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Rectal prolapse

Medicine > Gastrointestinal

Differential Diagnosis Schema 🧠

Rectal Conditions

  • Rectal prolapse: Full-thickness protrusion of the rectal wall through the anus, often with a history of straining or chronic constipation.
  • Hemorrhoids: Engorged veins in the anal canal that can prolapse, causing discomfort, bleeding, and a palpable mass.
  • Solitary rectal ulcer syndrome: Associated with rectal prolapse, characterized by a single ulcer in the rectum.
  • Rectal intussusception: Internal prolapse of the rectum without external protrusion, can lead to obstructive symptoms.
  • Anal fissure: A tear in the anal canal that can be confused with rectal prolapse due to associated pain and bleeding.
  • Rectocele: A herniation of the rectum into the posterior vaginal wall, seen in females, which may present with similar symptoms.
  • Anal cancer: Rare, but a mass at the anal verge may be mistaken for a prolapse.
  • Proctitis: Inflammation of the rectum that may cause rectal bleeding, pain, and tenesmus.
  • Rectal polyps: Can prolapse and present with bleeding and mucus discharge.

Other Pelvic Conditions

  • Uterine prolapse: Descent of the uterus into the vaginal canal, may be associated with rectal prolapse in women.
  • Vaginal vault prolapse: Seen in women post-hysterectomy, may coexist with rectal prolapse.
  • Cystocele: Prolapse of the bladder into the anterior vaginal wall, which may present alongside rectal prolapse.
  • Enterocele: Herniation of the small bowel into the vaginal canal, often occurs with rectal prolapse.
  • Pelvic organ prolapse: General term for prolapse of pelvic organs, including rectal prolapse.

Key Points in History 🥼

History of Presenting Complaint

  • Onset: Determine if the prolapse is acute or chronic. Chronic cases may have a long history of constipation or straining.
  • Symptoms: Ask about symptoms such as a mass protruding from the anus, pain, bleeding, mucus discharge, or incontinence.
  • Triggers: Assess factors that exacerbate symptoms, such as defecation, coughing, or physical activity.
  • Severity: Evaluate the impact on quality of life, including difficulties with defecation, hygiene, and social embarrassment.
  • Previous interventions: Inquire about previous treatments or surgeries, including manual reduction, and their outcomes.
  • Bowel habits: Assess for chronic constipation, diarrhea, or changes in stool caliber, which may suggest an underlying cause.
  • Urinary symptoms: Investigate any associated urinary symptoms, particularly in females, to assess for concomitant pelvic organ prolapse.
  • Gastrointestinal symptoms: Ask about rectal bleeding, pain, or tenesmus, which may suggest other conditions like rectal cancer or inflammatory bowel disease.
  • Pelvic floor dysfunction: Assess for symptoms of pelvic floor weakness, including stress incontinence or a sensation of pelvic pressure.

Background

  • Medical history: Review for chronic conditions such as COPD, which may predispose to rectal prolapse due to chronic coughing.
  • Surgical history: Previous pelvic surgeries, including hysterectomy, may increase the risk of prolapse.
  • Obstetric history: Multiple vaginal deliveries or traumatic deliveries can weaken the pelvic floor, leading to prolapse.
  • Family history: Assess for a family history of pelvic organ prolapse or connective tissue disorders.
  • Medication history: Review for medications that may cause constipation or straining, such as opioids.
  • Social history: Assess for activities or occupations involving heavy lifting or straining, which may exacerbate prolapse.
  • Dietary habits: Evaluate fiber intake and hydration status, which can impact bowel habits and straining.
  • Lifestyle factors: Consider weight, smoking status, and physical activity level, as these can influence pelvic floor health.
  • Pelvic floor exercises: Assess the patient’s knowledge and practice of pelvic floor strengthening exercises.
  • Previous imaging or investigations: Review prior colonoscopies or anorectal manometry results if available.

Possible Investigations 🌡️

Laboratory Tests

  • Full blood count (FBC): To assess for anemia, particularly if there has been rectal bleeding.
  • Electrolytes and renal function: To assess for dehydration or electrolyte imbalances, particularly in elderly patients.
  • Coagulation profile: To assess bleeding risk, especially if surgical intervention is being considered.
  • Stool studies: To evaluate for infectious causes of diarrhea if present, which may exacerbate prolapse.
  • Thyroid function tests: Hypothyroidism can cause constipation, which may contribute to prolapse.
  • C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR): To assess for inflammation, particularly if there is suspicion of inflammatory bowel disease.
  • Fecal occult blood test: To screen for colorectal cancer or other sources of rectal bleeding.
  • Vitamin D and calcium levels: Consider in elderly patients with osteoporosis, which may influence pelvic floor integrity.
  • Serum albumin: To assess nutritional status, particularly in chronically ill or elderly patients.
  • Liver function tests: To rule out hepatic causes of gastrointestinal symptoms, such as portal hypertension.
  • Urodynamic studies: May be indicated if there are concomitant urinary symptoms suggesting bladder dysfunction.
  • Autoimmune screen: If there is a suspicion of a connective tissue disorder contributing to pelvic organ prolapse.
  • Lactose intolerance test: Consider if chronic diarrhea is a contributing factor to prolapse.
  • Genetic testing: In cases where there is a suspicion of an inherited connective tissue disorder.
  • Urine analysis: To evaluate for urinary tract infections, which may exacerbate symptoms.

Imaging and Other Tests

  • Defecating proctography: A dynamic imaging study to assess the extent of rectal prolapse and associated conditions such as rectocele or intussusception.
  • Colonoscopic examination: To rule out neoplasms, polyps, or inflammatory bowel disease as contributing factors to prolapse.
  • MRI pelvis: Provides detailed imaging of pelvic floor anatomy and can identify other causes of prolapse.
  • Transrectal ultrasound: To evaluate the integrity of the anal sphincter complex in patients with incontinence.
  • Pelvic floor manometry: Measures the function of the pelvic floor muscles and may help in planning management.
  • CT scan of the abdomen and pelvis: Useful for assessing any associated intra-abdominal pathology, such as masses or adhesions.
  • Anorectal manometry: To assess sphincter function and rectal sensation, which can guide management.
  • Echocardiogram: To assess cardiac function, particularly in elderly patients or those undergoing surgery.
  • Urodynamic testing: Particularly in women with concomitant urinary symptoms, to assess for bladder dysfunction.
  • DEXA scan: To evaluate bone density in postmenopausal women or those with risk factors for osteoporosis.
  • Barium enema: Although less commonly used, it may provide useful information in cases where other imaging is inconclusive.
  • Electromyography (EMG) of pelvic floor muscles: To assess neuromuscular function in cases of suspected pelvic floor dysfunction.
  • Urethrocystoscopy: To assess the bladder and urethra in patients with concomitant urinary symptoms.
  • Perineal ultrasound: To visualize pelvic floor structures dynamically during straining or coughing.
  • Endoanal ultrasound: To assess the anal sphincter integrity, particularly in cases with incontinence.
  • Consultation with colorectal surgery: Often necessary for definitive management planning, particularly if surgical intervention is being considered.

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Gastrointestinal