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Case Report

Management of Rectal Prolapse in Elderly Women: A Study

P.S. Ramanujam, MD; K.S. Venkatesh, MD; Krishna P. Ramanujam

This study reviews the presentation and surgical treatment of 12 elderly women with incarcerated rectal prolapse, with special attention to a subgroup experiencing strangulation and gangrene.

Complete rectal prolapse—.ie, full-thickness protrusion of the rectum through the anal sphincter—is an uncommon disorder seen in elderly women, and can be disabling. Rarely, the prolapsed portion of the rectum can acutely become incarcerated or even strangulated. This article presents a study of 12 cases of acute, irreducible rectal prolapse.

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THE STUDY

Material and Methods

Between 1982 and 2002, 120 elderly patients with full-thickness rectal prolapse were treated in a retirement community in Phoenix, Ariz. Twelve of these patients presented with incarcerated rectal prolapse (Figure 1), four of whom had obvious strangulation with gangrenous areas (Figure 2). Unlike patients with chronic, recurrent rectal prolapse, these 12 patients experienced incarceration during their first and only episode of rectal prolapse. All of them were women aged > 70 years, and all were straining hard during defecation at the time of prolapse. All patients had a long history of chronic constipation, and none had any anal incontinence prior to prolapse. No patient had rectal neoplasm. Presenting symptoms of intense rectal pain, pressure, fullness, and bloodstained mucus drainage were associated with lower abdominal pain and nausea. Manual efforts to reduce the rectal prolapse were unsuccessful, even with ice packs, epinephrine injection into the rectal mucosa, and relaxation of the anal sphincter under anesthesia.

Figure not available online

Figure 1. Incarcerated rectal prolapse. Courtesy of P.S. Ramanujam, MD.

Figure not available online

Figure 2. Gangrenous rectal prolapse. The line of demarcation is clearly visible. Courtesy of P.S. Ramanujam, MD.

The patients received intravenous narcotics, hydration, and antibiotics prior to surgery. Mechanical bowel preparation was not possible in this acute situation, so patients were placed in the lithotomy position, and the rectum and distal colon were irrigated with antibiotic solution after induction of anesthesia.

Perineal excision was performed, consisting of a circular incision proximal to the dentate line on the viable portion of the rectal mucosa. The incision was continued through the full thickness of the rectal wall, and the mesenteric vessels were ligated. The prolapsed rectum was amputated up to the viable portion, with the full thickness of the proximal rectum then sutured to the distal rectum using a singlelayer technique and 3-0 polyglactin. The patients were kept on bowel rest until function returned. All were examined for peritoneal signs in the immediate postoperative period. The patients received a clear liquid diet after 24 hours, and then gradually switched to a full liquid diet. They were discharged on a soft diet for 10 days.

Results

Two of the four patients who had areas of gangrene in the prolapsed rectal segment developed pelvic peritonitis secondary to anastomotic leakage in the immediate postoperative period. Both of these patients underwent proximal diverting colostomy with pelvic drainage. The anastomotic leaks were small, with minimal peritoneal contamination. both patients recovered completely, and one underwent reversal of her colostomy after 6 months. The remaining 10 patients (including those with areas of gangrene), had an uneventful recovery, and there were no mortalities. During follow-up of 18 months to 11 years, all patients who underwent perineal excision had acceptable anal continence.

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DISCUSSION

Complete, full-thickness rectal prolapse is seen in elderly female patients, with significant associated medical problems.1-6 Rarely, the prolapsed rectum becomes irreducible, with subsequent incarceration and even strangulation. 6,7 A common pitfall in the diagnosis of rectal prolapse is the potential for confusion with prolapsed, incarcerated internal hemorrhoids. These conditions may be distinguished by close inspection of the direction of the prolapsed tissue folds. In cases of rectal prolapse, the folds are concentric, whereas hemorrhoidal tissue develops radical invaginations in line with the hemorrhoids. Rectal mucosal prolapse can easily be differentiated from full-thickness prolapse in that the former involves only the pink lining of the mucosa.

Goligher7 reported a case of gangrenous rectal prolapse managed by perineal rectosigmoidectomy, and Ramanujam et al8 described three cases of strangulated rectal prolapse treated by perineal excision with good results; the first case reported by Mickulicz9 in 1988 was also an irreducible rectal prolapse treated by perineal excision. Acute, irreducible, incarcerated rectal prolapse seems to occur during the first episode of prolapse8; this is in contrast to chronic, recurrent rectal prolapse that can easily be reduced.1-5 The exact mechanism of first-episode incarceration of rectal prolapse is unclear, but a lack of stretching of sphincter and perirectal tissues may be responsible. Also, the relatively tight sphincter prevents spontaneous reduction of the acute prolapse.

The surgical treatment options for acute, incarcerated rectal prolapse are very limited.8 Indeed, irreducibility with gangrene remains one of the few indications for perineal rectosigmoidectomy. 7,8,10-12 An abdominal approach is unworkable for an incarcerated prolapse, necessitates proximal colostomy, and confers unacceptable risk in these elderly patients. Careful follow-up is mandatory in the immediate postoperative period after perineal excision. In these 12 patients, two developed anastomotic leaks and required proximal colostomy. The incidence of anastomotic leakage after elective perineal excision in chronic, and recurrent rectal prolapse is low. Altemeier et al10 reported no anastomotic leaks in their 19-year review. Gopal et al4 treated 18 patients with no anastomotic leakage.4 Vascular compromise may have caused the anastomotic leakage in the two patients in this series.

Other techniques for correcting rectal prolapse are untenable in cases of incarceration. The Gantmiwa procedure with anal encircling is limited to Japan and would be impossible in an incarcerated rectal prolapse.13 The Italian stapled excision is only performed in patients with rectal mucosal prolapse and is likewise not applicable to incarcerated prolapse.14 Delorme's procedure—ie, circumferential excision of rectal mucosa in the form of a tube—is also impossible with incarceration.15 The French technique of transanal stapling is limited to internal rectal prolapse and is associated with significant complications.16

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CONCLUSION

Perineal excision remains the only effective surgical modality for treating incarcerated rectal prolapse. Colostomy can be prevented in most patients, with good recovery of bowel function.

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P.S. Ramanujam, MD, is staff colon and rectal surgeon, Department of Surgery, Walter O. Boswell Memorial Hospital, Sun City, Ariz. K.S. Venkatesh, MD, is staff colon and rectal surgeon, Department of Surgery, Desert Samaritan Hospital, Mesa, Ariz. Krishna P. Ramanujam is a student researcher and editor-inchief of Pre-Med Perspectives, Department of Molecular and Cellular Biology, University of California, Berkeley.

References

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