rectal prolapse

The anatomy of the lower rectum and anus is a wonder. The anus itself is said to be the most intelligent muscle of the body, since it must be able to distinguish reliably between a solid, a liquid, and a gas. At any event, the lower end of the colon - the rectum - is tethered in the nether regions of the pelvis by suspensory ligaments. In certain circumstances, for example chronic constipation and straining, these ligaments can become stretched and lose the ability to keep everything in place. When that happens, the inner surface of the rectum can protrude out of the anus, looking like a blood-red sausage. Despite the fact that this is basically a harmless phenomenon, it is not a pretty or reassuring sight for parents.

Technically, rectal prolapse occurs when the the rectal mucous membrane protrudes out through the anus and becomes visible as bright or dark red, moist tissue. The prolapse can be impressively large, up to 3-4 inches long. While it is possible for other things to cause a protrusion of tissue through the anus, most cases of visible tissue protruding through the anus are prolapse and not polyps, intussusception, or other tissues.

It usually happens during defecation; it is ordinarily painless or only a little uncomfortable. Sometimes the prolapse reduces (slips back inside the body) spontaneously, or the child or parent may manually push it back in. In very severe cases, the prolapsed rectum may remain chronically out, becomes congested and swollen, and is more difficult to reduce.

The first episode is usually somewhere between 1-5 years old, with the average age about three. Predisposing factors include intestinal parasites (particularly in endemic areas), malnutrition, acute diarrhea, chronic constipation and straining, ulcerature colitis, pertussis (whooping cough), Ehlers-Danlos syndrome, meningocele (more frequently associated with procidentia owing to the lack of perineal muscle support), and cystic fibrosis.

Management of the problem involves

  • evaluation for predisposing conditions and correcting those that can be corrected, e.g. chronic constipation
  • teaching parents how to gently push the prolapse back in by
    • covering the parent's little finger with some toilet tissue
    • placing the fingertip in the lumen or opening at the end of the mass
    • gently pushing the mass back inside the rectum
    • withdrawing the finger (the toilet paper sticks to the prolapse, allowing the finger to slide right out; the paper takes care of itself)
  • children are taught not to push so hard to have a BM
  • children are also taught to sit with their feet elevated off the floor, perhaps with a little footstool, when they have a BM
  • stool softeners and laxatives are used freely
  • surgery, while an option of last resort, is generally avoided if possible

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