Diagnosis

Diagnosis

Rectal prolapse is a clinical diagnosis based on patient's history and supported by physical examination findings (1).

A detailed history of patients should be obtained

• enquire about symptoms related to the condition including faecal incontinence versus constipation/obstructed defecation symptoms, as well as stool consistency
• it should include a history to detect medical conditions that might influence management choice or surgery eligibility.
• include an accurate drug history to identify any drugs may cause or exacerbate constipation and straining at stool and, thus, contribute to prolapse. Examples of these include opioids, anticholinergics, tricyclic antidepressants, antipsychotics, calcium channel blockers and iron
• check for anorexia, weight loss, persistent abdominal pain, and distension with constipation or diarrhoea to rule out cancer or colitis (1,2)

Physical examination

• abdominal
  • look for any signs of obstruction (eg, distention, visible peristalsis, increasing borborygmi), neoplasm (eg, palpable mass) or inflammation (eg, guarding, tenderness, mass)
    
    
• perianal
  • in patients with a history suggesting rectal prolapse but not detected on physical examination, the prolapse may be easily reproducible when the patient strains while in the lateral or jack-knifed position or in the sitting or squatting position
  • the aim is to differentiate a full-thickness rectal prolapse from mucosal prolapse or prolapsed haemorrhoids
    • mucosal prolapse - is thin and often segmental (not extending circumferentially around the anus)
    • full thickness prolapse - also may appear segmental, but more often it is circumferential and plum coloured, with concentric mucosal folds
    • prolapsed haemorrhoids, and mucosal rectal prolapse - typically have radial rather than concentric folds
      
      
• rectal examination
  • digital rectal examination helps in;
    • identifying anal sphincter hypotonia
    • differentiating rectal prolapse from an intussusception with prolapse that originates from a higher level than the rectum.
      • the majority of rectal prolapses begin in the anorectal region, hence a digit passed up and around the sides of the prolapse encounters resistance.
      • intussusception originates more proximally, and the digit may be passed freely around the prolapsed segment without resistance (1,2)

Note:

• rectal prolapse may also result as a complication of injury during a forceps delivery

References:

1. American Academy of Family physicians (AAFP). FP Comprehensive 2016 - Board Preparation. Anorectal conditions. Rectal prolapse
2. Bordeianou L et al. Rectal prolapse: an overview of clinical features, diagnosis, and patient-specific management strategies. J Gastrointest Surg. 2014;18(5):1059-69.