Frederick M. Ilgenfritz, MD, FACS Bitterroot General & Vascular Surgery 1150 Westwood Drive, Suite C Hamilton, MT 59840 363.4572 www.bgvs.us

Rectal Prolapse: When the bottom falls out!

Procidentia otherwise known as rectal prolapse is a very disturbing condition which involves the circumferential descent of the rectum through the anal canal. In essence the rectum is partially turned inside out and protrudes from the anus. It can be partial involving only the mucosa (lining) of the rectum or it can involve all layers. The diagnosis is fairly easy, as inspection of the anal area will show a large lemon sized protrusion of red colored moist tissue. It can be irritated and even bleeding slightly. Fortunately the immediate treatment is also fairly easy. With gentle pressure the tissue will return to its normal location through the anus. The problem is that with straining maneuvers or bowel movement the prolapse will commonly come right back out. The process of repeated manual return of the rectum to its normal location is not something most people are prepared to perform on a regular basis. As can be imagined, this becomes both distasteful and inconvenient and most patients seek medical assistance fairly early in the course of the problem.

The peak onset of prolapse is in 7th decade, and women are 6 times more likely than men to be affected. More than half of prolapse patients have a long term history of constipation with straining to move their bowels. It is not unusual to see prolapse in patients who have been instutionalized for many years. Because of damage to the anal sphincter muscles from the prolapse, over half of patients will have incontinence (difficulty controlling their bowels). Some of these patients will regain anal muscle control once the prolapse is treated. Physical therapy can also help patients with weak anal muscles to regain better control. More than 50 different procedures have been proposed and many are still used to treat prolapse. From this number the discerning reader might surmise that medical science has yet to agree on the perfect approach. The approaches tried include various forms of: anal encirclement, removal of the prolapsed tissue, lifting up of the colon and affixing it within the pelvis and repair of the pelvic floor. The technique of anal encirclement was also called the Thiersch wire. In this technique the surgeon placed a wire “purse string” suture around the anal opening to tighten it to the point where stool could come out but not the prolapse. Unfortunately this approach is often complicated by constipation and bowel obstruction or breakage of the wire. The multitudes of other options have been narrowed down to two major approaches. There is a trans-abdominal approach which involves pulling the rectum upward and attaching it to the back of the pelvis, and a transanal approach which involves removing the excess colon and rectum from below and repairing the pelvic floor. The decision regarding which approach to use tends to be determined by the surgeon’s experience and the patient’s co-existing diseases. Older and frailer patients are usually done trans- anally. One attraction of the transanal approach is a shorter hospital stay, usually just one night. Recurrence rates with either approach tend to be less than 10%, and in experienced hands are in the 3 to 5% range. With modern anesthesia techniques and careful selection of surgery to fit the patient, excellent outcomes can be expected in the vast majority of cases.

Questions or comments can be addressed to Frederick M. Ilgenfritz, MD, FACS, c/o Bitterroot General & Vascular Surgery, 1150 Westwood Drive, Suite C, Hamilton, MT 59840 or visit www.bgvs.us.