Rectal and Anal Prolapse

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Rectal and Anal Prolapse

 

Rectal and Anal Prolapse – eversion of one or more layers of the rectum through the anus. 

An anal prolapse (incomplete prolapse) is a protrusion of anorectal mucosa through the external anal orifice.

A rectal prolapse (complete prolapse) is a double-layer invagination of the full thickness of the rectal tube through the anal orifice.

 

SIGNALMENT

  • Dog and cat (especially Manx).
  • Any age, sex, or breed.
  • High prevalence for young, parasitized dogs or cats with diarrhea.

 

SIGNS

  • Persistent tenesmus.
  • Incomplete prolapse—protrusion of a portion of the circumference of the rectal mucosa that typically appears worse immediately after defecation and then subsides.
  • Complete prolapse appears as a tubular hyperemic mass protruding from the anus.
  • Chronic prolapses may be dark blue or black in color or the mucosa may be ulcerated.

 

CAUSES & RISK FACTORS

  • Gastrointestinal disorders that cause diarrhea and tenesmus, such as parasitism, colitis/enteritis, constipation/obstipation, rectal foreign body, rectal deviation and diverticulum, proctitis, and rectal or anal tumors.
  • Urogenital disorders, such as cystitis, urolithiasis, prostatitis, prostatic hypertrophy, and dystocia.
  • Tenesmus following perineal, rectal, or urogenital surgery (e.g., perineal herniorrhaphy).

 

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

  • Prolapsed intussusception—rule-out by passing a finger or blunt probe between the mass and the anus (the probe should not penetrate more than 1–2 cm before contacting the fornix; if the probe easily passes 5–6 cm, then suspect prolapsed intussusception) or by abdominal ultrasonography (look for increased intestinal layering).
  • Neoplasia—rule-out by palpation, fine-needle aspiration and cytology, and/or biopsy and histopathology.

 

CBC/BIOCHEMISTRY/URINALYSIS

  • Usually, unremarkable.
  • Inflammatory or stress leukogram may be present.

 

OTHER LABORATORY TESTS

  • Fecal examination may confirm parasitism.

 

IMAGING

  • Abdominal radiography and ultrasonography—usually unremarkable.
  • Abdominal radiography—may demonstrate foreign body, prostatomegaly, cystic calculi, or colonic fecal distention.
  • Abdominal ultrasonography—may demonstrate prostatomegaly, cystic calculi, bladder wall thickening, or intussusception.

 

DIAGNOSTIC PROCEDURES

  • Rectal examination to palpate for perineal hernia.
  • Colonoscopy may help evaluate recurrent prolapse for an underlying cause.

 

PATHOLOGIC FINDINGS

Assess viability of the prolapsed tissue by surface appearance and tissue temperature—vital tissue appears swollen and hyperemic, and red blood exudes from the cut surface; devitalized tissue appears dark purple or black, and dark cyanotic blood exudes from the cut surface; ulcerations may be present.

 

TREATMENT

  • Must identify and treat underlying cause.
  • Conservative medical management—gently replace prolapsed tissue through the anus with the use of lubricants and gentle massage; osmotic agents may help if severe swelling exists.
  • Use of an epidural may facilitate treatment and relieve discomfort.
  • Place a purse string suture to aid retention and prevent acute recurrence; place the suture loose enough to allow room for defecation.
  • Decrease straining with stool softeners.
  • Colopexy recommended for recurrent viable prolapses or if straining persists after rectal resection and anastomosis.
  • When prolapse is non-reducible and/or devitalized, rectal resection and anastomosis are necessary.

 

MEDICATIONS

DRUG(S) OF CHOICE

  • Appropriate anesthetic/analgesics as needed.
  • Consider epidural to facilitate surgery and reduce postoperative straining.
  • Appropriate perioperative antibiotics are recommended (e.g., cefoxitin sodium 30 mg/kg IV) for resection anastomosis.
  • Topical agents to aid in reduction—50% dextrose solution and KY Jelly.
  • Stool softeners—docusate sodium (dogs, 50–200 mg PO q8–12h; cats, 50 mg PO q12–24h) or lactulose (10 g/15 mL solution or syrup, 1 mL/4.5 kg q8–12h to effect); continue for 2–3 weeks after removal of the purse-string suture.
  • Feed a low-residue diet until purse-string suture is removed.

 

FOLLOW-UP

PATIENT MONITORING

  • Purse-string suture removal in 3–7 days.
  • Examine for rectal stricture if straining persists following anastomosis.
  • POSSIBLE COMPLICATIONS
  • Recurrence—especially if underlying cause is not eliminated.
  • Postoperative—may include infection, anastomosis dehiscence within 5–7 days postoperatively, or rectal stricture.
  • Fecal incontinence after resection (sensory incontinence resulting from removal of receptors in rectal wall).

 

MISCELLANEOUS

ASSOCIATED CONDITIONS

Intestinal parasitism

 

Visit your veterinarian as early recognition, diagnosis, and treatment are essential.

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