Post Operative Care
What is a rectal prolapse?
A rectal prolapse occurs when either the inner lining of the rectum (mucosal rectal prolapse) or the whole of the rectum (full thickness rectal prolapse) passes through the anus, usually during the passage of bowel action.
What causes a rectal prolapse?
Rectal prolapse is a result of a weakened pelvic floor, usually as a result of childbirth. A floppy or redundant lower bowel often leads to the more severe types of rectal prolapse.
What symptoms are caused by a rectal prolapse?
If a large prolapse stays out for a prolonged period of time, it can become quite uncomfortable. It can also stretch the anal muscles, leading to a degree of incontinence. The lining of the prolapsed bowel often bleeds which can lead to concerns of bowel cancer.
If the prolapse is less severe, it can lead to symptoms of deep pelvic discomfort and the feeling that the bowel is not properly empty after going to the toilet.
A mucosal prolapse does not cause discomfort or pain. The most common symptom is of leaking of liquid faeces, often in the period immediately after going to the toilet. Patients with mucosal prolapse also often complain that they cannot clean themselves after the bowels have been opened, using copious quantities of toilet paper.
How is prolapse investigated?
If the prolapse is obvious, little further investigation is required. If there has been any rectal bleeding, it is important to have a colonscopy to rule out other causes for the bleeding, such as bowel cancer and polyps.
If the diagnosis is less clear, there are two options;
How is a rectal prolapse fixed?
A mucosal rectal prolapse is often fixed by rubber band ligation, similar to the technique for small haemorrhoids (see section on haemorrhoids). The instrument that is used for a stapled haemorrhoidectomy can also be used for minor rectal prolapse.
Full thickness rectal prolapse;
There are two broad groups of operations for rectal prolapse;
Abdominal operations consist of completely mobilizing the rectum from above right down to the floor of the pelvis, pulling the rectum straight and stitching the top of the rectum to the top of the sacral bone at the back of the pelvis. Artificial mesh is sometimes used to anchor the rectum to the bone. (If a patient has constipation before this type of surgery, it will be worse afterwards. In this case, it is often recommended that a section of colon be removed as well).
It is often possible to perform these procedures laparoscopically (see section on laparoscopic bowel surgery).
Anal operations involve removal of the excess rectal lining after the prolapse has been pulled completely out of the anus. The bowel muscle is then sutured together to stop further prolapse. An alternative procedure is removal of the entire redundant bowel, followed by stitching of the remaining bowel back to the anus.
Which is the best operation for rectal prolapse?
The abdominal procedures provide a better long term outcome than the anal procedures ie the prolapse is much less likely to come back in the next ten years after as abdominal procedure. An abdominal operation is generally best in a young, fit patient.
The anal procedures are much less taxing on the patient than major abdominal surgery. The anal procedures can even be done without general anaesthetic (eg under a spinal block). An anal operation is a good choice in patients who are elderly or who have other medical problems.