When rectal prolapse requires a referral

colorectal

Rectal prolapse: It’s a visually alarming problem that can send worried parents straight to their child’s pediatrician, if not the emergency department. Despite its often-graphic appearance, rectal prolapse is usually benign and easily treated. Indeed, the majority of young children who experience rectal prolapse can be treated without surgery and won’t have a recurrence.

In some children, however, it can be a sign of a more serious condition that necessitates evaluation and treatment by a specialist. “Recurrent or severe rectal prolapse can indicate an underlying disorder and may require further evaluation and even surgical correction,” says Leonel Rodriguez, MD, co-director of the Colorectal and Pelvic Malformation Center at Boston Children’s Hospital.

Alarming but benign

 Rectal prolapse — the protrusion of the lining of a child’s rectum through the anal sphincter — occurs when the muscles and ligaments that support the rectum become weakened. In the pediatric population, it tends to occur in between ages 1 and 4 years old, and is most common during the first year of life.

Rectal prolapse can present as a dark red mass protruding from the anus, sometimes accompanied by blood or mucus, particularly when the child is straining. Parents may also notice slight bloody staining on the child’s diaper or underwear, which is sometimes enough to trigger a concerned phone call to their pediatrician.

When to seek specialty care

Fortunately, primary-care providers can address most cases of rectal prolapse by reducing them manually, as Rodriguez describes in a recent review. However, children who experience recurrent or severe prolapse — or who are older than age 4 — tend to have underlying conditions that can result in the problem. These children may require care from a specialist, including a gastroenterologist and a colorectal surgeon. Here’s what to consider when determining whether to refer for rectal prolapse.

Effectiveness of noninvasive approaches. Physicians should recommend lifestyle measures to help prevent recurrence of rectal prolapse. These include increasing dietary fiber and taking an over-the-counter stool softener. Parents can also lessen the likelihood of recurrence by having their child use an adult toilet or bedpan when having bowel movements, which can help support the buttocks while decreasing intra-abdominal pressure. If these measures don’t work or if rectal prolapse recurs in spite of them, evaluation by a specialist may be warranted.

Effectiveness of manual reduction. If manual reduction fails or if the prolapse recurs frequently, surgical correction may be necessary. Surgical options include sclerotherapy, Thiersch cerclage, trans-anal resection, laparoscopic sigmoid resection and rectopexy.

Presence of underlying conditions. Rectal prolapse is often the result of problems such as chronic constipation, acute or chronic diarrhea, malnutrition or straining while defecating. But in children who experience recurrent prolapse, a predisposing condition may be involved. Underlying disorders that increase the risk of rectal prolapse include cystic fibrosis, neurological conditions such as tethered cord or spinal cord injury and Hirschsprung’s disease and other colorectal and pelvic malformations, says Rodriguez.

Risk of complications. Recurrent or prolonged rectal prolapse can raise a child’s risk of complications, such as ulceration, venous obstruction and thrombosis, so evaluation by a specialist may be worthwhile in helping prevent future difficulties.

“Although the vast majority of kids recover well from rectal prolapse with manual reduction and lifestyle approaches, some will need further evaluation and treatment,” says Rodriguez. “For those with recurrent or refractory rectal prolapse, referral to a specialist can be key to successful treatment.”

Learn about the Colorectal and Pelvic Malformation Center.