In this episode of PodMD, consultant Colorectal and General Surgeon Dr David Lam will be discussing the topic of rectal prolapse, including what rectal prolapse is, the treatment options available, the main risks of this condition, the likelihood of recurrence, when to refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr David Lam
Dr David Lam is a consultant Colorectal & General Surgeon based in Melbourne. Dr Lam is passionate about all areas of both colorectal and general surgery but has particular expertise in pelvic floor disorders.
Dr Lam completed his medical degree with honours at the University of Melbourne in 2007 and qualified as a General Surgeon in 2016. He subsequently completed four years of Colorectal Surgery subspecialty training in Australia and the United Kingdom. Whilst in Oxford, he worked in the internationally renowned Pelvic Floor unit and was exposed to a high volume of prolapse surgery and sacral nerve stimulation. He is a member of the Association of Coloproctology of Great Britain and Ireland as well as the Colorectal Surgical Society of Australia and New Zealand.
Today, we’ll be discussing the topic of Rectal Prolapse.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
David, thanks for talking with us on PodMD today.
David : Thank you for having me.
The topic of today’s discussion is rectal prolapse. David, can you describe for our listeners what rectal prolapse is?
David: Yeah, so rectal prolapse is, I would say, an uncommon condition. It’s a protrusion of the rectum outside of the anal canal. So there’s some pelvic floor muscles that support the rectum, and when these become weak, the rectum then telescopes out and turns in on itself. This is a condition that’s more common in older females, but can occur at any age. So rectal prolapse can be classified further into external rectal prolapse when you can actually see the rectum protruding and also internal rectal prolapse where the rectum has started to telescope, but it hasn’t actually gone outside of the anal canal.
How would a patient with rectal prolapse typically present?
David: So the more common presentation is with external rectal prolapse, and obviously that they present with a lump at their back passage, and often this lump starts with when they strain when they use bowels, but eventually it can occur anytime. For example, whilst they’re walking or when they’re exercising. At the extreme end, it can be permanently protruding, or it can actually come out acutely and not be able to be reduced, and that can lead to an emergency presentation.
Along with the lump at the back passage, there’s associated symptoms as well of mucus discharge or passive faecal loss or bleeding from the irritation. We mentioned before about internal rectal prolapse, and these patients don’t necessarily see or feel a physical lump at their back passage, although they may feel some heavy sensation. Instead, what they have is obstructed defecation symptoms, and what these are is that they stools might feel blocked or they’re difficult to pass their stools. They might have to strain excessively to defecate, or they may be able to unable to keep themselves to wipe clean after they’ve used their bow.
So if a patient says they have a lump at the back passage, how can you tell whether it’s rectal prolapse or haemorrhoids?
David: That’s a great question. Haemorrhoids, which are protrusion of vascular cushions in the upper anal canal are indeed more common than rectal prolapse. When I see a patient, often they’ve actually taken some pictures off their lump and that can be really helpful. Rectal prolapse classically is a beefy red colour. It’s a single entity and it protrudes really from the middle of the of the anus.
This is in contrast to haemorrhoids, which are often more purplish in colour. There can be multiple and they appear at the edges of the anus. On examination what I think is the most helpful is to gently push and insert a finger up between the lump that you can see and the anal canal edge. If the finger hits the base of the lump, then you know that it’s a haemorrhoid. But if you can reach the finger all the way up beyond the anorectal junction, then that’s rectal prolapse.
What are the treatment options?
David: With rectal prolapse there’s always conservative as well as surgical options. The conservative options are really aimed at reducing straining because we know that straining produces the prolapse, so approaches may be including altering the stool consistency to make the stools easier to pass, and developing a good toileting routine.
Surgical options aim to correct the anatomical abnormality of rectal prolapse and these classically involve abdominal or perineal approaches. So perineal approaches which are through from the backside involve either stripping or the excess lining of the rectum which is prolapsing out or resecting the excess rectum and joining that to the anal canal.
Abdominal approaches, which are more invasive, would include either resecting the prolapsing rectum and then joining that to the low rectum or hitching the rectum to the sacrum. We call that a rectopexy.
Have there been any developments in treatment in the last years or are there any in trials or development now?
David: So I think the most common operation that we do now certainly in the last 10 years is what we call a ventral mesh rectopexy. And we typically do this laparoscopically, but more and more, we’re also doing this with robotic assistance. And as we mentioned before, the rectopexy is where we hitch the rectum to the sacrum. And inner ventral mesh rectopexy we do this by the means of a mesh which is secured to the front of the rectum only.
And why do we call it a ventral mesh rectopexy? Well what we think is that dissection at the back of the rectum, can injure the hypogastric nerves and result in worsening constipation and hence this dissection that we do to put the mesh on involves dissecting the front of the rectum only. It’s a very straightforward procedure with minimal complications. It’s well tolerated, patients only need to often stay overnight and they have minimal pain afterwards.
So are there any concerns with using mesh for rectal prolapse?
David: Yeah. So there’s has been a lot of recent controversy, especially with vaginal mesh for vaginal prolapse. I think it’s important to understand that when we use mesh for rectal prolapse, it’s a different kettle of fish. The mesh that we place is in a sterile area with an abdominal approach and therefore there’s much less complications in terms of erosion and chronic pain. I think the overall mesh related complications in rectal prolapse, have been shown to be 1 to 2% as opposed to vaginal mesh, which has a complication rate of up to 15%.
However, patients may still be concerned about the use of mesh. One emerging option is the use of biological mesh, which is absorbed by the body over time. Whatever mesh that’s used, I think the choice of mesh is an individual decision that should be made in consultation with the patient and patient should be given written information as well as time to make their decision.
What is the likelihood of recurrence of the condition?
David: Recurrence rates are quite low with ventral mesh rectopexy. Long term studies have shown that the recurrence rate is less well less than 10%, and this is definitely less than the recurrence rate when we use an perennial approach.
So do all patients with rectal prolapse need an operation?
David: The short answer is no. Rectal prolapse is a benign condition, and so a discussion with the patient needs to be made as to what the symptoms are and how much it affects their quality of life. However, those patients with an external rectal prolapse, because it’s a mechanical or anatomical problem, without an operation, this this lump won’t resolve. The other consideration is that with long term rectal prolapse where the prolapse is out all the time. This will make future episodes of faecal incontinence, more likely as the anus is constantly being stretched.
For those patients with internal rectal prolapse, I think again, an individual discussion needs to be happened, have with the patient. The symptoms that often these patients have, which is of obstructed defecation is often multifactorial. There’s a lot of factors that go into defecation and correcting their anatomy by fixing their prolapse may not necessarily restore their function completely.
So when should a GP refer a patient with rectal prolapse?
David: I think anybody who feels or sees a lump at their back passage should be referred, as we mentioned before, it may be haemorrhoids, but really this could be an anal cancer or a rectal cancer, even if it is clinically obviously a rectal prolapse, I would recommend that all patients have their rectum visualised with either a sigmoidoscopy or colonoscopy to ensure that the rectum is not being dragged down because of a more proximal lesion like a cancer.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on rectal prolapse?
David: So the first thing to say is that whilst a lump of the back passage is the most common presenting symptom of rectal prolapse and not all patients with rectal prolapse present with a lump. So, I think for patients who have either faecal incontinence or difficulty with passing stools have rectal prolapse at the back of your mind. The second message is that rectal prolapse is different from haemorrhoids, and you can actually tell them apart clinically. The third message is that our modern treatment of rectal prolapse being a ventral mesh rectopexy is very effective, with minimal morbidity and low recurrence rates.
Thanks for your time and the insights you’ve provided.
David: Thank you so much for everyone’s time