Rectal Prolapse in Elderly - Know the Unknown

Introduction

Elimination of the waste product from the body is necessary. Accumulating this product in the body may cause harm like chronic infection, inflammation, and organ damage. The stool is one of the main waste products of the human body. Undigested food, water, and certain toxic products are eliminated in the form of stool via the rectum. The lower part of the digestive tract is known as the rectum. It is considered as the last part of the large intestine. The opening of the rectum which is seen from the outside is known as rectal opening or anal opening. The rectum is a continuous part of the sigmoid colon and is around five to six inches long. The pelvic diaphragm is a sheet of muscles that runs to the juncture of the rectum and anal canal. Also, a longitudinal sheet of muscle surrounds the rectum. These two muscles are helpful to keep the rectum in position and maintain its functionality.

What Is Rectal Prolapse?

The protrusion of the rectum from the anus is known as rectal prolapse. This is mainly seen in elderly individuals and newborns. It is most commonly seen in elderly women. Also, it is seen in pregnant women, obese persons, patients suffering from chronic constipation, and perineal injury can be associated with this. Anatomical abnormalities in the sigmoid colon may also be responsible for this. Rectal prolapse can be either complete or incomplete. In the complete rectal prolapse, the entire rectum with all its layers is protruded out. In this condition, the concentric folds of the rectum can be visible from the outside. In incomplete prolapse, the protrusion of the rectum is only limited to the anal canal. This is also known as occult rectal prolapse or internal rectal intussusception. Also, mucosal prolapse can be seen, which is caused by a prolapse of the portion of the rectal wall or only the anal mucosa. However, this should be differentiated from rectal prolapse.

What Is Rectal Prolapse in the Elderly Population?

The causative factors for rectal prolapse are not known, but according to some researchers, it has familial tendencies. Several risk factors are associated with this. These are chronic constipation, obesity, and hormonal changes. In women, it is seen around the sixth to seventh decades of life. During defecation, a rise in the intra-abdominal pressure is observed. Due to increased age, loss of the tonicity of the muscular sheet around the rectum is common. This loss of pelvic floor muscles is seen due to menopause, increased age, and hormonal changes. Weakness of the pelvic floor muscles can be caused by injury to the perineal nerve due to trauma or surgery. These changes are responsible for the protrusion of the rectum from the anus. Increased intra-abdominal pressure in patients suffering from constipation and obesity is also responsible for this. It is also seen in patients suffering from depression and taking medications for psychological disorders. However, several researchers have pointed out other factors that are responsible for this. The deep position of the anterior rectovaginal pouch (an extended portion of the peritoneum into the female reproductive system). Some other researchers believe that intussusception (a condition where a portion of the intestine slides into another) is associated with this. This type of intussusception is seen five to six inches above the anal hole in the rectal mucosa.

Symptoms:

1. In the early stage, the protrusion is seen only during defecation. This is sometimes associated with passage with blood and mucosa.

2. In the later stage, spontaneous protrusion is observed. This is sometimes associated with sneezing and coughing.

3. In the later stage, a loss of control over defecation and sudden passage of stool are seen.

4. The protruded part of the rectum is tender. The rectal prolapse part often appears edematous and congested with mucosa.

5. Rectal prolapse is often associated with other urinary problems like urinary incontinence, bladder stones, or urethral stricture.

How to Manage Rectal Prolapse in the Elderly Population?

Rectal prolapse, in many cases, healed spontaneously. In such cases, no treatment is needed. Body weight maintenance, along with treatment of constipation, is useful in the elderly population. Exercises for strengthening the pelvic floor are helpful for such patients. These exercises are responsible for strengthening the pelvic floor muscles and increasing the muscle's contractile ability. Increased muscle contraction increases the pelvic floor's volume and lifts the levator plate. Stiffness due to the contraction of muscles is responsible for increased intraabdominal pressure.

Manual repositioning of the prolapsed party can also be done. This is done under local anesthesia while placing the patient in a head-down position. Cold compression in the affected area is given to reduce the swelling and inflammation. Pressure is given to place the prolapsed part inside the body. However, this may lead to strangulation of the prolapsed.

The most common approach for correction of rectal prolapse is surgical interventions. Different surgical approaches are used for this purpose.

These are;

1. Thiersch proposed an encirclement technique involving the insertion of a prosthesis around the anus to reduce the size of the anal opening. Nowadays, materials such as sutures, nylon, dacron, silastic, Teflon, and silicon rubber are utilized due to ulcers and other issues, rather than wires. If the anal opening becomes excessively narrow, fecal impaction could occur. This procedure is indicated in elderly people with serious medical complications. Postoperative infection in the surgical site is the most common complication.

2. The perineal approach is a cautious method used to excise or eliminate the herniated region in patients at high risk for surgery. Conversely, the abdominal approach is a more assertive and thorough procedure performed via laparotomy or laparoscopy. The abdominal technique typically requires intricate bowel dissection and stabilization; hence, the surgical procedure is categorized based on the method or site of bowel stabilization. Different abdominal approaches are, Rectopexy, Anterior sling rectopexy, and Posterior prosthetic rectopexy.

3. Since the early 1990s, laparoscopic colectomy has been successfully conducted to treat rectal prolapse. Nowadays, laparoscopic surgery for rectal prolapse has gained significant recognition—the surgical techniques involved in this procedure, such as fixation or resection. Laparoscopic surgery offers several benefits, including quicker recovery, shorter hospitalization, faster return to work, improved cosmetic outcomes, and reduced postoperative discomfort.

Conclusion

Rectal prolapse is a serious problem seen in the elderly population. It commonly affects the elderly women. Hormonal changes, age-related changes, and psychological disorders are risk factors for this condition. Rectal prolapse at an early stage does not cause any complications. However, advanced lesions may cause serious health issues. Surgical interventions are needed to treat this condition.