A 65-year-old woman comes to the office due to abnormal bowel habits. The patient's stools are pellet-like and extremely difficult to pass despite increased fluid and fiber intake. She also reports frequent fecal incontinence and wears a diaper in public. The patient has no bloody stools, unexpected weight loss, diarrhea, nausea, or vomiting. She has 5 children who were all vaginally delivered. The patient has an active lifestyle and no prior medical history. She is up to date with colon cancer screening and has never had colon polyps. Temperature is 36 C (96.8 F), blood pressure is 138/76 mm Hg, pulse is 85/min, and respirations are 13/min. Heart and lung sounds are normal. The abdomen is nontender and nondistended. Rectal examination reveals a 3-cm, erythematous mass with concentric rings that protrudes out the anal canal while the patient bears down. It subsequently retracts and is no longer visible when she relaxes. Which of the following is the best next step in management?
Rectal prolapse | |
Risk factors |
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Management |
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This older woman has a protruding rectal mass that increases in size with the Valsalva maneuver; the most likely diagnosis is rectal prolapse (RP). RP causes the rectum to protrude out the anus and is often related to defects in the pelvic floor or rectal tissue fascia. It is most common in women age >40; risk factors include multiparity, vaginal delivery, and chronic constipation or straining.
RP causes fecal incontinence, constipation, and abdominal discomfort. An erythematous mass with concentric rings that protrudes out the anus and increases in size with intraabdominal pressure (eg, Valsalva maneuver) is a typical finding for full-thickness prolapse; radial invaginations are seen in non–full-thickness prolapse.
Fiber supplementation and pelvic floor exercise can be considered for non–full-thickness prolapse and in frail, elderly patients, but those with debilitating symptoms and/or full-thickness prolapse, such as this patient, should be offered surgery because the risk of progressive deterioration is high. Rectopexy is usually the preferred operation.
(Choice A) Biofeedback therapy (ie, sensor-assisted pelvic floor muscle retraining) is sometimes used to treat fecal incontinence in patients who are poor surgical candidates but is less effective in preventing long-term functional deterioration. Operative management would be preferred in this patient who has full-thickness prolapse and who lacks significant comorbidities.
(Choice B) Colonoscopy is used to identify colon cancer, which is unlikely in someone who is up to date with screening and has no weight loss, fatigue, or hematochezia. Concentric rings are not typical of colon malignancy.
(Choice C) Rubber band ligation can be used to treat reducible prolapsed internal hemorrhoids that fail to respond to conservative treatment (eg, hydrocortisone cream). Hemorrhoids usually appear as blue or purple bulges rather than an erythematous mass with concentric rings.
(Choice E) Transvaginal ultrasound can be used to diagnose ovarian cancer, which may cause constipation but would not explain this patient's prolapsing mass. Furthermore, ovarian cancer tends to cause bloating and weight loss.
Educational objective:
Full-thickness rectal prolapse presents as an erythematous mass with concentric rings that protrudes out the anus and enlarges with intraabdominal pressure (eg, Valsalva maneuver). It is most common in women age >40; other risk factors include multiparity, vaginal delivery, and chronic constipation. Symptomatic patients (eg, debilitating constipation, fecal incontinence) and those with full-thickness prolapse should be offered surgical repair.