Rectal prolapse in children

INTRODUCTION — 

This topic discusses the clinical manifestations, diagnosis, and management of rectal prolapse in children.

Rectal prolapse in adults is discussed separately. (See "Overview of rectal procidentia (rectal prolapse) in adults" and "Surgical approach to rectal procidentia (rectal prolapse) in adults".)

DEFINITION AND CLASSIFICATION — 

Rectal prolapse occurs when some or all of the rectal wall is mobilized distally towards the anus and may fully extrude through the external anal sphincter (figure 1) [1-3]. There are two types of rectal prolapse [2]:

●Type I – Type I rectal prolapse, also known as false procidentia, partial, or mucosal prolapse, has protrusion of the mucosa only, is usually <2 cm long, and has characteristic radial folds at the junction with the anal skin (figure 1) [3].

●Type II – Type II, also known as true procidentia, or complete prolapse, involves full thickness extrusion of the rectal wall and is characterized by concentric folds in the prolapsed mucosa (picture 1). This group is subdivided into three subsets according to the degree of the prolapse [3]:

•First degree – First degree prolapse (most severe) includes the mucocutaneous junction. The length of the protrusion from the anal verge usually is greater than 5 cm.

•Second degree – Second degree prolapse occurs without involvement of the mucocutaneous junction. The length of the protrusion from the anal verge usually is between 2 and 5 cm.

•Third degree – Third degree prolapse is internal, concealed, or occult and does not pass through the anal verge.

EPIDEMIOLOGY — 

Rectal prolapse usually occurs in children younger than four years of age, with the highest incidence in the first year of life [4-6]. During childhood, rectal prolapse may occur more frequently in males than females, although evidence is limited [4,7-9]. Most children with rectal prolapse (up to 80 percent) have an underlying predisposing condition, especially those older than four years of age [3,6,10]. Rectal prolapse without an underlying condition is unlikely in older children and is more common in infants [4,5].

In resource-abundant settings, chronic constipation is the most common underlying condition among children with rectal prolapse who are receiving specialty care. Diarrheal disease, neurologic abnormality, or congenital anatomic conditions are other important etiologies [10]. Cystic fibrosis is an uncommon cause in regions with routine newborn screening but remains an important diagnostic consideration. In resource-limited settings, malnutrition and diarrheal disease are the main conditions that predispose to rectal prolapse in children [6,11]. (See 'Predisposing conditions' below.)

PATHOGENESIS — 

Based upon information from anatomic studies in adults and manometry and dynamic radiologic studies in children [12], rectal prolapse develops from circumferential intussusception of the upper rectum and rectosigmoid colon.

Underlying medical conditions that cause straining during defecation (eg, constipation and cystic fibrosis), tenesmus (eg, diarrheal illness, malnutrition, or anatomic lead points), pelvic floor weakness (eg, neurologic disorders, surgical interventions), or anal trauma increase the risk of rectal prolapse (table 1). (See 'Predisposing conditions' below.)

The following anatomic considerations may account for the increased incidence of rectal prolapse in early childhood [2,13-17]:

●The rectum has a vertical course along the surface of the sacrum and coccyx.

●The rectum is in a relatively lower position than the other pelvic organs.

●The sigmoid colon has greater mobility.

●The levator ani muscle offers relatively little support.

●The redundant rectal mucosa is attached only loosely to the underlying muscularis.

●Houston valves are absent in approximately 75 percent of infants younger than one year of age (Houston valves are prominent mucosal folds that provide structural integrity to the rectum).

PREDISPOSING CONDITIONS — 

In the majority of children, rectal prolapse is a symptom of an underlying condition [1,2,4,6,10,18-21]. Predisposing conditions include (table 1):

●Constipation and other causes of increased intra-abdominal pressure – Factors that increase the intra-abdominal pressure include:

•Chronic constipation (increased straining during defecation is a major contributor [10])

•Toilet training with fecal withholding and straining [17]

•Protracted coughing (eg, pertussis, chronic lung disease) [10]

•Excessive vomiting (eg, infectious gastroenteritis or bulimia nervosa) [10]

•Straining with urination (eg, phimosis in uncircumcised males) [2]

•Abdominal tumors (rare) [22]

Among patients with rectal prolapse in resource-abundant settings, up to 65 percent have underlying constipation [23]. The diagnosis is made based on a careful history and physical examination. In selected patients with findings suggesting organic disease (table 2), additional adjunctive testing may be needed. (See "Constipation in infants and children: Evaluation".)

Behavioral and psychiatric conditions that predispose to stool withholding and straining against a closed anal sphincter may make medical treatment of constipation or other underlying challenging and make rectal prolapse more likely to recur [24]. Behavioral interventions are an important adjunct to medical therapy in these patients. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)

Children with recurrent rectal prolapse and chronic functional constipation who do not improve with medical and behavioral interventions may benefit from surgical therapy [24,25]. (See 'Indications for specialty consultation' below.)

Increased intra-abdominal pressure caused by forced vomiting may account in part for the association of rectal prolapse and bulimia nervosa; additional factors include diarrhea (from laxative use) and/or malnutrition [26].

●Diarrheal disease – Infectious and noninfectious diarrhea, with associated tenesmus:

•Infectious diarrhea – Acute or chronic diarrheal infections with tenesmus can predispose to rectal prolapse [10,11,27,28]. Rectal inflammation may also play a role. Any viral, bacterial, or parasitic infection that causes frequent diarrhea can cause rectal prolapse; Shigella species and E.coli are important bacterial pathogens specifically associated with rectal prolapse [29,30]. (See "Shigella infection: Epidemiology, clinical manifestations, and diagnosis", section on 'Intestinal complications'.)

Intestinal parasites are a common cause of rectal prolapse in children, particularly in resource-limited countries [11,31]. Rectal prolapse is a characteristic finding in patients with trichuriasis, especially heavily infected individuals, but may occur with other pathogens:

-(See "Enterobiasis (pinworm) and trichuriasis (whipworm)".)

-(See "Giardiasis: Epidemiology, clinical manifestations, and diagnosis" and "Giardiasis: Treatment and prevention".)

-(See "Intestinal Entamoeba histolytica amebiasis".)

-(See "Ascariasis".)

Diagnosis and, with selected pathogens, treatment of the underlying cause of infectious diarrhea are essential to the management of rectal prolapse. The evaluation and management of acute diarrhea depend upon available resources as discussed separately. (See "Diagnostic approach to diarrhea in children in resource-abundant settings" and "Approach to the child with acute diarrhea in resource-limited settings".)

•Noninfectious diarrhea – Noninfectious diarrhea sufficient to cause rectal prolapse may occur in patients with ulcerative colitis, laxative abuse, and malabsorption conditions such as celiac disease or short bowel syndrome [3,10,32]. In these patients, malnutrition may also be an important co-contributor. Clinical findings, initial testing, and indications for intestinal biopsy (required for diagnosis in most patients) are described separately. (See "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in children" and "Diagnosis of celiac disease in children" and "Chronic complications of short bowel syndrome in children".)

●Cystic fibrosis — In regions without routine newborn screening for cystic fibrosis (CF), rectal prolapse in an infant or young child is an indication for diagnostic testing. (See "Cystic fibrosis: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

Historically, rectal prolapse was a common presentation of classic CF in infants and children. Contributing mechanisms included coughing, diarrhea with fat malabsorption, malnutrition, and chronic constipation. This manifestation of CF is now uncommon in populations that undergo routine newborn screening. However, even in regions with established newborn screening, routine testing for CF is still warranted in children who present with rectal prolapse and have an unknown CF status unless there is another established medical condition that explains the prolapse. (See "Cystic fibrosis: Clinical manifestations and diagnosis", section on 'Rectal prolapse'.)

Newborn screening enables earlier diagnosis and treatment of CF. Observational studies in populations with routine neonatal screening for CF found that approximately 2 to 3 percent of children with unknown CF status were diagnosed with CF after presenting with rectal prolapse, typically before age 5 years [10,33]. Newborn screening for CF is discussed in greater detail separately. (See "Cystic fibrosis: Clinical manifestations and diagnosis", section on 'Newborn screening'.)

●Malnutrition — Worldwide, malnutrition is the most common condition associated with the development of rectal prolapse. Several mechanisms are postulated [2,7]:

•Malnutrition causes hypoproteinemia, which may lead to mucosal edema and an increased potential for prolapse.

•Many children with malnutrition live in settings with high rates of infectious diarrhea as a co-contributing condition. Malnutrition also interferes with immune function and results in an increased susceptibility to enteric infections.

•Protein-calorie deprivation can diminish the ischiorectal fat pad, thereby decreasing perirectal support.

Improvement in nutritional status can reduce the frequency of prolapse. For example, in one controlled trial, 75 malnourished children with acute dysentery caused by shigellosis were randomly assigned to an energy-dense or control diet [34]. No differences existed between the groups in resolution of fever, dysenteric stools, or stool frequency. However, resolution of rectal prolapse was better in the treatment group after 10 days of dietary intervention despite an increased frequency of vomiting in the treatment group.

The diagnosis of acute malnutrition relies on physical findings that include poor growth, wasting, and, in patients with kwashiorkor, edema (table 3 and table 4). Treatment depends upon the degree of malnutrition as discussed separately:

•(See "Malnutrition in children in resource-limited settings: Clinical assessment".)

•(See "Management of uncomplicated severe acute malnutrition in children in resource-limited settings" and "Management of complicated severe acute malnutrition in children in resource-limited settings".)

•(See "Management of moderate acute malnutrition in children in resource-limited settings".)

●Pelvic floor weakness – Causes of pelvic floor weakness include neurologic disorders (eg, myelomeningocele, tethered cord, spinal cord injury) or surgical interventions for anorectal anomalies (eg, Hirschsprung disease or imperforate anus) [10,35,36]. Patients with these conditions are at risk for recurrent rectal prolapse and fecal incontinence [37,38]. (See "Myelomeningocele (spina bifida): Anatomy, clinical manifestations, and complications" and "Closed spinal dysraphism: Clinical manifestations, diagnosis, and management".)

Other less common causes of pelvic floor laxity and rectal prolapse include:

•Ehlers-Danlos syndrome [39] (see "Ehlers-Danlos syndromes: Clinical manifestations and diagnosis")

•Williams syndrome [40] (see "Williams syndrome")

•Congenital hypothyroidism [41] (see "Clinical features and detection of congenital hypothyroidism")

●Anatomic abnormalities (lead points) – Inflammatory polyps, polypoid lesions, ulcerative colitis-associated pseudopolyps, or lymphoid hyperplasia can act as lead points for rectal prolapse [10,42]. Neoplasms and solitary rectal ulcers are rare but important causes [2,42]. Evaluation for lead points typically includes imaging and colonoscopy in consultation with a pediatric gastroenterologist. Diagnosis requires colonoscopy. (See 'Complications' below.)

●Anal trauma (child abuse) – Rectal prolapse may complicate extensive perineal burns and anal penetration [10,43-45]:

•Perineal burns – Abusive burns to the perineum commonly result from scalding in which the perpetrator immerses a young child in hot water as punishment for stool incontinence during toilet training. These injuries have specific characteristics described separately (see "Physical child abuse: Recognition", section on 'Intentional burns'). These patients require involvement of burn specialists, evaluation for other traumatic injuries, and diagnostic evaluation with a multidisciplinary child abuse team. (See "Moderate and severe thermal burns in children: Emergency management" and "Physical child abuse: Diagnostic evaluation and management".)

•Repeated anal penetration (sexual abuse) – Because of the association with anal penetration, the possibility of sexual abuse must be considered in children who present with rectal prolapse [21,46]. Physical findings suggestive of sexual abuse are discussed separately (see "Evaluation of sexual abuse in children and adolescents", section on 'Perianal area'). However, the physical examination in sexually abused children can be normal. Thus, for children without predisposing conditions, it may be appropriate to consult with a child abuse specialist to review the case and determine the need for a forensic evaluation, including a patient history by a trained examiner.

Clinicians caring for patients with suspected physical or sexual abuse should also report their concern to Child Protective Services; this report is mandatory in many regions. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

CLINICAL MANIFESTATIONS — 

The clinical presentation of rectal prolapse frequently consists of a dark red mass that protrudes from the rectum during straining, with or without mucus and blood. The mass typically prompts the parent or primary caregiver to seek urgent medical attention [2,3]. As a general rule, prolapse is painless, but it can be associated with mild discomfort. A digital rectal examination may reveal decreased or absent anal tone initially, but normal tone returns within a few hours, except in children with an underlying neurologic condition such as myelomeningocele.

The presentation of occult prolapse (type II, third-degree rectal prolapse) is more subtle; the diagnosis may be delayed unless a high degree of suspicion is present. The patients, usually adolescents, complain of tenesmus and anorectal pain, with the passage of blood and mucus [2]. (See 'Definition and classification' above.)

Associated findings depend upon the underlying cause and may include constipation, diarrhea with blood or mucus, hematochezia, signs of malnutrition, rectal ulcer or polyps, or evidence of rectal trauma. (See 'Predisposing conditions' above.)

DIAGNOSIS — 

The diagnosis of rectal prolapse relies on history or physical examination findings. If the prolapse has not spontaneously reduced, a painless, dark red mass at the anal verge with or without mucus is present on physical examination. Radial folds suggest a mucosal (Type I or incomplete) prolapse. Circumferential folds indicate a complete (Type II, first- or second-degree) prolapse (picture 1). Palpation of the prolapsed mucosa between the thumb and forefinger permits the examiner to distinguish between mucosal (Type I) or complete (Type II) rectal prolapse [2]. With type II prolapse, the tissue feels thicker, and the examiner can sense sliding of the two tissue layers against each other when rubbing the prolapsed tissue between the thumb and forefinger. (See 'Definition and classification' above.)

If spontaneous reduction has occurred, the parents' description of such a mass that appeared during straining may suffice to make the diagnosis. A digital photograph can also help establish the diagnosis [47]. Examining the child in the squatting position or asking them to strain may demonstrate the prolapse.

The diagnosis of third degree (occult) rectal prolapse usually is made during sigmoidoscopy that reveals erythema and granularity of the distal rectum, or a polypoid white-topped mucosal lesion on the anterior rectal wall [48]. Alternatively, specialized imaging techniques such as fluoroscopic defecography or magnetic resonance imaging can be used to visualize the prolapse and associated pelvic floor anomalies, which can guide surgical interventions [49-51]. Occult rectal prolapse may be an early finding in solitary ulcer of the rectum syndrome [48,52,53]. (See 'Complications' below.)

DIFFERENTIAL DIAGNOSIS — 

The following conditions may appear similar to a rectal prolapse but can be distinguished by careful examination [54,55]:

●Ileocecal intussusception – Although a rare presentation, in children with an ileocolic intussusception and a long intussusceptum, the prolapsed bowel and/or appendix may protrude through the anus, looking similar to a rectal prolapse. The child with intussusception typically appears ill and has complaints of intermittent severe abdominal pain, although some children may appear well between bouts of pain. In addition, in intussusception, the examiner's finger can be passed between the apex of the prolapsed bowel and the anal sphincter [2]. By contrast, in children with rectal prolapse, the protruding mucosa is continuous with the perianal skin. (See "Intussusception in children", section on 'Clinical manifestations'.)

●Prolapsing rectal polyp or rectal hemorrhoids – Examination of the prolapsed tissue also can distinguish polyps and hemorrhoids from rectal prolapse because prolapsed polyps and hemorrhoids do not involve the entire rectal mucosa and do not have a hole in the middle.

INITIAL MANAGEMENT

Manual reduction — A child who presents with a rectal prolapse requires manual reduction. This procedure should be performed as soon as possible if the prolapse has not resolved spontaneously [2]. If the prolapse is not reduced, the prolapsed tissue will be irritated by the child's undergarments, causing more bleeding; eventually, the exposed rectum will become ulcerated, congested, edematous, and more difficult to reduce. Rarely, emergency surgical reduction is necessary.

Manual reduction of rectal prolapse is performed with gloves, lubricant, gauze, and tape. Use of sedation and analgesia may be necessary depending upon the size of the prolapse and the child's level of discomfort. For patients with suspected sexual abuse or other painful anal trauma, sedation, as for other moderately painful procedures, is indicated. (See "Procedural sedation in children: Approach" and "Procedural sedation in children: Selection of medications", section on 'Moderately or severely painful procedures'.)

The procedure is performed as follows (figure 2):

●Place the child prone in the knee-chest position on the examination table or the parent's or primary caregiver's lap.

●Use well-lubricated gloves to apply gentle, but firm, persistent pressure to the prolapsed mucosa. The clinician may also place a finger in the rectum to guide reversal of the prolapse. The prolapse should reduce within 5 to 15 minutes.

●Perform a digital rectal examination after reduction to ensure that the reduction is complete [2].

●Apply a pressure dressing consisting of lubricant, gauze, and tape. The clinician may tape the buttocks together with adhesive tape for several hours if the prolapse recurs immediately after reduction [2].

●If the rectal prolapse is very large and/or difficult to reduce, the clinician may apply up to one-half cup (113 g) of sugar to reduce the size of the swelling and permit manual reduction [56].

In the uncommon circumstance that the rectal prolapse cannot be manually reduced, the clinician should obtain emergency surgical consultation to assist with reduction either under sedation or general anesthesia. These patients warrant admission to an inpatient service under the care of a pediatric surgeon. Prolonged rectal prolapse may cause complications, including [43]:

●Atonic rectal sphincter

●Fecal incontinence

●Mucosal ulceration

●Rectal bleeding

●Gangrene of the bowel wall

Once reduced, children with rectal prolapse should undergo a thorough history, physical examination, and diagnostic testing as indicated by clinical findings to identify the underlying cause (table 1). (See 'Predisposing conditions' above.)

Aftercare — The family should receive anticipatory guidance to help prevent early recurrence of the rectal prolapse and to emphasize the need for further evaluation in patients with recurrence. The clinician may also initiate presumptive treatment based upon clinical findings at the index visit in selected patients.

Anticipatory guidance — After successful manual reduction, the clinician can teach parents/primary caregivers and older patients how to manually reduce the prolapse if it recurs. During the recovery phase, providing adequate support to the buttocks and decreasing intra-abdominal pressure during defecation are also important [2]. These goals may be achieved by use of a potty seat, an adult toilet with proper positioning (figure 3), and a seat insert to provide buttock support, or use of a fracture bedpan during bowel movements. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment", section on 'Behavior modification'.)

Evaluate for and treat underlying cause — Children with rectal prolapse require further evaluation to determine the presence of an underlying cause. A careful history and physical examination and selected testing based upon the clinical suspicion usually provides a working diagnosis. However, consultation with the appropriate specialist is often necessary to confirm the diagnosis. (See 'Predisposing conditions' above.)

The table provides conditions that predispose to rectal prolapse and are typically responsive to medical therapy (table 1). After confirmation of the underlying diagnosis, these patients should first undergo medical treatment (algorithm 1). (See 'Predisposing conditions' above.)

The underlying treatment of these causes is provided separately:

●Functional constipation – Before treatment of functional constipation, all children require a careful evaluation to exclude an organic cause (table 2). Treatment may involve prolonged laxative use and behavioral therapy. For some infants and young children with constipation who have recurrent rectal prolapse despite osmotic laxatives (eg, polyethylene glycol), stimulant laxatives are an important part of the bowel regimen. Our approach is to add sennosides as the first stimulant laxative when osmotic laxatives are not sufficient to control the symptoms and escalate to bisacodyl when needed. The bowel regimen should continue until the child has regular bowel movements for several months without rectal prolapse. In a retrospective review of 47 children with constipation-related rectal prolapse, most of whom received simulant laxatives as part of their regimen, only three patients (6 percent) subsequently required surgical intervention [57]. (See "Constipation in infants and children: Evaluation" and "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)

●Infectious diarrhea – In resource-abundant settings, these patients should be evaluated for possible infection with pathogens associated with rectal prolapse, especially Shigella species, E. coli, and intestinal parasites (eg, Trichuris trichiura, enterobiasis [pinworm], and giardiasis). Management depends upon the specific infection, empiric antibiotic treatment for presumed bacterial enteritis is not appropriate. (See "Diagnostic approach to diarrhea in children in resource-abundant settings".)

In resource-limited settings, antibiotic therapy is guided by clinical circumstances based upon the regional presence of outbreaks and by type of diarrhea (watery versus bloody). (See "Approach to the child with acute diarrhea in resource-limited settings", section on 'Diagnostic evaluation'.)  

●Malabsorption syndromes – Syndromes associated with rectal prolapse caused by diarrhea or steatorrhea:

•Celiac disease – The diagnosis of celiac disease relies on results of celiac-specific antibody testing and intestinal biopsy; management consists of a life-long gluten-free diet. (See "Diagnosis of celiac disease in children" and "Management of celiac disease in children".)

•Short bowel syndrome – Management of patients with watery diarrhea due to short bowel syndrome includes fluid replacement, trials of dietary changes, and pharmacotherapy. (See "Management of short bowel syndrome in children", section on 'Additional strategies for refractory cases' and "Chronic complications of short bowel syndrome in children".)

●Malnutrition – Malnutrition is most often encountered in resource-limited settings. Treatment depends upon the degree of malnutrition (table 3). (See "Management of uncomplicated severe acute malnutrition in children in resource-limited settings" and "Management of complicated severe acute malnutrition in children in resource-limited settings" and "Management of moderate acute malnutrition in children in resource-limited settings".)

●Cystic fibrosis – In regions without routine newborn screening for cystic fibrosis (CF), rectal prolapse in an infant or young child is an indication for diagnostic testing and referral to a CF center. However, even in regions with established newborn screening, it is critical to ensure that cystic fibrosis is excluded by reviewing family history and newborn screening results and/or specific diagnostic testing. (See "Cystic fibrosis: Clinical manifestations and diagnosis" and "Cystic fibrosis: Assessment and management of pancreatic insufficiency".)

SURGICAL MANAGEMENT

Indications for specialty consultation — The following findings suggest that medical therapy was not successful (refractory prolapse); pediatric gastroenterology and/or surgical consultation is warranted [21]:

●A total of two or more episodes of rectal prolapse requiring manual reduction

●Persistent rectal pain

●Persistent rectal bleeding

●Perineal excoriation

In addition, specialty consultation is warranted for patients with rectal prolapse associated with one of the following conditions, because these generally are not responsive to medical therapy (table 1) [21,25]:

●Permanent pelvic floor weakness (eg, myelomeningocele, spinal cord injury, or tethered cord)

●Anatomic anomalies (lead points such as polyps, lymphoid hyperplasia, solitary rectal ulcer, or tumors [rare])

●Surgically corrected Hirschsprung disease or imperforate anus

●Recto-anal trauma (physical or sexual child abuse)

For patients with these conditions, we encourage early referral to a pediatric gastroenterologist for advanced testing and trial of medical interventions prior to pediatric surgical consultation. Alternatively, the patient can be referred to a multidisciplinary team including a pediatric gastroenterologist and a surgeon with pediatric expertise.

Children ≥4 years old with functional constipation and behavioral or mental health conditions are also more likely to have rectal prolapse that is not amenable to medical therapy and may also benefit from early referral to address these issues.

Procedures — Multiple surgical interventions are used for rectal prolapse caused by chronic conditions or that does not respond to nonoperative management. Consensus is lacking regarding the optimal management [21,23,58-63]. Interventions include local sclerotherapy and surgical repair (rectopexy) with or without resection [21]. The choice of procedure is determined by multiple factors, including the degree of prolapse, severity of symptoms, associated disorders, underlying conditions, and the treating physician's expertise. The algorithm provides an approach (algorithm 1).

●Local sclerotherapy – Sclerotherapy (submucosal injection of sclerosing solutions) is the least invasive procedure and has a variable success rate of 29 to 100 percent; it is the first choice for uncomplicated, recurrent prolapse (eg, patients with a treatable underlying conditions that have not responded to medical therapy) [58,64-66]. Sclerotic agents with the highest success rates include ethanol, phenol in oil, normal saline, and dextranomer/hyaluronic acid (Deflux) [64]. Major complications associated with sclerotherapy include mucosal ulceration with sloughing, perianal fistula, rectovaginal fistula, and abscess formation [21]. Those complications requiring anesthesia and surgery occur in <1 percent of patients receiving sclerotherapy.

Anal cerclage combined with sclerotherapy has also been described and has a success rate of 90 percent after one or two procedures [21,67,68].

●Surgical rectopexy – Surgical repair (eg, Ekehorn rectopexy, laparoscopic or robotic suture rectopexy, or posterior sagittal rectopexy) has typically been reserved for patients in whom local sclerotherapy is unsuccessful or as the first option if local sclerotherapy is likely to fail (table 1) [25]. Ekehorn rectopexy has an estimated success rate as high as 96 to 100 percent [21,58,69]. With experienced surgeons, laparoscopic rectopexy repair also has low rates of recurrence [70]. In severe cases, surgical resection of redundant rectosigmoid colon is performed in addition to rectopexy [65].

In a single-center retrospective study of 67 children referred for surgical evaluation of rectal prolapse, rectopexy or transanal resection with or without sclerotherapy as the initial intervention was associated with a higher resolution rate than sclerotherapy alone [25].

COMPLICATIONS — 

Local pain and self-limited mucosal bleeding are the most common complications in cases that reduce spontaneously or are manually reduced [1,2,18,19,54]. As mentioned above, prolonged rectal prolapse can lead to ulceration, venous obstruction, and thrombosis. In contrast to hernias, strangulation is a rare occurrence.

Solitary rectal ulcer syndrome is a rare complication of chronic rectal prolapse [71]. It is a benign condition usually diagnosed in adolescents who complain of rectal bleeding, pain, and passage of mucus. It may begin as an occult rectal prolapse with the above complaints and progress to the development of single or multiple localized areas of necrosis and ulceration of the mucosa, which are apparent on endoscopy [2,72]. (See "Solitary rectal ulcer syndrome".)

Inflammatory cloacogenic polyps are also associated with rectal prolapse. They are polypoid formations, usually 0.4 to 1.2 cm in diameter, that arise from the transitional zone between the columnar rectal and squamous anal epithelium and represent a regeneration process [2]. They usually present with rectal bleeding and are diagnosed endoscopically. Inflammatory cloacogenic polyps and the lesions of solitary rectal ulcer syndrome have been hypothesized to be caused by mucosal ischemia related to rectal prolapse [2,72].

PROGNOSIS — 

The prognosis of rectal prolapse depends upon the underlying etiology. Approximately 90 percent of infants and children <4 years old with rectal prolapse respond to medical treatment and do not require surgery; recurrences rarely occur after six years of age. The remaining 10 percent of children with rectal prolapse have recurrences that persist into adulthood [2,28].

Children who present with rectal prolapse after four years of age usually have neurologic or musculoskeletal defects of the pelvis or chronic functional constipation and are less likely to respond to nonoperative measures. These children warrant timely referral for surgical evaluation and potential surgical intervention [2,73].

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Rectal prolapse".)

INFORMATION FOR PATIENTS — 

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Rectal prolapse in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition – Rectal prolapse refers to the extrusion of some or all of the rectal mucosa through the external anal sphincter (figure 1). (See 'Definition and classification' above.)

●Predisposing conditions – Most children with rectal prolapse have an underlying condition (table 1). (See 'Predisposing conditions' above.)

●Clinical manifestations and diagnosis – The diagnosis of rectal prolapse relies on history or physical examination findings. If the prolapse has not spontaneously reduced, the examination reveals a painless, dark red mass at the anal verge with or without mucous. Radial folds suggest a mucosal (Type I or incomplete) prolapse. Circumferential folds indicate a complete (Type II, first- or second-degree) prolapse (picture 1). (See 'Clinical manifestations' above and 'Diagnosis' above.)

●Differential diagnosis – Conditions that can mimic rectal prolapse include intussusception with a long intussusceptum or a prolapsed rectal polyp or hemorrhoid. (See 'Differential diagnosis' above.)

●Initial management of prolapse – Patients with rectal prolapse require timely manual reduction and aftercare to prevent acute recurrence pending evaluation of the underlying cause:

•Manual reduction – Management consists of manual reduction as soon as possible if spontaneous reduction does not occur (figure 2). Emergency surgical referral is indicated if rectal prolapse cannot be manually reduced because long-term complications (eg, atonic rectal sphincter, incontinence, ulceration, bleeding, or gangrene of the bowel wall) may result. (See 'Manual reduction' above.)

•Aftercare – After successful manual reduction, the clinician can teach parents/primary caregivers and older patients how to manually reduce the prolapse if it recurs. They should also provide guidance to ensure a toileting position that provides adequate support to the buttocks and decreases intra-abdominal pressure during defecation. Other interventions may be necessary depending upon the presumed underlying condition (see 'Predisposing conditions' above and 'Aftercare' above):

-Constipation – Patients with presumed constipation should receive a bowel regimen (eg, polyethylene glycol and increased dietary fiber) and guidance to address behavioral contributors (toilet training, stool withholding). These patients also require a careful evaluation to assess for organic causes of constipation (table 2). (See "Constipation in infants and children: Evaluation" and "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)

-Infectious diarrhea – Patients with diarrhea should undergo testing for infection and receive antimicrobial treatment if indicated. (See "Diagnostic approach to diarrhea in children in resource-abundant settings" and "Approach to the child with acute diarrhea in resource-limited settings".)

-Cystic fibrosis – In regions without routine newborn screening for cystic fibrosis (CF), rectal prolapse is an indication for diagnostic testing. In settings with routine newborn screening, it is critical to ensure that cystic fibrosis is excluded by review of family history and newborn screening results. If testing is equivocal or was not performed, the clinician should obtain diagnostic testing. (See "Cystic fibrosis: Clinical manifestations and diagnosis", section on 'Diagnosis'.)

-Anorectal trauma (burns or suspected repeated penetration) – In addition to a diagnostic evaluation in consultation with a multidisciplinary child abuse team, clinicians of patients with rectal prolapse and suspected physical or sexual abuse should also report their concern to Child Protective Services; this report is mandatory in many regions. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

•Diagnostic evaluation – Children with rectal prolapse require further evaluation to identify the underlying cause (table 1). A careful history and physical examination and selected testing usually provide a working diagnosis. However, consultation with the appropriate specialist is often necessary for confirmation. (See 'Predisposing conditions' above.)

●Definitive care – The approach to rectal prolapse depends upon the underlying cause and likelihood of success with medical versus surgical treatment (algorithm 1). (See 'Indications for specialty consultation' above.)

•Local sclerotherapy – For children with recurrent rectal prolapse, or for those with a condition unlikely to respond to medical therapy, we suggest initial treatment with local sclerotherapy rather than surgical repair (Grade 2C). Sclerotic agents with the highest success rates include ethanol, phenol in oil, normal saline, and dextranomer/hyaluronic acid (Deflux). Some experts combine sclerotherapy with anal cerclage.

•Surgical rectopexy – Surgical rectopexy is generally reserved for patients in whom sclerotherapy is unsuccessful.