Transcript Rectal Prolapse - St. Luke's Roosevelt Hospital Center

Rectal Prolapse
Basic Science
September 28, 2005
Which of the following are risk
factors for rectal prolapse?
1.
2.
3.
4.
5.
Chronic constipation
Chronic diarrhea
Mental retardation
Prior history of intussusception
Female sex
Which of the following are risk
factors for rectal prolapse?
1.
Chronic constipation
True
2.
Chronic diarrhea
True
3.
Mental retardation
True
4.
Prior history of intussusception
False- Rectal prolapse is thought of as a type of intussusception- having
intussusception at an anatomically distant location doesn’t increase risk,
but rectal prolapse does tend to recur and progress.
5.
Female sex
True- but childbearing is only part of the reason- half of patients are men or
nulliparous women
All of the following are anatomic
abnormalities seen in patients with rectal
prolapse except:
1.
2.
3.
4.
5.
Deep rectovaginal or rectovesical pouch
Lax pelvic floor musculature
Failure of normal relaxation of the external
sphincter
Foreshortened mesorectum
Redundant sigmoids
All of the following are anatomic
abnormalities seen in patients with rectal
prolapse except:
1.
2.
3.
4.
5.
Deep rectovaginal or rectovesical pouch
Lax pelvic floor musculature
Failure of normal relaxation of the external
sphincter
Foreshortened mesorectum
Redundant sigmoids
Classification of rectal prolapse:





Partial:
Complete:
Grade 1:
Grade 2:
Grade 3:
Classification of rectal prolapse:





Partial: prolapse of rectal mucosa only
Complete: prolapse with all layers
Grade 1: occult prolapse
Grade 2: prolapse to but not through anus
Grade 3: any protrusion through anus
True or False:



Urinary incontinence is associated with prolapse
Colonoscopy is useful for the diagnosis of
prolapse
In grade 3 prolapse, rectal prolapse is easily
confused with hemorrhoids
True or False:

Urinary incontinence is associated with prolapse


Colonoscopy is useful for the diagnosis of
prolapse


True
False
In a grade 3 prolapse, rectal prolapse is easily
confused with hemorrhoids

False- grade 2 prolapse can be confused with
prolapsing hemorrhoids
Complications of
prolapse include:
Complications of prolapse include:




Ulceration
Strangulation
Urinary and fecal incontinence
Spontaneous rupture with evisceration
Perineal rectosigmoidectomy is
appropriate for:
1.
2.
3.
Younger patients who want to minimize
recurrence
Patients with a grade 3 prolapse protruding at
least 3 cm
Patients who are poor candidates for trans
abdominal surgery
Perineal rectosigmoidectomy is
appropriate for:
1.
Younger patients who want to minimize recurrence

2.
Patients with a grade 3 prolapse protruding at least 3
cm

3.
False- better suited for elderly patients that are poor
candidates for abd surgery due to high recurrence rate
True
Patients who are poor candidates for trans abdominal
surgery

True
Transabdominal approaches to rectal prolapse repair
(ie transabdominal rectopexy):
1.
2.
3.
Are associated with problems with defecation
and constipation
Have a lower recurrence rate than
transperineal approaches
Require resection of the redundant sigmoid
Transabdominal approaches to rectal prolapse
repair (ie transabdominal rectopexy):
1.
Are associated with problems with defecation
and constipation

2.
Have a lower recurrence rate than
transperineal approaches

3.
true
true
Require resection of the redundant sigmoid

not necessarily
Fecal incontinence is corrected by
surgical repair of prolapse in:
1.
2.
3.
4.
5.
90% of patients
70%
50%
30%
10%
Fecal incontinence is corrected by
surgical repair of prolapse in:
1.
2.
3.
4.
5.
90% of patients
70%- return of continence may take as
long as 1 year
50%
30%
10%

1) Rectal prolapseis due to sliding herniation through pouch of Douglas
through pelvic floor fascia into anterior aspect of rectum
B) Is a full thickness rectal intusseception starting ~3inches
above dentate line and extending beyond anal verge
C) Is six times more common in males than females
D) Peak incidence in the 7th decade of life
E) Young male patients tend to have psychiatric disorders
A)

1) Rectal prolapseB) Is a full thickness rectal intusseception starting
~3inches above dentate line and extending beyond anal
verge
D) Peak incidence in the 7th decade of life
E) Young male patients tend to have psychiatric
disorders

2) Chronic or lifelong constipation w/ component of straining has been found to be
present in ~what percentage of patients w/ prolapse?
A) 15%
B) 35%
C) 100%
D) 50%
E) 5%

2) Chronic or lifelong constipation w/ component of straining has been found to be
present in ~what percentage of patients w/ prolapse?
D) Present in over 50% of patients according to
case reviews aimed at elucidating predisposing
factors other than the frequently found
anatomic characteristics- ex. diasthesis of levator
ani; abnormally deep cul-de-sac; redundant
sigmoid colon; patulous anal sphincter; loss of
rectal sacral attachments
3) Rectal prolapse can be distinguished from
prolapsed incarcerated internal hemorroids by
the characteristic _______
(invaginated/concentric) folds of rectal prolapse
and by the _______ (painful/painless) reduction
if not incarcerated.
3) Rectal prolapse can be distinguished from
prolapsed incarcerated internal hemorroids by
the characteristic concentric folds of rectal
prolapse and by the painless reduction if not
incarcerated.
4) Two predominant approaches, ________ and
_________, are considered in operative repair
of rectal prolapse. Generally believed that the
_______ approach results in less perioperative
morbidity and pain an reduced length of
hospital stay.
4) Two predominant approaches, abdominal and
perineal, are considered in operative repair of
rectal prolapse. Generally believed that the
perineal approach results in less perioperative
morbidity and pain an reduced length of
hospital stay.

5) Solitary rectal ulcer syndrome (SRUS)-
A) Gross
pathology always demonstrates the typical
crater like ulcer with fibrinous central depression
B) Typical patient is young and female w/ history
of straining and difficult evacuation
C) Most located on posterior aspect of rectum 4-12
cm from anal verge
D) Diagnostic evaluation by defecography is
radiologic procedure of choice

5) Solitary rectal ulcer syndrome (SRUS)-
C) Typical patient is young and female w/ history
of straining and difficult evacuation
D) Diagnostic evaluation by defecography is
radiologic procedure of choice
* Always located on anterior aspect of rectum.
Gross pathology can range from typical ulcer to
polypoid lesion.
6) Rectocele is abnormal sac like projection of
anterior rectum that extends from distal rectum
to distal anal canal. Usually begins just _____
(above/below) the sphincter complex. Rectal
pressures are ______ (higher/lower) than in the
vagina. Major symptom of rectocele is
________ ( diarrhea/stool trapping).
6) Rectocele is abnormal sac like projection of
anterior rectum that extends from distal rectum
to distal anal canal. Usually begins just above
the sphincter complex. Rectal pressures are
higher than in the vagina. Major symptom of
rectocele is stool trapping.
7) It is rare that a rectocele less than ____ is
symptomatic.
A) 0.5cm
B) 1cm
C) 2cm
D) 3cm
E) 5cm

7) It is rare that a rectocele less than ____ is
symptomatic.
C) 2cm; although small rectoceles are common.
Criteria for operative intervention include
symptomatic stool trapping requiring digital
evacuation or vaginal support and large
protruding rectoceles pushing vaginal mucosa
past introitus producing dryness, ulceration and
discomfort


8) Colonic inertia
A) Estimated that 10% of population suffers from
chronic, unremitting functional constipation
B) Majority of patients are female w/ mean age older
than 50.
C) Delay in gastric emptying and small bowel follow
through has been noted in these patients implying
global motility problem
D) Barium enema is useful initial examination
8) Colonic inertia
C) Delay in gastric emptying and small bowel follow
through has been noted in these patients implying
global motility problem
D) Barium enema is useful initial examination
* Estimated that 2% of population suffers from chronic
functional constipation. Majority of patients female
with mean age younger than 30. Abdominal pain,
bloating and nausea usually accompany the
constipation.

9) Neurologic constipation
A) As a group 50% of these patients are male
B) Responds well to medical management
C) Commonly presents as slow transit constipation
in presence of dilated colon
D) Includes adult Hirschsprung’s disease, Chagas’
disease and neuronal intestinal dysplasia

9) Neurologic constipation
A) As a group 50% of these patients are male
C) Commonly presents as slow transit
constipation in presence of dilated colon
D) Includes adult Hirschsprung’s disease, Chagas’
disease and neuronal intestinal dysplasia


A)
B)
C)
D)
10) Laparoscopic colon resectionBenefits similar to those mentioned for lap cholecystectomyshorter hospital stay; less post op pain; earlier return of bowel
function
Most colon and rectal diseases are amenable to lap approach
except can not do for sigmoid resection for diverticulitis
Port site recurrence appears equivalent to recurrence of cancer
in incision of patients treated by conventional operation
Post operative recovery of lap colectomy is prolonged on
average if hand assisted techniques are used or if anastamosis
has to be performed extracorporeally

10) Laparoscopic colon resection-
A) Benefits similar to those mentioned for lap
cholecystectomy- shorter hospital stay; less post
op pain; earlier return of bowel function
C) Port site recurrence appears equivalent to
recurrence of cancer in incision of patients
treated by conventional operation according to
Sabiston