Indian J Pediat 51: 89-94, 1984

Rectal prolapse in childhood. B. Bhandari, M.D. and S.L Mandowara, M.D. Rectal prolapse is a distressing problem in childhood having varied aetiology as well as methods of management. It is 'complete' when all the coats of rectum descend and 'partial' when only mucus membrane descends either in anal canal or protrudes through the anal orifice)

Etiology Owing to special anatomical factors (Table Ia), infants and children are predisposed to this condition, whenever they suffer from any exciting/triggering disease. The exciting factors (Table Ib) are briefly reviewed here.

Gastrointestinal Infections and Infestations Even though amoebiasis is common and seen in severe forms in tropics, surprisingly its role in causing rectal prolapse remained unreported for a long time 25 and in spite of higher prevalence of amoebiasis than cystic fibrosis in the west, the later is reported to be the commonest cause of rectal prolapse in children. 6 Vyas7 for the first time reported amoebiasis as cause of prolapse rectum in 1969 which was further supported by other authors, sll Chacko and vishwanathan, 8 Narsangi 9, Bhandari and Ameta l~ and Bhandari etaP ~reported it as etiological factor for rectal prolapse in 61.74, 76.6, 55 and Department of Pediatrics, R.N.T. Medical College Udaipur-313 001.

58.4 percent cases respectively. Straining colicky pain and tenesmus because ofproctocolitis due to amoebiasis, raises intra rbdominal pressure and accompanying anorexia, nausea and diarrhea/dysentery often decreases the nutritional status of the child; the combined result is emergence of prolapse. Most of the workers 1~ have reported bacillary dysentery as cause of rectal prolapse next to amoebiasis. Tenesmus, gripping pain along with colitis is responsible for causation of prolapse. Giardial infestations have also been reported to cause rectal prolapse by many workers. 8-11 Probably like amoebiasis, colicky pain, straining at stools, chronic diarrhea combined with malabsorption might be responsible for causing rectal prolapse. Lymphoid hyperplasia produced by it may be additionally responsible for raising the intra luminal pressure resulting in more straining and there by occurrence of prelapse, t3-14 Apart from very common causes, the other contributory conditions are chronic/ recurrent bacterial diarrhea, II ulcerative colitis, 15-16trichriasis 17 and bilharziasis) s Protein energy Malnutrition: Hypotonia and wasting of muscles supporting the rectum, reduction of ischiorrctal fat and weakning of the sphincteric tone in P E M leads to prolapse rectum whenever triggering factors are present. Since the role P E M p e r se in its causation can not be ascertained with certainity, incidence varying from 2.5 percent 11 to 100 percent 9 have been reported. Raised intra a b d o m i n a l pressure: Straining at

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Table. Etiology o f prolapse rectum in children

(B) E~/ans~c~,~

(A) l~,disposing special anatomical fector 1. Under developed sacral concavity. 2. Short straight rectum. 3. Loose connective tissue between rectum and sacrum. 4. Prominent submicosal lymphoid tissue. 5. Redundant mucosa. 6. Diminished ischiorectal fat. 7. Weak external sphincter. (1) Gastrointestional infestations and infection: i) Amoebiasis --Amoebic dysentery --Nondysentetic amoebiasis ii) Bacillary dysentary --Acute --Chronic iii) Giardiasis iv) Mixed dysentery v) Chronic/recurrent bacterial diarrhea vi) Uic~rativ9 colitis vii) Trichuri~is viii) Bitharziasis

(21 Primary PEM. i) ii) iii) iv)

v)

(3) Raised intra abdominal pressure. Constipation. i) Chronic cough ii) Undue straining & squaUing at iii) stools, Straining at iv) micturation; stricture urethra, v) phimosis, vesieal calculus. Ascites-Tubercular.

(4~ C'NS causes

(51 Local causes

Spina bifida Polyp, Meningomy Hemorrhoi~ locele Cauda equina lesion. Sacral nerve injuries Cerebral damage

(6)

Miscellaneous i) Cystic fibrosis ii) Hereditary, congenital familial iii) Ehlers Danlos syndmms iv) Ectopia vesicae

Nephrofic syndrome.

stools in constipation leads to raised intra abdominal pressure and rectal prolapse. It was reported as cause of prolapse rectum in 0.70 percent cases by Bhandari et al t~ and 37.7 percent cases of by Nixon) 9 Prolonged bouts of cough of long duration such as in whooping cough, leads to raised intra abdominal pressure as well as pressing down the lower part of the gut every time and thereby cause prolapse rectu m.S-t t.~ Excessive undue straining at stools have been mentioned as cause of prolapse rectum in most of the patients m series of Nixon. l~ Jha 21 reported maximum rise of pressure in squatting position while defecation which may be aggrevating factor. Straining at micturation as in Vesical calculus, stricture of

urethra and phimosis act as exciting factors. Ascitis by raising intra abdominal pressure can cause rectal prolapse (Bhandari et alll). Central nervous system causes." Meningomyelocele, injury to sp!nal cord and nerves, tumors of the spinal cord etc'. lead to atony of perineal muscles and laxity of the sphincter at times resulting in prolapse. 22 Complete rectal prolapse following removal of tumors of cauda equina have been reported by Butler. 23 CNS damage because of neonatal asphyxia has also been reported responsible for causing prolapse rectum) '~ Miscellaneous." Polyp, by its dragging effect on rectal mucosa during defecation causes prolapse rectum? ~ L20 Cystic fibrosis have been reported to be

BHANDARIAND MANDOWARA: RECTALPROLAPSE cause of prolapse rectum in 20-25 percent cases by Angese. 6 Kulazychi 24 also mentioned it as responsible for repeated episodes of prolapse rectum. Jewish community have been reported 2s to be having hereditary predisposition for this condition. Douglas 26 and Beighton e t a [ 2; reported Ehlcr--Danlos syndrome as a cause of rectal prolapse. Nixon 19 and Jones 28 reported Ectopia visicae cause of rectal prolapse. Mechanism of prolapse: very tew studies are available in literature to explain the mechanism of emergence of prolapse rectum. Alaxis Moschowitz 29firsttime reported the classical account of mechanism of complete rectal prolapse by pointing out it as 'sliding-hernia', of the pouch of Douglas, which presses the anterior rectal wall into the rectal lumen and then through the anal canal to the exterior. H e suggested an anatomical weak point in the transversalis or pelvic fascia from where rectum leaves the abdominal cavity. The theory of sliding hernia was further supported by the studies of Ripstein and Lanter, 30 Pantanowitz and levine 31 and Bhandari et al. 32 The sliding hernia theory was challenged by Devdhar, 33 Broaden and Snellman 34 and Theurkaufet aP 5 by proving complete rectal prolapse as an Intussusception. Those who favour the theory of sliding hernia manage it by reducing the displaced rectum and sigmoid, remove the hernial sac and repair the defect of anterior pelvic floor while those who favour the intussuception theory manage it by resecting the rectosigmoid after opening the peritonium and resuturing the two ends. All the studies done so far to prove mechanism of rectal prolapse and subsequent line of management; the subjects were adults except the study of Bhandari et al. 32

91

Clinical picture Though prolapse rectum can occur at any age, the highest number of cases have been reported below three years of the age and males out numbered the females. The child is brought with the complaint of some thing coming out of the anus during the act of defecation or coughingwith variable duration, from a day to years. Initially when this entity starts as mucosal prolapse, it reduces by itself but it becomes progressively irreducible by itself and may present eith prolapse extruded outside. Other symptoms preceding or accompanying depend on the etiological exciting factors, like loose motions with or without mucus and/or blood, tenesmus, colicky pain abdomen, prolong bouts of cough, constipation or any urinary complaint. Physical examination may reveal evidences of malnutrition. mineral and vitamin deficiencies, distension of abdomen and other findings according to the etiological factor. Prolapse may be partial or complete which could be confirmed by local examination; in partial (incomplete or mucosal) prolapse only mucosa descends, it is usually small (1.25 to 3.5 cm) red, congested and occasionally bleeding and palpation gives a feeling of thin double layer of mucus membrane only, while in complete prolapse (Procedentia) all the coasts of bowel descend, usually the length is more than 3.5 cm and congestion, ulcers, and bleeding may be there from it and on palpation'it feels thicker as it contains all the layers of rectal wall, often including a peritoneal pouch anteriorly in which sometimes a loop of intestine herniates. There is considerable degree of dilatation of external sphincter which is hypotonic and patulous in complete comparison to good tone in partial prolapse. 9Proctosigrnoidoscopy may reveal typical

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THE INDIAN JOURNALOF PEDIATRICS

ulceration in cases of amoebic aria t~acillary dysentery. Skiagram chest, Mantoux test and other relevent investigations may be required for diagnosis of exciting factors confirmation of which is mandatory for specific treatment.

Vol. 51, No. 408

by mother holding the buttocks together digitally or perferably by adhesive plaster applied to cover each buttock, then they are approximated. A piece of strapping 2.5 cm wide is placed across the natal cleft adhering only to the square of strapping on either side. This is left even during defecation, after Management which the strip is painlessly removed, the buttocks, covered with their square of A lot of controversies exist in medical adhesive, cleaned, and a new transverse strip literature for management of prolapse rec- is applied. tum in children. According to many surgical Correction of constipation by giving laxtexts 22.36-37 this entity has been considered atives and regular habit of defecation is to be essentially a self limiting one which need no instituted. Partial prolapse cases rarely need active treatment; provided the child is dis- surgery, they are cured with the therapy of couraged from excessive straining at stool underlying exciting causes. and prolapse is replaced as necessary, the Surgical: If digital reposition fails after 6 wk trouble gradually ceases over a period of trial, injections of 5 percent phenol in several weeks or months. The view has also almond oil may be carried out under general been supported by many research papers, 19. anesthesia. The submucosa at the apex of 38-40but others 9.41 have reported need of sur- the prolapse is injected circularly, so as to gery in all the cases. Bhandari et ak II after form a raised ring, upto 10 ml of the solution. studying 187 cases of amoebic rectal pro- being injected and a similar injection is lapse by antiamoebic drugs and placebo made at the base of the prolapse. If prolapse observed that all the cases need treatment as can not be brought down, the injections are spontaneous cure do not occur and most of given through proctoscope. As a result of the the cases of partial prolapse do not require aseptic inflammation following these injecsurgery while in complete prolapse there is tions, the mucous membrane becomes need of surgical interference. tethered to the muscle coat. Digital reposition: This is an easy method of Thiersch's operation: When prolapse persists reduction where a finger is covered with a in spite ofthesemeasures, Thiersch's operapiece of toilet paper and introduced into the tion is almost certain to succeed in childlumen of the mass which is then pushed gen- hood prolapse 42 and strong chromic catgut tly into the rectum and the finger is then is preferred in infants and children over immediately withdrawn. The toilet paper silver wire. adheres to the mucous membrane, permitOther measures like Perirectal injection ting release of the finger; the paper when sof- of alcohol, linear cauterization of mucosa tened, is expelled by itself. The method can can also be used as a palliative surgery for be taught to the mother to replace the pro- rectal prolapse in infants and children. lapse at home also. Major surgical operations like Recto-sigmoidectomy, Ivalon sponge implant operation, Suppo, ling the anus manually or by strapping." Ripstein procedure, abdominal proctoplexy In more severe cases the anus may also be and surgical resection, may be required in supported during defecation by the nurse or extremely rare circumstances in children.

BHANDARI AND MANDOWARA: RECTAL PROLAPSE

References 1 James Fallis: Prolapse and procldentia of the rectum and sigmoid. In Nelson's Text book of pedlat. rics, (XI Ed) W.B. Saunders Company, Philadelphia, 1979, p 1106 2. Anand B.R: A source of carriers of intestinal parasites in Rajasthan with special reference to E. histolytica. J Indian Med Assoc 23: 398, 1954 3. Gupta S: Amoebiasls in infancy and childhood. Indian Practitioner 20: 149, 1967 4. Chuttani PIN: Clinical diagnosis of Amoebiasis in India. Indian Practltion~r 21: 675, 1968 5. WHO Technical report series No. 421, 1969 6, Agnese PA dlsant's, Vidauretta AM: Cystic fibrosis of pancrease. JAMA 172: 2065, 1960 7. Vyas KJ: Amoebiasis in Infants and children. Pediatr Clln of India 4: 169, 1969 8. Chacko RL Vlshwanathan J: Prolapse of the rectum in amoebiasis. Indian Pedialz 9: 816, 1972 9. Narsangi SS: Rectal prolapse in ~hildren. J lnab,~ Med A u o c 62: 378, 1974 10. Bhandari B, Ameta DK: Etiology of prolapse rectum In children with special reference to amoebiasis. Indian Pediatr 14:635 1977 11. Bhandari B, Mandowara SL Ameta DK, Sankh]a K, All SM, Belg Ferzana"Amoebic rectal prolapse In children. Indian Pediaff (under press). 12. Chacko RL Vishwanathan J: Report of a research project on amoebiasis in children. Indian Practitioner 26: 223, 1973 13. Marvin E Amernt, Hans D 0cho: Structure and function of gastrointestinal tract in primary immunodeficiency andromes--A study of 39 patients, Medicine 52: 227, 1973 14. Webster ABD: The gut in immuno deficiency ayndromes. Clln Gastroenterol 2: 5, 1976 15. Shah, PR, Chauhan HR, Desai AB: Ulcerative colitis in children. Indian Pediatr 19: 695, 1982 16. Platte JW, Sohlesinger BE, Benson PF: Ulcerative colitis in childhood, a study of its natural history. Q J Med 29: 257, 1960 17. Gilman RH, Davis C, Fitzergarland F: Heavy trichuris infestation and amoebic dysentery in Orang Asli children, a comparison of two diseases. Tmns R Soc Trop Med H~g 70: 313, 1976 18. Abul Khair MH: Bilharziasis and prolapse of the Rectum. Br J $urg 63: 1891, 1976 19. Nixon HH: Rectal prolapse in childhood. Proc R Soc Meal 55: 1093, 1962 20. Porter N: Collective results of operation for rectal

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prolapse. ProR Soc Med 55: 1087, 1962 21. Jha BN, Om 'Prakash, Coudhari DK, Prasad PB: Rectal pressure in child with prolapse rectum. Indian Pediatr t0: 595, 1973 22. Goligher JC: Surgery of the anus, rectum and golon. (IV Erl~ Casell and Company Ltd. London, 1980 p 2~4 23. Butter ECB: A case report of two cases of prolapse due to tumours of Cauda equina. Proc R ~ Med 47: 521, 19152 24. Kulcqychi LL: Studies on cystic fibrosis of pancrease occurrence of rectal prolapse. N Engl J Med 259: 409, 1958 25. Kupfer CA, Goligher JC: One hundred cases of complete prolapse rectum treated by operatic'l. Br J Surg 57: 481, 1970 26. Douglas ES: Rectal prolapse in the Ehlers Danios syndrome. Aust Pediatr J 9: 109, 1973 27. Be,ghton Peter. Ehlers Danlos syndrome. St Thomas Hospital, london, William Heinnman Medical Boom Ltd. 28. Peter G Jones: Clinical Pediatric Surgery. The Anus, Rectum and Perineum. Bristol John Wright and Sons Ltd. 1970, p 251 29. Moschowtiz AV: The pathogenesls, anatomy and cure of prolapse of the rectum. $mql Glmal OIl~tet 7: 15, 1912 30. Ripsteln CB, Lanter B: Etiology and surgical therapy of massive prolapse of the rectum. A n n Stall 157: 259, 1963 3t. Pantanowitz E Levine: The mechanism of rectal prolapse~ South AIx J Su~il 1: 13, 1975 32. Bhandari B, ByasC, Mandowara SL: Mechanism of rectal prolapse in children. Indian P~lialx (Under Press) 33. Devadhar SC, Daniel. A new concept of mechanism and treatment of rectal procidentia. Di6 Colon Rectum 8: 75, 1965 34. Broden B, Snellman B" Procidentia' of rectum studied with cineradiography. A contribution to the discussion of causative mechanism. Dis Colon Rectum 11: 330, 1968 35. Theurkauf Jr FJ, Beahra OH, Hill Jr. Rectal prolapse causation and surgical treatment. Ann $ur9 171: 819, 1970 . 36. Thomas V: Santu]lt--Rectal prolapse. Pediatric surgery. Mustard WT, Ravitch MM, Snyder JR and Banson CD (Eds)II edition 2 nd Volume, Year Book Publisher INC, 1969 p 1007 37. Bailey, Love: Short practice of surgery 18th Edition, The English Language book Society and HK Lewis and Company Ltd: London 1981, p 1096

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38. Muir EG: Treatment of complete rectal prolapse. Proc R Soc Med 55: 1086, 1962 39. Porter N: Collective results of operation for rectal prolapse. I~ror R Soc Meal 55: 1087, 1962 40. Nigro D: Procedenita of the rectum: Sm'g cll

Vol. 51, No. 408 North Am 58: 539, 1978 41. Nwakof: Rectal prolapse in Nigerian children, l n t Surg 60: 284, 1975 42. Das K: Operative surgery. 6th Ed. Dr. S Das, 13 Old Mayor's Court Calcutta 1978, p 218