 9 ] creating “ a tube within a tube ”. [ 10 ] Another definition is “ where the rectum collapses but does not exit the anus ”. [ 11 ] many sources differentiate between inner rectal intussusception and mucosal prolapse, implying that the former is a full thickness prolapse of rectal wall. however, a publication by the american Society of Colon and Rectal Surgeons stated that inner rectal intussusception involved the mucosal and submucosal layers separating from the underlying muscularis mucous membrane layer attachments, resulting in the disjointed part of rectal lining “ sliding ” down. [ 5 ] This may signify that authors use the terms inner rectal prolapse and internal mucosal prolapse to describe the same phenomenon. Mucosal prolapse ( fond rectal mucosal prolapse ) [ 12 ] refers to prolapse of the loosening of the submucosal attachments to the muscularis propria of the distal rectummucosal layer of the rectal wall. Most sources define mucosal prolapse as an external, metameric prolapse which is easily confused with prolapse ( 3rd or 4th degree ) hemorrhoid ( piles ). [ 9 ] however, both internal mucosal prolapse ( see below ) and circumferential mucosal prolapse are described by some. [ 12 ] Others do not consider mucosal prolapse a true form of rectal prolapse. [ 13 ] Internal mucosal prolapse ( rectal inner mucosal prolapse, RIMP ) refers to prolapse of the mucosal level of the rectal wall which does not protrude outwardly. There is some controversy surrounding this condition as to its relationship with hemorrhoidal disease, or whether it is a distinguish entity. [ 14 ] The term “ mucosal hemorrhoidal prolapse ” is besides used. [ 15 ] Solitary rectal ulcer syndrome ( SRUS, lone rectal ulcer, SRU ) occurs with home rectal intussusception and is part of the spectrum of rectal prolapse conditions. [ 5 ] It describes ulceration of the rectal lining caused by duplicate frictional price as the internal intussusception is forced into the anal canal during straining. SRUS can be considered a consequence of internal intussusception, which can be demonstrated in 94 % of cases. Mucosal prolapse syndrome ( MPS ) is recognized by some. It includes lonely rectal ulcer syndrome, rectal prolapse, proctitis cystica profunda, and inflammatory polyps. [ 16 ] [ 17 ] It is classified as a chronic benign inflammatory disorderliness. rectal prolapse and inner rectal invagination has been classified according to the size of the prolapse section of rectum, a function of rectal mobility from the sacrum and invagination of the rectum. This classification besides takes into account sphincter liberalization : [ 18 ]

  • Grade I: nonrelaxation of the sphincter mechanism (anismus)
  • Grade II: mild intussusception
  • Grade III: moderate intussusception
  • Grade IV: severe intussusception
  • Grade V: rectal prolapse

Rectal home mucosal prolapse has been graded according to the level of origin of the intussusceptum, which was predictive of symptom severity : [ 19 ]

  • first degree prolapse is detectable below the anorectal ring on straining
  • second degree when it reached the dentate line
  • third degree when it reached the anal verge

A. normal anatomy : ( roentgen ) rectum, ( a ) anal canal
B. Recto-rectal intussusception
C. Recto-anal invagination The most wide used classification of internal rectal prolapse is according to the height on the rectal/sigmoid wall from which they originate and by whether the intussusceptum remains within the rectum or extends into the anal canal. The altitude of invagination from the anal duct is normally estimated by defecography. [ 10 ] Recto-rectal (high) intussusception ( intra-rectal intussusception ) is where the intussusception starts in the rectum, does not protrude into the anal canal, but stays within the rectum. ( i.e. the intussusceptum originates in the rectum and does not extend into the anal canal. The intussuscipiens includes rectal lumen distal to the intussusceptum merely ). These are normally intussusceptions that originate in the upper rectum or lower sigmoid. [ 10 ] Recto-anal (low) intussusception ( intra-anal intussusception ) is where the intussusception starts in the rectum and protrudes into the anal canal ( i.e. the intussusceptum originates in the rectum, and the intussuscipiens includes part of the anal canal ) An Anatomico-Functional classification of internal rectal intussusception has been described, [ 10 ] with the argument that other factors apart from the height of invagination above the anal duct appear to be crucial to predict symptomology. The parameters of this categorization are anatomic descent, diameter of intussuscept intestine, associated rectal hyposensitivity and associated delay colonic irrigation transit :

  • Type 1: Internal recto-rectal intussusception
    • Type 1W Wide lumen
    • Type 1N Narrowed lumen
  • Type 2: Internal recto-anal intussusception
    • Type 2W Wide Lumen
    • Type 2N Narrowed lumen
    • Type 2M Narrowed internal lumen with associated rectal hyposensitivity or early megarectum
  • Type 3: Internal-external recto-anal intussusception

diagnosis [edit ]

history [edit ]

Patients may have associated gynecological conditions which may require multidisciplinary management. [ 5 ] History of constipation is important because some of the operations may worsen constipation. faecal dissoluteness may besides influence the choice of management .

physical interrogation [edit ]

rectal prolapse may be confused easily with prolapsing hemorrhoids. [ 5 ] Mucosal prolapse besides differs from prolapsing ( 3rd or 4th degree ) hemorrhoid, where there is a segmental prolapse of the hemorrhoidal tissues at the 3, 7 and 11 o’clock positions. [ 12 ] Mucosal prolapse can be differentiated from a full thickness external rectal prolapse ( a complete rectal prolapse ) by the orientation of the folds ( furrows ) in the prolapse section. In full thickness rectal prolapse, these folds run circumferential. In mucosal prolapse, these folds are radially. [ 9 ] The folds in mucosal prolapse are normally associated with internal hemorrhoids. furthermore, in rectal prolapse, there is a sulcus present between the prolapse intestine and the anal scepter, whereas in hemorrhoidal disease there is no sulcus. [ 3 ] Prolapsed, imprison hemorrhoids are extremely irritating, whereas adenine long as a rectal prolapse is not strangulated, it gives little annoyance and is easy to reduce. [ 5 ] The prolapse may be obvious, or it may require distortion and squatting to produce it. [ 5 ] The anus is normally patulous, ( loose, receptive ) and has reduced lie and thrust pressures. [ 5 ] Sometimes it is necessary to observe the patient while they strain on a gutter to see the prolapse happen [ 20 ] ( the perineum can be seen with a mirror or by placing an endoscope in the stadium of the toilet ). [ 9 ] A phosphate enema may need to be used to induce straining. [ 3 ] The perianal skin may be macerated ( softening and whitening of clamber that is kept constantly wet ) and show abrasion. [ 9 ]
These may reveal congestion and edema ( swelling ) of the distal rectal mucous membrane, [ 20 ] and in 10-15 % of cases there may be a nongregarious rectal ulcer on the front tooth rectal wall. [ 5 ] Localized excitement or ulcer can be biopsied and may lead to a diagnosis of SRUS or colitis cystica profunda. [ 5 ] rarely, a tumor ( tumor ) may form on the leading edge of the intussusceptum. In addition, patients are frequently aged and therefore have increased incidence of colorectal cancer. Full length colonoscopy is normally carried out in adults prior to any surgical interposition. [ 5 ] These investigations may be used with contrast media ( barium enema ) which may show the associated mucosal abnormalities. [ 9 ]

Videodefecography [edit ]

This investigation is used to diagnose internal invagination, or demonstrate a suspect external prolapse that could not be produced during the examination. [ 3 ] It is normally not necessary with obvious external rectal prolapse. [ 9 ] Defecography may demonstrate associate conditions like cystocele, vaginal vault prolapse or enterocele. [ 5 ]

colonic transit studies [edit ]

colonic irrigation theodolite studies may be used to rule out colonic inertia if there is a history of dangerous stultification. [ 3 ] [ 5 ] Continent prolapse patients with slow transit stultification, and who are match for operation may benefit from subtotal colectomy with rectopexy. [ 5 ]

anorectal manometry [edit ]

This probe objectively documents the functional status of the sphincters. however, the clinical meaning of the findings are disputed by some. [ 9 ] It may be used to assess for pelvic floor dyssenergia, [ 5 ] ( anismus is a contraindication for certain surgeries, e.g. STARR ), and these patients may benefit from post-operative biofeedback therapy. Decreased squeeze and rest pressures are normally the findings, and this may predate the growth of the prolapse. [ 5 ] Resting shade is normally preserved in patients with mucosal prolapse. [ 20 ] In patients with dilute pillow pressure, levatorplasty may be combined with prolapse rectify to further improve continence. [ 9 ]

Anal electromyography/Pudendal nerve testing [edit ]

It may be used to evaluate dissoluteness, but there is discrepancy about what relevance the results may show, as rarely do they mandate a variety of surgical design. [ 5 ] There may be denervation of striate muscular structure on the electromyogram. [ 20 ] Increased steel conduction periods ( nerve damage ), this may be significant in predicting post-operative incontinence. [ 5 ]

complete rectal prolapse [edit ]

A severe example of arrant ( external ) rectal prolapse. Note circumferential placement of mucosal folds. rectal prolapse is a “ falling down ” of the rectum so that it is visible externally. The appearance is of a redden, proboscis-like object through the anal sphincters. Patients find the condition embarrassing. [ 9 ] The symptoms can be socially debilitating without treatment, [ 5 ] but it is rarely dangerous. [ 9 ] The on-key incidence of rectal prolapse is unknown, but it is thought to be rare. As most sufferers are aged, the condition is by and large under-reported. [ 21 ] It may occur at any long time, even in children, [ 22 ] but there is point onset in the one-fourth and seventh decades. [ 3 ] Women over 50 are six times more probable to develop rectal prolapse than men. It is rare in men over 45 and in women under 20. [ 20 ] When males are affected, they tend to be young and report meaning intestine function symptoms, particularly obstruct defecation, [ 5 ] or have a predispose perturb ( for example, congenital anal atresia ). [ 9 ] When children are affected, they are normally under the age of 3. 35 % of women with rectal prolapse have never had children, [ 5 ] suggesting that pregnancy and labor are not meaning factors. anatomic differences such as the wide-eyed pelvic mercantile establishment in females may explain the skew gender distribution. [ 9 ] Associated conditions, particularly in younger patients include autism, developmental stay syndromes and psychiatric conditions requiring several medications. [ 5 ]

Signs and symptoms [edit ]

Signs and symptoms include :
initially, the mass may protrude through the anal duct alone during defecation and strive, and spontaneously return afterwards. late, the multitude may have to be pushed back in following defecation. This may progress to a chronically prolapsed and severe condition, defined as spontaneous prolapse that is unmanageable to keep inside, and occurs with walk, prolonged stand, [ 5 ] cough or sneeze ( Valsalva maneuvers ). [ 3 ] A chronically prolapsed rectal tissue may undergo pathological changes such as thickening, ulcer and run. [ 5 ] If the prolapse becomes trapped outwardly outside the anal sphincters, it may become strangulate and there is a risk of perforation. [ 20 ] This may require an pressing surgical operation if the prolapse can not be manually reduced. [ 5 ] Applying granulated sugar on the expose rectal tissue can reduce the edema ( swelling ) and facilitate this. [ 20 ]

cause [edit ]

The precise induce is unknown, [ 3 ] [ 9 ] [ 8 ] and has been much debated. [ 5 ] In 1912 Moschcowitz proposed that rectal prolapse was a sliding hernia through a pelvic fascial defect. [ 9 ] This theory was based on the observation that rectal prolapse patients have a fluid and unsupported pelvic floor, and a hernia sauk of peritoneum from the Pouch of Douglas and rectal wall can be seen. [ 5 ] early adjacent structures can sometimes be seen in summation to the rectal prolapse. [ 5 ] Although a bulge of Douglas hernia, originating in the cul de pouch of Douglas, may protrude from the anus ( via the front tooth rectal wall ), [ 20 ] this is a different situation from rectal prolapse. curtly after the invention of defecography, In 1968 Broden and Snellman used cinedefecography to show that rectal prolapse begins as a circumferential invagination of the rectum, [ 3 ] [ 9 ] which lento increases over clock. [ 20 ] The leading edge of the intussusceptum may be located at 6–8 curium or at 15–18 curium from the anal brink. [ 20 ] This proved an older theory from the eighteenth century by John Hunter and Albrecht von Haller that this condition is basically a full-thickness rectal invagination, beginning about 3 inches above the dentate trace and protruding externally. [ 5 ] Since most patients with rectal prolapse have a long history of stultification, [ 9 ] it is thought that prolong, excessive and repetitive puree during defecation may predispose to rectal prolapse. [ 3 ] [ 8 ] [ 20 ] [ 23 ] [ 24 ] [ 25 ] Since rectal prolapse itself causes functional obstruction, more strive may result from a small prolapse, with increasing damage to the anatomy. [ 8 ] This excessive deform may be due to predisposing pelvic floor dysfunction ( e.g. obstructed defecation ) and anatomical reference factors : [ 9 ] [ 20 ]

  • Abnormally low descent of the peritoneum covering the anterior rectal wall
  • poor posterior rectal fixation, resulting in loss of posterior fixation of the rectum to the sacral curve[5]
  • loss of the normal horizontal position of the rectum[3] with lengthening (redundant rectosigmoid)[3][5] and downward displacement of the sigmoid and rectum
  • long rectal mesentery[3]
  • a deep cul-de-sac[3][5]
  • levator diastasis[3][5]
  • a patulous, weak anal sphincter[3][5]

Some authors question whether these abnormalities are the cause, or secondary to the prolapse. [ 3 ] early predisposing factors/associated conditions include :

  • pregnancy[3] (although 35% of women who develop rectal prolapse are nulliparous)[3] (have never given birth)
  • previous surgery[3] (30-50% of females with the condition underwent previous gynecological surgery)[3]
  • pelvic neuropathies and neurological disease[20]
  • high gastrointestinal helminth loads (e.g. Whipworm)[26]
  • COPD[27]
  • cystic fibrosis [28]

The association with uterine prolapse ( 10-25 % ) and cystocele ( 35 % ) may suggest that there is some underlie abnormality of the pelvic floor that affects multiple pelvic organs. [ 3 ] Proximal bilateral pudendal neuropathy has been demonstrated in patients with rectal prolapse who have faecal dissoluteness. [ 5 ] This find was shown to be absent in healthy subjects, and may be the cause of denervation-related atrophy of the external anal sphincter. Some authors suggest that pudendal nerve damage is the causal agent for pelvic floor and anal sphincter debilitative, and may be the underlie campaign of a spectrum of pelvic floor disorders. [ 5 ] Sphincter serve in rectal prolapse is about constantly reduced. [ 3 ] This may be the result of direct sphincter injury by chronic extend of the prolapse rectum. alternatively, the intussuscepting rectum may lead to chronic foreplay of the rectoanal inhibitory reflex ( RAIR – contraction of the external anal sphincter in reply to stool in the rectum ). The RAIR was shown to be absent or blunted. Squeeze ( maximum voluntary contraction ) pressures may be affected deoxyadenosine monophosphate well as the resting tone. This is most probable a denervation injury to the external anal sphincter. [ 3 ] The assume mechanism of faecal dissoluteness in rectal prolapse is by the chronic stretch and trauma to the anal sphincters and the bearing of a direct conduit ( the intussusceptum ) connecting rectum to the external environment which is not guarded by the sphincters. [ 5 ] The wear mechanism of obstructed defecation is by disturbance to the rectum and anal canal ‘s ability to condense and amply evacuate rectal contents. The intussusceptum itself may mechanically obstruct the rectoanal lumen, creating a blockage that strain, anismus and colonic irrigation dysmotility exacerbate. [ 5 ] Some believe that internal rectal intussusception represents the initial form of a progressive spectrum of disorders the extreme of which is external rectal prolapse. The mediator stages would be gradually increasing sizes of intussusception. however, internal intussusception rarely progresses to external rectal prolapse. [ 29 ] The factors that result in a affected role progressing from internal intussusception to a full thickness rectal prolapse remain unknown. [ 5 ] Defecography studies demonstrated that degrees of inner invagination are present in 40 % of asymptomatic subjects, raising the hypothesis that it represents a normal random variable in some, and may predispose patients to develop symptoms, or exacerbate other problems. [ 30 ]

discussion [edit ]

button-down [edit ]

surgery is thought to be the only choice to potentially cure a complete rectal prolapse. [ 6 ] For people with medical problems that make them unfit for operating room, and those who have minimal symptoms, conservative measures may be beneficial. dietary adjustments, including increasing dietary character may be beneficial to reduce stultification, and thereby reduce straining. [ 6 ] A bulk shape agent ( e.g. fleawort ) or stool softener can besides reduce stultification. [ 6 ]

surgical [edit ]

surgery is often required to prevent foster price to the anal sphincters. The goals of operating room are to restore the convention human body and to minimize symptoms. There is no globally agreed consensus as to which procedures are more effective, [ 6 ] and there have been over 50 different operations described. [ 5 ] surgical approaches in rectal prolapse can be either perineal or abdominal. A perineal approach ( or trans-perineal ) refers to surgical access to the rectum and sigmoid colon via an incision around the anus and perineum ( the area between the genitals and the anus ). [ 31 ] Abdominal approach ( trans-abdominal approach ) involves the surgeon cutting into the abdomen and gaining surgical access to the pelvic cavity. Procedures for rectal prolapse may involve obsession of the intestine ( rectopexy ), or resection ( a assign removed ), or both. [ 6 ] Trans-anal ( endo-anal ) procedures are besides described where access to the internal rectum is gained through the anus itself .

abdominal procedures [edit ]

The abdominal approach carries a small risk of powerlessness in males ( e.g. 1-2 % in abdominal rectopexy ). [ 9 ] Abdominal operations may be open or laparoscopic ( keyhole operation ). [ 3 ] Laparoscopic procedures Recovery clock following laparoscopic operation is shorter and less irritating than following traditional abdominal surgery. [ 31 ] alternatively of opening the pelvic cavity with a wide incision ( laparotomy ), a laparoscope ( a thin, lighted tube ) and surgical instruments are inserted into the pelvic pit via belittled incisions. [ 31 ] Rectopexy and anterior resection have been performed laparoscopically with dependable results .

perineal procedures [edit ]

The perineal approach broadly results in less post-operative pain and complications, and a abridge duration of hospital bide. These procedures by and large carry a higher recurrence rate and poorer functional result. [ 5 ] The perineal procedures include perineal rectosigmoidectomy and Delorme repair. [ 3 ] aged, or other medically bad patients are normally treated by perineal procedures, [ 3 ] as they can be performed under a regional anesthetic, or even local anesthetic with intravenous sedation, therefore avoid the risks of a general anesthetic. [ 9 ] alternatively, perineal procedures may be selected to reduce risk of nerve price, for exercise in young male patients for whom intimate dysfunction may be a major concern. [ 5 ] Perineal rectosigmoidectomy The goal of Perineal rectosigmoidectomy is to resect or remove the pleonastic intestine. This is done through the perineum. The lower rectum is anchored to the sacrum through fibrosis in order to prevent future prolapse. [ 6 ] The wax thickness of the rectal wall is incised at a level just above the dentate occupation. pleonastic rectal and sigmoid wall is removed and the new edge of colon is reconnected ( anastomosed ) with the anal canal with stitches or staples. [ 9 ] This procedure may be combined with levatorplasty, to tighten the pelvic muscles. [ 6 ] A combined a perineal proctosigmoidectomy with front tooth levatorplasty is besides called an Altemeier routine. [ 3 ] Levatorplasty is performed to correct levator diastasis which is normally associated with rectal prolapse. [ 3 ] Perineal rectosigmoidectomy was foremost introduced by Mikulicz in 1899, and it remained the prefer discussion in Europe for many years. [ 3 ] It was Popularized by Altemeier. [ 9 ] The routine is simple, safe and effective. [ 3 ] Continence levatorplasty may enhance restoration of continence ( 2/3 of patients ). [ 3 ] Complications occur in less than 10 % of cases, and include pelvic bleed, pelvic abscess and anastomotic dehiscence ( splitting apart of the stitches inside ), bleeding or leak at a dehiscence [ 3 ] Mortality is low. [ 9 ] Recurrence rates are higher than for abdominal repair, [ 3 ] 16-30 %, but more holocene studies give lower recurrence rates. [ 3 ] Additional levatorplasty can reduce recurrence rates to 7 %. [ 3 ] Delorme Procedure This is a modification of the perineal rectosigmoidectomy, differing in that entirely the mucous membrane and submucosa are excised from the prolapse segment, quite than full thickness resection. [ 9 ] The prolapse is exposed if it is not already present, and the mucosal and submucosal layers are stripped from the pleonastic length of intestine. The muscle layer that is left is plicated ( folded ) and placed as a buttress above the pelvic floor. [ 6 ] The edges of the mucosal are then stitched back together. “ Mucosal proctectomy ” was first discussed by Delorme in 1900, [ 9 ] now it is becoming more popular again as it has low morbidity and avoids an abdominal incision, while effectively repairing the prolapse. [ 3 ] The routine is ideally suited to those patients with full-thickness prolapse limited to overtone circumference ( for example, anterior wall ) or less-extensive prolapse ( perineal rectosigmoidectomy may be unmanageable in this situation ). [ 3 ] [ 9 ] Fecal dissoluteness is improved following operating room ( 40 % –75 % of patients ). [ 5 ] [ 9 ] Post operatively, both mean rest and squeeze pressures were increased. [ 5 ] Constipation is improved in 50 % of cases, [ 5 ] but much importunity and tenesmus are created. Complications, including infection, urinary retention, bleed, anastomotic dehiscence ( open of the stitched edges inside ), stricture ( narrowing of the gut lumen ), diarrhea, and faecal impaction occur in 6-32 % of cases. [ 5 ] [ 9 ] Mortality occurs in 0–2.5 % cases. [ 9 ] There is a higher recurrence rate than abdominal approaches ( 7-26 % cases ). [ 5 ] [ 9 ] Anal encirclement (Thirsch procedure) This operation can be carried out under local anesthetic. After reduction of the prolapse, a hypodermic suture ( a stich under the skin ) or other material is placed encircling the anus, which is then made taut to prevent farther prolapse. [ 6 ] Placing silver wire around the anus inaugural described by Thiersch in 1891. [ 9 ] Materials used include nylon, silk, silastic rods, silicone, Marlex enmesh, Mersilene mesh, dashboard, tendon, and Dacron. [ 9 ] This process does not correct the prolapse itself, it merely supplements the anal sphincter, narrowing the anal canal with the target of preventing the prolapse from becoming external, meaning it remains in the rectum. [ 9 ] This goal is achieved in 54-100 % cases. Complications include breakage of the blockade material, faecal impaction, sepsis, and erosion into the bark or anal duct. recurrence rates are higher than the early perineal procedures. This routine is most much used for people who have a severe condition or who have a senior high school risk of adverse effects from general anesthetic, [ 6 ] and who may not tolerate other perineal procedures.

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Internal rectal invagination [edit ]

Internal rectal intussusception ( rectal intussusception, home invagination, internal rectal prolapse, occult rectal prolapse, internal rectal procidentia and rectal invagination ) is a medical stipulate defined as a funnel shaped invagination of the rectal wall that can occur during defecation. [ 8 ] This phenomenon was first described in the deep 1960s when defecography was beginning break and became widespread. [ 5 ] Degrees of home invagination have been demonstrated in 40 % of asymptomatic subjects, raising the possibility that it represents a normal variant in some, and may predispose patients to develop symptoms, or exacerbate early problems. [ 30 ]

Symptoms [edit ]

Internal invagination may be asymptomatic, but coarse symptoms include : [ 3 ]
Recto-rectal intussusceptions may be asymptomatic, apart from balmy obstructed defecation. “ interrupt defaecation ” in the dawn is thought by some to be characteristic. [ 10 ] Recto-anal intussusceptions normally give more dangerous symptoms of strain, incomplete evacuation, need for digital evacuation of stool, need for patronize of the perineum during defecation, urgency, frequency or intermittent faecal incontinence. [ 10 ] It has been observed that intussusceptions of thickness ≥3 millimeter, and those that appear to cause obstruction to rectal evacuation may give clinical symptoms. [ 34 ] [ 35 ]

cause [edit ]

There are two schools of thought regarding the nature of home invagination, viz : whether it is a chief phenomenon, or secondary to ( a consequence of ) another condition. Some believe that it represents the initial form of a progressive spectrum of disorders the extreme point of which is external rectal prolapse. The mediator stages would be gradually increasing sizes of intussusception. The fold segment of rectum can cause repeated trauma to the mucous membrane, and can cause lone rectal ulcer syndrome. [ 9 ] however, internal intussusception rarely progress to external rectal prolapse. [ 29 ] Others argue that the majority of patients appear to have rectal intussusception as a consequence of obstruct defecation preferably than a campaign, [ 36 ] [ 37 ] possibly related to excessive strive in patients with obstructed defecation. [ 34 ] Patients with other causes of obstruct defecation ( release obstruction ) like anismus besides tend to have higher incidence of inner intussusception. Enteroceles are coexistent in 11 % of patients with internal invagination. [ 38 ] Symptoms of internal invagination overlap with those of rectocele, indeed the 2 conditions can occur together. [ 39 ] Patients with lone rectal ulcer syndrome combined with inner invagination ( as 94 % of SRUS patients have ) were shown to have altered rectal rampart biomechanics compared to patients with internal intussusception alone. [ 40 ] The presume mechanism of the obstruct defecation is by telescoping of the intussusceptum, occluding the rectal lumen during attempted defecation. [ 34 ] One study analysed resected rectal wall specimens in patients with obstructed defecation associated with rectal intussusception undergoing stapled trans-anal rectal resection. They reported abnormalities of the intestinal skittish system and estrogen receptors. [ 41 ] One study concluded that invagination of the front tooth rectal wall shares the same induce as rectocele, namely deficient recto-vaginal ligamentous patronize. [ 42 ]

Comorbidities and complications [edit ]

The following conditions occur more normally in patients with inner rectal intussusception than in the general population :

diagnosis [edit ]

Unlike external rectal prolapse, inner rectal invagination is not visible outwardly, but it may still be diagnosed by digital rectal interrogation, while the patient strains as if to defecate. [ 10 ] Imaging such as a defecating proctogram [ 45 ] or moral force MRI defecography can demonstrate the abnormal fold of the rectal wall. Some have advocated the use of anorectal physiology testing ( anorectal manometry ). [ 5 ]

treatment [edit ]

Non surgical measures to treat home invagination include pelvic floor retrain, [ 46 ] a bulk agent ( e.g. fleawort ), suppositories or enemas to relieve constipation and try. [ 20 ] If there is incontinence ( faecal escape or more hard FI ), or paradoxical contraction of the pelvic floor ( anismus ), then biofeedback retrain is indicated. [ 47 ] Some researchers advise that home intussusception be managed conservatively, compared to external rectal prolapse which normally requires surgery. [ 48 ] As with external rectal prolapse, there are a great many different surgical interventions described. Generally, a section of rectal rampart can be resected ( removed ), or the rectum can be fixed ( rectopexy ) to its original side against the sacral vertebra, or a combination of both methods. Surgery for internal rectal prolapse can be via the abdominal approach path or the transanal access. [ 49 ] It is clear that there is a wide spectrum of symptom badness, mean that some patients may benefit from surgery and others may not. many procedures receive conflicting reports of success, leading to a lack of any consensus about the best way to manage this trouble. [ 47 ] Relapse of the intussusception after treatment is a problem. Two of the most normally use procedures are discussed below .

laparoscopic ventral ( interlock ) rectopexy ( LVR ) [edit ]

This routine aims to “ [ adjust ] the origin of the buttocks and middle pelvic compartments combined with reward of the rectovaginal septum ”. [ 49 ] Rectopexy has been shown to improve anal incontinence ( faecal escape ) in patients with rectal invagination. [ 50 ] The operation has been shown to have broken recurrence rate ( around 5 % ). [ 51 ] It besides improves obstruct defecation symptoms. [ 52 ] Complications include constipation, which is reduced if the technique does not use posterior rectal mobilization ( freeing the rectum from its attached second surface ). [ 53 ] The advantage of the laproscopic access is decreased curative meter and less complications. [ 51 ]

Stapled trans-anal rectal resection ( STARR ) [edit ]

This operation aims to “ remove the anorectal mucous membrane circumferential and reinforce the anterior anorectal articulation wall with the consumption of a circular stapler ”. [ 43 ] [ 44 ] In contrast to other methods, STARR does not correct the descent of the rectum, it removes the pleonastic tissue. [ 49 ] The technique was developed from a like staple procedure for prolapsing hemorrhoids. Since, specialized circular staplers have been developed for use in external rectal prolapse and inner rectal intussusception. [ 54 ] Complications, sometimes serious, have been reported following STARR, [ 55 ] [ 56 ] [ 57 ] [ 58 ] [ 59 ] but the routine is nowadays considered safe and effective. [ 58 ] STARR is contraindicated in patients with weak sphincters ( faecal incontinence and urgency are a potential complication ) and with anismus ( paradoxical compression of the pelvic floor during try defecation ). [ 58 ] The operation has been shown to improve rectal sensitivity and decrease rectal volume, the rationality thought to create importunity. [ 49 ] 90 % of patients do not report importunity 12 months after the process. The anal sphincter may besides be stretched during the process. STARR was compared with biofeedback and found to be more effective at reducing symptoms and improving quality of life. [ 60 ]

Mucosal prolapse [edit ]

Rectal mucosal prolapse ( mucosal prolapse, anal mucosal prolapse ) is a sub-type of rectal prolapse, and refers to abnormal lineage of the rectal mucous membrane through the anus. [ 20 ] It is different to an inner invagination ( occult prolapse ) or a complete rectal prolapse ( external prolapse, procidentia ) because these conditions involve the full thickness of the rectal wall, quite than only the mucous membrane ( lining ). [ 12 ] Mucosal prolapse is a different discipline to prolapse ( 3rd or 4th degree ) hemorrhoids, [ 12 ] although they may look similar. rectal mucosal prolapse can be a cause of obstruct defecation ( wall socket obstruction ). [ 8 ] and rectal malodor .

Symptoms [edit ]

Symptom asperity increases with the size of the prolapse, and whether it ad lib reduces after defecation, requires manual reduction by the patient, or becomes irreducible. The symptoms are identical to advanced hemorrhoidal disease, [ 12 ] and include :

induce [edit ]

The condition, along with complete rectal prolapse and inner rectal intussusception, is thought to be related to chronic strain during defecation and constipation. Mucosal prolapse occurs when the results from loosening of the submucosal attachments ( between the mucosal level and the muscularis propria ) of the distal rectum. [ 3 ] The section of prolapse rectal mucous membrane can become ulcerate, leading to bleed .

diagnosis [edit ]

Mucosal prolapse can be differentiated from a entire thickness external rectal prolapse ( a complete rectal prolapse ) by the orientation of the folds ( furrows ) in the prolapse section. In full thickness rectal prolapse, these folds run circumferential. In mucosal prolapse, these folds are radially. [ 9 ] The folds in mucosal prolapse are normally associated with inner hemorrhoids. [ 20 ]

treatment [edit ]

EUA ( examination under anesthesia ) of anorectum and band of the mucous membrane with rubber bands .

lone rectal ulcer syndrome and colitis cystica profunda [edit ]

Solitary rectal ulcer syndrome ( SRUS, SRU ), is a disorder of the rectum and anal canal, caused by straining and increased pressure during defecation. This increase imperativeness causes the anterior assign of the rectal line to be forced into the anal canal ( an inner rectal invagination ). The lining of the rectum is repeatedly damaged by this clash, resulting in ulcer. SRUS can consequently be considered to be a consequence of home intussusception ( a substitute type of rectal prolapse ), which can be demonstrated in 94 % of cases. It may be asymptomatic, but it can cause rectal pain, rectal bleed, rectal malodor, incomplete elimination and obstructed defecation ( rectal mercantile establishment obstruction ) .

Symptoms [edit ]

Symptoms include : [ 17 ] [ 20 ] [ 61 ]

prevalence [edit ]

The stipulate is thought to be uncommon. It normally occurs in young adults, but children can be affected excessively. [ 62 ]

causal agent [edit ]

The essential cause of SRUS is thought to be related to excessively much straining during defecation. overactivity of the anal sphincter during defecation causes the patient to require more attempt to expel fecal matter. This atmospheric pressure is produced by the modified valsalva manovoure ( attempted forced halitus against a closed glottis, resulting in increased abdominal and intra-rectal coerce ). Patiest with SRUS were shown to have higher intra-rectal pressures when straining than goodly controls. [ 63 ] SRUS is besides associated with prolong and incomplete evacuation of fecal matter. [ 64 ] More effort is required because of attendant anismus, or non-relaxation/paradoxical contraction of puborectalis ( which should normally relax during defecation ). [ 65 ] The increase blackmail forces the anterior rectal line against the condense puborectalis and frequently the line prolapses into the anal canal during straining and then returns to its normal placement afterwards. The perennial trap of the line can cause the tissue to become swell and congested. ulceration is thought to be caused by resulting poor blood add ( ischemia ), combined with perennial frictional trauma from the prolapsing lining, and photograph to increased press are thought to cause ulcer. Trauma from hard stools may besides contribute. The site of the ulcer is typically on the anterior wall of the rectal ampulla, about 7–10 centimeter from the anus. however, the area may of ulcer may be closer to the anus, deeper inside, or on the lateral pass or later rectal walls. The list “ lone ” can be misleading since there may be more than one ulcer present. furthermore, there is a “ preulcerative phase ” where there is no ulcer at all. [ 66 ] pathological specimens of sections of rectal wall taken from SRUS patients show thicken and refilling of muscle with fibrous tissue and excess collagen. [ 67 ] rarely, SRUS can present as polyps in the rectum. [ 68 ] [ 69 ] SRUS is consequently associated and with home, and more rarely, external rectal prolapse. [ 64 ] Some believe that SRUS represents a spectrum of different diseases with different causes. [ 70 ] Another condition associated with internal invagination is colitis cystica profunda ( besides known as CCP, or proctitis cystica profunda ), which is cystica profunda in the rectum. Cystica profunda is characterized by constitution of mucin cysts in the muscle layers of the intestine line, and it can occur anywhere along the gastrointestinal nerve pathway. When it occurs in the rectum, some believe to be an exchangeable diagnosis with SRUS since the histological features of the conditions overlap. [ 71 ] [ 72 ] indeed, CCP is managed identically to SRUS. [ 73 ] electromyography may show pudendal boldness motive reaction time. [ 17 ]

Complications [edit ]

Complications are uncommon, but include massive rectal bleeding, ulcer into the prostate gland gland or formation of a stenosis. [ 74 ] [ 75 ] [ 76 ] Very rarely, cancer can arise on the section of prolapse rectal line. [ 16 ]

diagnosis and investigations [edit ]

SRUS is normally misdiagnosed, and the diagnosis is not made for 5–7 years. [ 62 ] Clinicians may not be companion with the condition, and treat for Inflammatory intestine disease, or simple constipation. [ 77 ] [ 78 ] The thicken lining or ulceration can besides be mistaken for types of cancer. [ 79 ] [ 80 ] [ 81 ] [ 82 ] The differential diagnosis of SRUS ( and CCP ) includes : [ 9 ]

  • polyps
  • endometriosis
  • inflammatory granulomas
  • infectious disorders
  • drug-induced colitis
  • mucus-producing adenocarcinoma

Defecography, sigmoidoscopy, transrectal sonography, mucosal biopsy, anorectal manometry and electromyography have all been used to diagnose and study SRUS. [ 17 ] [ 65 ] Some recommend biopsy as substantive for diagnosis since ulcerations may not always be present, and others country defecography as the probe of choice to diagnose SRUS. [ 61 ] [ 72 ] [ 77 ]

discussion [edit ]

Although SRUS is not a medically good disease, it can be the cause of significantly reduced quality of life for patients. It is difficult to treat, and treatment is aimed at minimizing symptoms. Stopping straining during intestine movements, by use of discipline position, dietary fiber intake ( possibly included majority forming laxatives such as fleawort ), stool softeners ( e.g. polyethylene diol, [ 83 ] [ 84 ] and biofeedback retraining to coordinate pelvic floor during defecation. [ 85 ] [ 86 ] surgery may be considered, but only if not surgical treatment has failed and the symptoms are dangerous enough to warrant the intervention. improvement with surgery is about 55-60 %. [ 87 ] ulcer may persist even when symptoms resolve. [ 88 ]

Mucosal prolapse syndrome [edit ]

A group of conditions known as Mucosal prolapse syndrome ( MPS ) has now been recognized. It includes SRUS, rectal prolapse, proctitis cystica profunda, and incendiary polyps. [ 16 ] [ 17 ] It is classified as a chronic benign incendiary perturb. The mix feature is varying degrees of rectal prolapse, whether inner invagination ( occult prolapse ) or external prolapse .

pornography [edit ]

Rosebud pornography and Prolapse pornography ( or rosebudding or rectal prolapse pornography ) is an anal sexual activity practice that occurs in some extreme anal pornography wherein a pornographic actor or actress performs a rectal prolapse wherein the walls of the rectum slip out of the anus. rectal prolapse is a serious medical condition that requires the attention of a medical professional. however, in rosebud pornography, it is performed measuredly. Michelle Lhooq, writing for VICE, argues that rosebudding is an model of producers making ‘extreme ‘ message due to the easy handiness of dislodge pornography on the internet. She besides argues that rosebudding is a room for pornographic actors and actresses to distinguish themselves. [ 89 ] Repeated rectal prolapses can cause intestine problems and anal escape and therefore risk the health of pornographic actors or actresses who participate in them. [ 89 ] Lhooq besides argues that some who participate in this form of pornography are unaware of the consequences. [ 89 ]

terminology [edit ]

prolapse refers to “ the falling down or slipping of a torso share from its common stead or relations ”. It is derived from the Latin pro- – “ ahead ” + labi – “ to slide ”. “ Prolapse ”. Merriam-Webster Dictionary. Prolapse can refer to many unlike medical conditions other than rectal prolapse. procidentia has a exchangeable mean to prolapse, referring to “ a slump or prolapse of an organ or part ”. It is derived from the Latin procidere – “ to fall forward ”. [ 90 ] Procidentia normally refers to uterine prolapse, but rectal procidentia can besides be a synonym for rectal prolapse. invagination is defined as invagination ( infolding ), particularly referring to “ the slipping of a length of intestine into an adjacent assign ”. It is derived from the Latin intus – “ within ” and susceptio – “ action of contract ”, from suscipere – “ to take up ”. “ Intussusception ”. Merriam-Webster Dictionary. rectal invagination is not to be confused with early intussusceptions involving colon or minor intestine, which can sometimes be a medical emergency. rectal intussusception by contrast is not dangerous.

Intussusceptum refers to the proximal section of rectal wall, which telescopes into the lumen of the distal section of rectum ( termed the intussuscipiens ). [ 9 ] What results is 3 layers of rectal wall overlay. From the lumen outwards, the first layer is the proximal wall of the intussusceptum, the center is the wall of the intussusceptum folded back on itself, and the forbidden is the distal rectal wall, the intussuscipiens. [ 9 ]

See besides [edit ]

References [edit ]

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