ANAL PROBLEMS

DR.YOSAF IBRAHIM
SUPERVISED BY: DR. HASSAN ABBAS
 Hemorrhoids
Hemorrhoids are normal vascular structures in the anal canal, arising from a
channel of arteriovenous connective tissues that drains into the superior and
inferior hemorrhoidal veins.
External hemorrhoids are located distal to the dentate line
Internal hemorrhoids are located proximal to the dentate line
Mixed hemorrhoids are located both proximal and distal to the dentate line
 Types
Internal hemorrhoids arise from the superior hemorrhoidal cushion.
Their three primary locations (left lateral, right anterior, and right posterior)
correspond to the end branches of the middle and superior hemorrhoidal veins.
The overlying columnar epithelium is viscerally innervated; therefore, these
hemorrhoids are not sensitive to pain, touch, or temperature.

External hemorrhoids arise from the inferior hemorrhoidal plexus.

They are covered by modified squamous epithelium (anoderm), which contains
numerous somatic pain receptors, making external hemorrhoids extremely painful
on thrombosis.

Internal and external hemorrhoids communicate with one another and drain into
the internal pudendal veins, and ultimately the inferior vena cava.
 Classifications
according to the degree to which they prolapse from the anal canal.

Grade I hemorrhoids are visualized on anoscopy and may bulge into the lumen but
do not prolapse below the dentate line
Grade II hemorrhoids prolapse out of the anal canal with defecation or with
straining but reduce spontaneously
Grade III hemorrhoids prolapse out of the anal canal with defecation or straining,
and require manual reduction
Grade IV hemorrhoids are irreducible and may strangulate
Pathology
Anal canal cancer
Anal fissure
Cirrhosis/portal hypertension
Colorectal cancer
Condyloma
Inflammatory bowel disease
Perianal abscess
Rectal polyp
History Examination Findings
Persistent pain, rectal bleeding, perianal mass Ulcerated or fungating mass at anal verge or in
or ulcer, constipation or diarrhea, weight loss, anal canal, inguinal lymphadenopathy
anorexia
Constipation, severe pain on defecation (ie, Fresh laceration (usually posterior midline,
sensation of passing razor blades or cut glass), occasionally anterior midline or lateral),
rectal bleeding marked sphincter spasm; digital examination
or anoscopy reproduces pain
Anorexia, nausea, vomiting, abdominal Scleral icterus, parotid enlargement,
distention, jaundice, leg swelling gynecomastia, spider nevi, clubbing, palmar
erythema, asterixis, ascites, splenomegaly,
enlarged abdominal wall collaterals, testicular
atrophy, pedal edema
Rectal bleeding (with or without pain), sense of Mass felt on abdominal or rectal examination,
incomplete defecation, abdominal pain, abdominal distention, nontender hard
anorexia, abdominal distention, weight loss hepatomegaly, ascites
Perianal irritation and discharge, swelling, Single or multiple warty lesions, sometimes
genital warts, anal intercourse encompassing the circumference of the anal
canal; perianal excoriation
Abdominal pain, bloody diarrhea, weight loss, Perianal sinuses or abscess, proctosigmoiditis
anorexia, fever, extraintestinal manifestations on proctoscopy or flexible sigmoidoscopy
(joint pain, skin nodules/erythema nodosum,
uveitis, primary sclerosing cholangitis)
Persistent dull ache or throbbing; perianal pain Perianal redness and induration, tender
worse on coughing, sneezing, and/or sitting; fluctuant mass at anal verge (perianal abscess)
relieved by defecation or felt through the rectal wall (ischiorectal
Perianal redness and swelling abscess)
Fever and chills, constipation or diarrhea
Blood or pus drainage on rupture
Painless rectal bleeding Normal perianal examination; proctoscopy or
flexible sigmoidoscopy shows rectal or sigmoid
lesion
 Risk factors
Advancing age
Low fiber diet
Irregular bowel habits (constipation/diarrhea)
Increased intra-abdominal pressure (due to pregnancy, obesity, or ascites)
multiple vaginal deliveries
Cirrhosis or portal HTN
Prolonged sitting
Straining (in exercise)
Pelvic tumors
Family history
 Clinical features
hematochezia, pain associated with a thrombosed hemorrhoid, perianal pruritus,
or fecal soilage.
bright red and coats the stool at the end of defecation or may drip into the toilet.
chronic blood loss can cause iron deficiency anemia with associated symptoms of
weakness, headache, irritability, and varying degrees of fatigue and exercise
intolerance
mild fecal incontinence, mucus discharge, wetness, or a sensation of fullness in the
perianal area
Irritation or itching of perianal skin
Prolapsed Internal Hemorrhoids
Thrombosed External Hemorrhoids
 Evaluation
One prospective study of 290 patients with hemorrhoids and rectal bleeding who
underwent colonoscopy showed that coincidental pathology was common and
included diverticula (43.4%), polyps (17.2%), inflammatory bowel disease (2.8%),
cancer (1.7%), and angiodysplasia (2.1%).
Advancing age increases the risk of such findings approximately eightfold, with
cancers appearing most frequently among patients 50 years and old.

current recommendations are that patients older than 50 years with rectal
bleeding should undergo colonoscopy, even if hemorrhoids are present, as should
those 40 years or older if there is a family history of colorectal cancer.
 Other investigations
CBC
Imaging (IBS. Cancer)
evaluate extent of the disease.
 Non surgical management
Modality Indications Options
Lifestyle and dietary changes, local measures Grades I through IV Exercise and weight reduction if patient is
Thrombosed and prolapsed hemorrhoids overweight or obese
Posthemorrhoidectomy Fiber intake 20 to 35 g/day
Increased fluid intake
Fiber supplements (psyllium, methylcellulose,
polycarbophil)
Sitz baths

Pharmacotherapy (oral or topical) Grades I through IV Oral analgesics/anti-inflammatory drugs

Thrombosed and prolapsed hemorrhoids Oral flavonoids
Topical glyceryl trinitrate 0.2% ointment
Topical nifedipine 0.3% with lidocaine 1.5%
ointment
Rubber band ligation Grades I, II, III Traditional banding using Allis forceps
Vacuum suction banding (superior to traditional
banding)

Sclerotherapy Grades I, II, III Injection of a sclerosant (approximately 5 mL

sodium morrhuate, 5% phenol in oil, hypertonic
saline) through the anoscope at the apex of the
hemorrhoid

Cauterization/coagulation of hemorrhoids Grades I, II, III Infrared coagulation (most useful in grades I, II)
Coagulation using direct or bipolar cautery
Radiofrequency ablation

Hemorrhoidectomy Grades III, IV Excisional hemorrhoidectomy (traditional open and

Grades I, II, III after failure of primary measures
(rubber band ligation, sclerotherapy, cautery)
closed hemorrhoidectomy, electrothermal
vessel/tissue sealing procedure)
Stapled hemorrhoidopexy
Doppler-guided transanal hemorrhoidal ligation
(transanal hemorrhoidal dearterialization)
 Fiber and sitz baths
minimizes straining, maintains bulk and softness in stool, and decreases
recurrence rates.
Fiber intake should be approximately 20 to 35 g/day for 6 weeks for favorable
results. Fiber supplements (eg, psyllium, methylcellulose, polycarbophil) are
acceptable alternatives.
Continue after resolution to prevent recurrence.

Twice/day, relieve pain, decrease tissue edema, and relax sphincter spasm in
patients with thrombosed hemorrhoids and in those who have undergone
hemorrhoidectomy. Potential complications include skin burns, dissolution of
perianal sutures, and dissemination of preexisting genital herpes infections in
postpartum mothers
 When to refer
Patients with minimal bright red blood per rectum in the following categories
should be referred for endoscopic evaluation regardless of age if they have any of
the following :
1. Patients with a history of melena, dark red blood per rectum, or postural vital sign
abnormalities should be evaluated for upper gastrointestinal (GI) tract pathology
first. Even if a lower GI tract source is considered possible.
2. Patients with symptoms suggestive of malignancy such as constitutional
symptoms, anemia, or change in frequency, caliber, or consistency of stools,
should undergo colonoscopy.
3. Patients with fecal occult blood positive stools are known to derive mortality
benefit from investigation with colonoscopy .Hemorrhoids do not affect the
prevalence of positive occult blood tests
4. Patients with family histories suggestive of familial polyposis or hereditary
nonpolyposis colon cancer syndromes
 Drugs
Topical Corticosteroids
Administered as creams, ointments, or suppositories, topical corticosteroids are the
most widely used nonsurgical first-line management for nonthrombosed hemorrhoids.

Analgesics and Anti-Inflammatory Drugs

These drugs can relieve pain and swelling from thrombosed hemorrhoids.

Flavonoids
Flavonoids are plant products with venotonic and anti-inflammatory properties. Oral
formulations are thought to reduce fluid retention and edema and improve lymphatic
drainage.
Other topical medications:
Glyceryl trinitrate 0.2% ointment applied 3 times/day for 14 days, reduces
discomfort and bleeding, and improves stooling, especially for patients with grades
I or II hemorrhoids.

Topical nifedipine 0.3% with lidocaine 1.5% ointment 2 times/day works by easing
sphincter spasm.
Most patients (86%) in a study of 98 patients with hemorrhoids experienced
complete relief of pain within 1 week compared with 50% of patients receiving
only topical lidocaine.
Thrombosed hemorrhoids resolved within 2 weeks in 92% of patients receiving
the combination compared with 46% receiving topical lidocaine alone.
 Non thrombosed hemorrhoids
Rubber band ligation:
requires bowel preparation. One procedure involves application of the rubber band
with a handheld ligator. (video)

Sclerotherapy:
It involves injection of a sclerosant, typically phenol, through the anoscope into the
submucosa at the hemorrhoidal apex (the tip, not the base, of the hemorrhoid),
causing vessel thrombosis, ischemia, and fibrosis.(video)
Complications: urinary retention, mucosal ulceration, fibrosis and stricture, perianal
infection, and sepsis.

Coagulation and ablation:

involves direct application of infrared waves via a cautery, producing coagulation and
fibrosis of the hemorrhoidal vasculature.
Thrombosed External hemorrhoids
presenting within 72 hours of symptom onset benefit from excision and
evacuation of the clot, with earlier resolution of symptoms, longer remission
times, and lower recurrence rates. (Video)
After the procedure, conservative measures are continued until healing is
complete.
 Surgical Management
Hemorrhoidectomy
Hemorrhoidopexy
Doppler guided tran-anal hemorrhoidal ligation
 Anal fissure
linear tears or splits in the mucosa of the anal canal.
In any age group.
Acute: within 8 weeks
Chronic: longer than 8 to 12 weeks.

Primary fissures:
Posterior more than 90% (located at the 6 oclock position with the patient lying
supine).
Anterior fissures occur more commonly among women (more than 25%).

Secondary fissures:
lateral or posterior
 Risk Factors
low fiber intake
passage of hard stools
chronic constipation
excessive laxative use
and anal trauma.
Acute anal fissure
 Clinical Presentation
acute fissures, pain is severe, occurring during and after bowel movements
(described as sensation of passing razor blades or cut glass), often with a tearing
sensation during passage of hard stool or with explosive diarrhea. Anal fissures
often lead to dyschezia.
bleeding
anal discharge, pruritus, and a perianal mass.
 Examination
Acute fissures :
fresh lacerations, typically in the posterior midline.

Chronic fissures :
more fibrotic, indurated, and less tender
raised edges and exposure of the white, fibers of the internal sphincter.

skin tag at the base of the fissure extending distally (ie, a sentinel pile, guarding
the mouth of the fissure) may be seen in acute and chronic fissures.
Increased sphincter tone

NB. If fissures are located laterally, other etiologies must be considered (syphilis,
tuberculosis,IBS, bacterial abscesses, herpes virus, or HIV) esp in elderly
Nonsurgical (for acute fissures; usually continued for 6 weeks)
Fiber Dietary fiber (20 to 35 g/day)
Fiber supplements (psyllium, methylcellulose, polycarbophil)
Increase intake over 6 weeks
Bloating in approximately 50% of patients
Oligo-antigen elimination diet Elimination of cows milk and derivatives, wheat, eggs, tomatoes,
and chocolate for 8 weeks
Used in conjunction with fiber supplementation and medicated
ointments
Benefits noticed in 4 weeks
Sitz baths Potential for spreading herpes infection in mothers and
newborns
Skin burns and dissolution of perianal sutures
Medicated gels/ointments Nitroglycerin 0.2% or 0.4% ointment applied 2 times/day for 8
weeks
Diltiazem gel or ointment 2% applied 2 times/day for 8 weeks
Nifedipine 0.3% with lidocaine 1.5% ointment applied 2
times/day for 6 weeks
OnabotulinumtoxinA (formerly called botulinum toxin type A) 20 units injected bilaterally into the internal sphincter muscle

Surgical (for chronic fissures and acute fissures not healing with nonsurgical management)

Lateral internal sphincterotomy Open and closed techniques; full thickness of internal sphincter
divided distal to the dentate line away from the fissure
Often combined with excision of the sentinel pile

Tailored lateral internal sphincterotomy Sphincterotomy stopped at apex of fissure and not continued to
dentate line
Anal advancement flap and subcutaneous fissurotomy For patients with preexisting continence problems
UPTODATE
AAFP
 Surgical
Lateral internal sphincterotomy
anal advancement flap, subcutaneous fissurotomy
 Anal fistula
abnormal tract connecting the rectum or anal canal to the perianal skin surface.
Because fistula typically is associated with infection, a mucopurulent or feculent
discharge often is present.
twice as common among men as they are among women. Among infants, they
occur almost exclusively in boys.
develop because of epithelialization of a drainage tract in association with rupture
or surgical drainage of a perianal abscess.
complicate inflammatory bowel disease, cancer, radiation, actinomycosis,
lymphogranuloma venereum, hidradenitis, tuberculosis, trauma, or a rectal foreign
body.
Classification
classified based on their location
within the sphincter complex .
50% of all fistulas in this classification
scheme are type 1 (intersphincteric), in
which the fistulous tract is between
the internal and external sphincters.
Fistulas also may be designated as
simple or complex based on their
extent and associated pathology.
Approximately 80% of fistulas are
categorized as simple.

Complex fistula: high risk of treatment

failure and cannot be safely treated by
routine fistulotomy. involving more
than 30 percent of the external
sphincter
Classification by Location
Location Type Frequency Description
Lowa 1 Intersphincteric 45% Most common type
Fistulous tract only in the intersphincteric plane
2 Transsphincteric 30% Fistulous tract passes from intersphincteric plane through external
sphincter into the ischiorectal fossa
Horseshoe fistula is a variant in which the fistula results from infection
spreading behind the rectum and anal canal into the ischiorectal space;
the fistulous tract wraps around behind the anal canal and opens onto
the skin on both sides of the anus

Higha 3 Suprasphincteric 20% Fistulous tract from anal canal in intersphincteric plane passing over
puborectalis, down through levator ani into the ischiorectal fossa and
skin

4 Extrasphincteric 5% Fistulous tract passing from perineal skin outside the 2 sphincters,
through ischiorectal fat and levator muscles into the rectum

Classification by Complexity
Simple 80% Intersphincteric fistulas traversing through <30% of the
external sphincter
Low transsphincteric fistulas
Complex 20% High transsphincteric, extrasphincteric, or
suprasphincteric fistulas
Fistulas in patients with inflammatory bowel disease
(Crohn disease) or locoregional cancer after radiation
Anterior fistulas in women
 Evaluation
aim to identify risk factors and comorbid conditions that might be contributing to
or causing the fistula, and that might influence management.

History: previous abscess drainage, dyschezia, prior pelvic trauma, surgery, and
radiation, along with CD and systemic infections (eg, tuberculosis, HIV).

Physical examination:
Physicians with experience in evaluating anorectal fistulas are able to use the location,
by Goodsall rule, to predict the path and complexity of the fistulous tract accurately.

Imaging:
Useful in complex fistula (endorectal ultrasound, computed tomography scan, and
MRI).

Others:
Anoscopy or sigmoidoscopy is useful in visualizing internal openings.
Goodsall rule
(A)openings on the skin posterior to a
line between the ischial spines, with
external openings within 3 cm of the
anal margin, have a curvilinear course
to the posterior midline of the anal
canal (B).

(C)skin openings anterior to the line

between the ischial spines originate
from the nearest anal crypt and have a
straight course to the anal canal(D).
 Management
obliterate the tract and its openings but produce negligible sphincter damage to
minimize fecal incontinence.
Management choice is determined by the etiology and anatomy of the fistula,
intensity of symptoms, and patient comorbidities.
With the exception of asymptomatic fistulas associated with CD, which need no
treatment, most fistulas should be treated.

Fistulotomy:
involves opening the fistulous tract, draining pus and other fluid from it, and
allowing it to heal by secondary intention.
Most internal openings of the fistula are located around the anal glands
surrounding the dentate.
extremely successful, with rates of healing exceeding 90%. However, because it
involves division of the anal sphincter, incontinence can occur.
Coexisting abscess and fistula in infants and children may resolve spontaneously
after abscess drainage and antibiotic treatment.
Fistulectomy:
involves removing the entire fistula via division of the anal sphincter.
produces larger tissue defects and requires longer healing times, and incontinence
is a more common complication.

Antibiotics:
Antibiotics are not needed routinely for anorectal fistula management.
Their use should be reserved for patients with immunosuppression (including
those with diabetes), extensive cellulitis, or prosthetic devices.
 Anal abcess
obstructed anal crypt gland, with the resultant pus collecting in the subcutaneous
tissue, intersphincteric plane, or beyond (ischiorectal space or supralevator space)

A perianal abscess is a simple anorectal abscess.

Perirectal abscesses are more complex and can involve different planes in the
anorectum, have distinct clinical presentations, and require more nuanced
management.
 Clinical features
History:
constant severe pain in the anal or rectal area.
Constitutional symptoms such as fever and malaise are common. Purulent rectal
drainage may be noted if the abscess has begun to drain spontaneously.

physical examination:
superficial (eg, perianal) abscess : an area of fluctuance or a patch of
erythematous, indurated skin overlying the perianal skin
deeper (eg, supralevator) abscess: no physical findings on external examination,
and the abscess can only be felt via digital rectal examination or by imaging.
 Imaging
For deep anorectal abscess: computed tomography (CT), magnetic resonance
imaging (MRI) , and transperitoneal or endorectal ultrasound .
Chronic fissure Pilonidal sinus
Buttock skin abscess (carbuncle) Hidradenitis suppurativa
 Management
all perianal and perirectal abscesses should be drained promptly; lack of
fluctuance should not be a reason to delay treatment.
Any undrained anorectal abscess can continue to expand into adjacent spaces as
well as progress to generalized systemic infection.

Incision.
Wound packing Wound packing is commonly performed after incision and
drainage of anorectal abscesses but has no proven benefit according to data from
randomized trials. In two small trials, not packing the wound after draining
anorectal abscesses resulted in similar rates of recurrence and fistula formation
and similar healing time but less postoperative pain compared with packing the
wound .
Antibiotics After drainage of an anorectal abscess, we prescribe antibiotics
(either Augmentin or a combination of ciprofloxacin and metronidazole) to
patients with:
1. Extensive perianal/perineal cellulitis
2. Signs of systemic infection
3. Diabetes
4. Valvular heart disease
5. Immunosuppression
 Surgical
Surgery : according to location
 Rectal prolapse (aafp)
protrusion of the layers of the rectal wall through the anal canal, may be partial
(mucosal) or complete (full thickness).
Although prolapse is most common among older women, it affects individuals of
all ages, including children.
Among patients older than 50 years, women are 6 times more likely than men to
develop rectal prolapse. Men who experience rectal prolapse tend to be younger
(ie, younger than 40 years).
Rectal prolapse also occurs in infants and children, typically before age 3 years,
with the majority of cases occurring in the first year of life.

Associated fecal incontinence and constipation are typical. Urinary incontinence

and uterovaginal/bladder prolapse also may coexist. Some patients may have
rectal ulcers.
Diagnosis is predominantly clinical; visualization of the prolapse may require the
patient to strain while sitting or squatting.
 Rectal prolapse(upto)
Rectal procidentia, also called rectal prolapse, is a pelvic floor disorder that
typically occurs in older adult women but can occur in men and women of all ages.
Rectal prolapse results in local symptoms (eg, pain, bleeding, and seepage), bowel
dysfunction (eg, constipation, incontinence), and a diminished and disabled quality
of life.
Male pelvic anatomy
Female pelvic anatomy
 Complete rectal prolapse
complete rectal prolapse : the protrusion of all layers of the rectum through the
anus, manifesting as concentric rings of rectal mucosa .

No standard method of classification has been widely accepted. Complete rectal

procidentia is a circumferential full thickness rectal wall prolapse beyond the anal
canal

Partial procidentia :involves prolapse of the mucosa only

 Rectal Prolapse
complete mucosal
 RISK FACTORS(aafp)
Factors that increase the risk of rectal procidentia include :
1. Age over 40 years
2. Female gender
3. Multiparity
4. Vaginal delivery
5. Prior pelvic surgery
6. Chronic straining
7. Chronic diarrhea
8. Chronic constipation
9. Cystic fibrosis
10. Dementia
11. Stroke
12. Pelvic floor dysfunction (eg, paradoxical puborectalis contraction, nonrelaxing
puborectalis muscle, abnormal perineal descent)
13. Pelvic floor anatomic defects (eg, rectocele, cystocele, enterocele, deep cul-de-sac)
 RISK FACTORS (uptodate)
Infants and Children
Anatomical/structural abnormalities
Absent Houston valves (seen in 75% of prolapse in children <1 year)

Anorectal hypotonia
Low position of the rectum
Megacolon (Hirschsprung disease)
Poor underlying tissue support for anal mucosa
Redundant sigmoid colon
Underdeveloped sacral curve leading to direct downward course of the rectum

Functional causes
Chronic straining associated with constipation
Infectious disease
Chronic diarrhea
Parasitic infestations (trichuriasis)
Other
Cystic fibrosis
Malnutrition
Neoplasm (polyps)
Neurologic disorders (meningomyelocele)
Adults
Anatomical/structural abnormalities
Lack of or poor attachment of the rectum to the retrorectal tissues and sacrum

Pelvic floor muscle weakness

Prior pelvic surgery
Neurologic disorders
Cerebrovascular accident
Dementia
Pudendal neuropathy
Other
Multiparity
Psychiatric disorders
 Clinical features
Bowel protrusion associated with passage of blood and mucus.
A persisting dull perianal ache typically is present, plus/minus strangulation ( pain
is severe and associated with constitutional symptoms, such as fever, chills,
diaphoresis, nausea, and vomiting).
One systematic review ,one-half to three-fourths of patients with rectal prolapse
also experience fecal incontinence.
Up to two-thirds of patients may experience constipation, (probably related to
bowel dysmotility and pelvic floor dyssynergia).
More than one-half have urinary incontinence.
one-fourth have associated utero-vaginal prolapse or cystocele.
 Evaluation
Drug history is also essential because many commonly used drugs and
supplements (eg, opioids, anticholinergics, tricyclic antidepressants,
antipsychotics, calcium channel blockers, iron) may cause or exacerbate
constipation and straining at stool and, thus, contribute to prolapse.
Anorexia, weight loss, persistent abdominal pain, and distention with constipation
or diarrhea mandate ruling out cancer or colitis.
Medical evaluation, if influence surgical management.
 Evaluation
Abdominal Examination.
Abdominal examination should focus on detecting signs of obstruction (eg,
distention, visible peristalsis, increasing borborygmi), neoplasm (eg, palpable
mass) or inflammation (eg, guarding, tenderness, mass).
Perianal Examination.
Perianal inspection should be performed, ideally with the patient straining while in
the sitting or squatting position, because this positioning assists the physician in
differentiating full-thickness rectal prolapse from mucosal prolapse or prolapsed
hemorrhoids.
Mucosal prolapse is thin and often segmental (not extending circumferentially
around the anus). Full-thickness rectal prolapse also may appear segmental, but
more often it is circumferential and plum colored, with concentric mucosal folds.
Prolapsed hemorrhoids and mucosal rectal prolapse typically have radial rather
than concentric folds. Larger prolapses are usually full thickness (complete),
typically contain a fold of peritoneum, and may contain small bowel, although that
is uncommon.
 Evaluation
Rectal Examination.
Digital rectal examination typically identifies anal sphincter hypotonia. A digital
rectal examination also facilitates differentiation of rectal prolapse from an
intussusception with prolapse that originates from a higher level than the rectum.
Because most rectal prolapse begins in the anorectal region, a digit passed up and
around the sides of the prolapse encounters resistance. Intussusception originates
more proximally, and the digit may be passed freely around the prolapsed segment
without resistance. If no prolapse is seen but the patient convincingly describes a
prolapse, the patient should be encouraged to document the prolapse with a
photograph when it occurs.
 Grading of rectal prolapse
Mucosal Prolapse Full-Thickness Prolapse

Degree Description Grade Description

First Rectal mucosa prolapsing into Low grade Grade I (high rectal) Prolapse that does not descend
anal canal below anorectal ring beyond proximal limit of rectocele

Second Rectal mucosal prolapsing to level Grade II (low rectal) Prolapse descending to level of
of dentate line rectocele but not onto
sphincter/anal canal

Third Rectal mucosa prolapsing to anal High gradea Grade III (high anal) Prolapse impinging on
verge sphincter/anal canal

Grade IV (low anal) Prolapse entering anal canal

Grade V (overt) Prolapse protruding outside anal

canal
 Nonsurgical management (eg, increased fiber intake, fiber supplements,
biofeedback) often is therapeutic in minor (first- or second-degree) mucosal
prolapse and can help alleviate constipation and incontinence before and after
surgery for patients with full-thickness prolapse.

However, for full-thickness prolapse, transabdominal procedures are the most

effective management and are favored for healthy patients, irrespective of age.

Perineal procedures (eg, rubber band ligation, mucosal excision) can be used for
patients with full-thickness prolapse who are not candidates for transabdominal
surgery and for those with second- and third-degree mucosal prolapse.
 Nonsurgical management
Nonsurgical management alone is appropriate for only first- or second-degree
mucosal prolapse.
This differs from full-thickness prolapse, which almost always must be managed
with surgical and nonsurgical measures.
Nonsurgical management for mucosal prolapse and as adjuncts to surgery for full-
thickness prolapse focuses first on softening the stool and improving defecation
include increasing fiber intake (20 to 35 g/day); taking fiber supplements; and
using stool softeners to reduce constipation, minimize straining, and heal rectal
ulcers.
Modality
Nonsurgical
Surgical, perineal approach
Surgical, abdominal approach
Method
Fiber and fiber supplements
Antibiotics, anthelmintics
Biofeedback
Granulated sugar
Rubber band ligation
Mucosal sleeve resection (Delorme procedure)
Proctosigmoidectomy (Altemeier procedure)
Many different techniques
Details
Useful for all patients, especially those with first-degree mucosal
prolapse
Dietary fiber (20 to 35 g/day)
Fiber supplements (psyllium, methylcellulose, polycarbophil)
Causes bloating in approximately 50% of patients
Management of infectious diarrheas and parasitosis, especially
in children
Useful in retraining and enhancing sphincter function in all
patients
Improves constipation both before and after surgery and
improves incontinence after surgery for >60% of patients
Improves symptoms and enhances healing in solitary rectal ulcer
syndrome
Useful in decreasing edema in prolapsed mucosa, facilitating
reduction of prolapse
Useful for second- and third-degree mucosal prolapse
Useful for older adult patients with short full-thickness rectal
prolapse
Involves resection of prolapsed rectum followed by shortening
the rectum and mucosal anastomosis
Benefits: significant improvement in incontinence, low
recurrence
Risks: postoperative infection, urinary retention, bleeding, fecal
impaction
Useful for older adults with longer full-thickness rectal prolapse
Excision of redundant rectosigmoid and anastomosis
Improves incontinence; low mortality, morbidity, and recurrence
rates
Useful for all patients with full-thickness rectal prolapse who
have acceptable risk for surgery
Mobilization of the rectum followed by fixing a polyester mesh
to the sacrum and lateral rectal wall, the anterolateral
extraperitoneal rectal wall, or the anterior rectal wall
Improves incontinence and constipation in the majority of
patients, low recurrence
Algorithm
 Additional Studies

Further testing, including defecography, colonoscopy (typically with rectal ulcer

biopsies), barium enema, and urodynamic studies, is useful in making the
diagnosis and identifying pathology that might be contributing to the prolapse.
Defecography

Defecography involves instillation of radiopaque barium paste into the rectum

followed by fluoroscopic imaging as the patient defecates in a special commode.

Defecography, also called evacuation proctography, is cost effective and most

useful for confirming the diagnosis for patients in whom prolapse is suspected but
not evident or reproducible on physical examination.
Dynamic Magnetic Resonance Defecography

In dynamic magnetic resonance imaging, the rectum is filled with a gadolinium-

containing gel, and imaging visualizes changes in the pelvic floor and rectum during
Valsalva maneuver and evacuation of the rectum. Its key advantages over traditional
fluoroscopic defecography are that it provides no exposure to ionizing radiation,
provides multicompartment (slice) images, and is more accurate for defining anatomy
and confirming the presence of prolapse.
However, it is not available in all communities, it is expensive, and it is not always
covered by health insurance plans.
Colonoscopy

Colonoscopy is indicated for evaluation of rectal bleeding when it occurs in

conjunction with rectal prolapse in patients in an age group or with a family history
that puts them at risk of colon cancer. However, in the absence of bleeding,
colonoscopy can still be useful, especially in older patients.
One study involving a series of 255 patients older than 80 years who had lower
gastrointestinal symptoms (including, but not necessarily, rectal prolapse) showed
that more than 50% had colon pathology, including cancer (approximately 10%),
adenomatous polyps (more than 15%), and diverticular disease (22% to 30%).
Thus, assuming a patients physical condition and life expectancy are such that
identification of these abnormalities would be of benefit, colonoscopy might be
considered for all older patients who present with definite or suspected rectal
prolapse, with or without rectal bleeding.