Patient Presentation
A 22-month-old female came to the emergency room with increasing abdominal pain over the past few days and now she was have intermittent crying spells. She had a history of chronic constipation treated with polyethylene glycol which she hadn’t been taking for a while. Her mother said she had not had a bowel movement in several days and had noticed her abdomen becoming larger overall. She denied any blood or mucous in the diaper. She also had no diarrhea, emesis, fever, or abnormal urine. She hadn’t been eating or drinking as much and wasn’t awakened by the pain.

The pertinent physical exam showed a female who was crying. She was afebrile and her weight was at the 50% and tracking previous weights. HEENT, heart and lungs were normal. Her abdomen was rounded and protuberant. She would cry during the examination but did not seem to have any particular location for pain and had no guarding. There was no specific hepatosplenomegaly but there were obvious fecal masses on exam. She had a normal anal wink and no hemorrhoids or anal fissures noted. The hymen was intact without discharge. The resident was in the process of ordering a work-up for abdominal pain with abdominal radiograph and blood work, when she started to really scream and passed an ~8 cm hard ball of stool. The mother and nursing staff quickly called the resident as her rectum was now emanating from her anus.

The diagnosis of rectal prolapse was made with healthy pink tissue circumferentially located ~1.5 cm from the anus with the anus being quite patulous. The child did not seem bothered specifically by the mass but was whimpering. The attending emergency room physician was called and he felt the prolapse would probably resolve, but was more concerned about the patulousness of the rectum. A surgical consultation was called. The surgeon was delayed an hour and by this time the prolapse had resolved and the patulousness had markedly improved. The child was also calmer. The examination at this time showed a decreased but still slightly rounded abdomen. There was a normal anal wink and enlarged rectal vault on exam. The surgeon recommended aggressive treatment for constipation and warned the mother that this could potentially occur again as the child obviously had additional stool burden that needed to be passed. Specific instruction on how to digitally replace the prolapse was given to the mother and she was told to attempt it once if needed and then to come to the emergency room if this did not resolve. The patient was to follow up with her regular doctor in 2-3 days.

Discussion
Rectal prolapse is defined as a herniation of the rectum through the anal verge. In children it is also usually mucosal prolapse and not full thickness. Partial or mucosal prolapse usually is seen as radial folds occurring 1 – 2.5 cm from the anal verge. Full thickness will protrude more than 5 cm. It affects genders equally and occurs most commonly in children under age 4. This is due to vertical course and low position of the anus, looser supporting tissues and less muscular support. These children are more likely to have prolapse but are less likely to have it recur. After age 4 the rectum takes the adult shape and more posterior position which lowers its occurrence. However, in older children it is more likely to recur.

Presentation is usually during defecation and is usually painless but patients may feel the mass or have a feeling of incomplete defecation or tenesmus. The prolapse looks like a beefy red mass. As prolapse usually resolves, having the patient perform a Valsalva maneuver or squat may reproduce the prolapse. Prolapses that do not resolve may become edematous, with bleeding and ulceration sometimes occurring. This also makes reduction more difficult. Rectal prolapse can be, but rarely is incarcerated.

Treatment includes spontaneous resolution as noted. Digital replacement is often the next step and may require take several minutes to allow the tissues to become less edematous and remain in place. Some have used sugar to reduce the edema similar to its use for stoma prolapse and edema. For recurrences requiring more treatment, injection sclerotherapy is a common first-line therapy, followed by more invasive surgical management if needed.

Treatment of the underlying cause is obviously important. Constipation is a common problem in any age group. In the young pediatric age group, caregivers should be instructed to treat with medications to allow passage of frequent soft stools (e.g. polyethylene glycol), adequate fluid intake avoiding sugar sweetened beverages, increased fiber which may require specific supplementation, and proper positioning for toileting. Families may not realize that having a foot stool placed under the feet not only allows the child to gain access to the toilet, but also put the child into a bent-kneed position which is an optimal position for the body to perform defecation. Underlying treatable causes of constipation should also be considered such as hypothyroidism

Learning Point
Many of the causes listed below are because of increased abdominal pressure and lack of rectal support. Lead points or general edema may develop leading to rectal prolapse. Chronic malnutrition and diarrhea decreases the ischiorectal fat which leads to decreased rectal support.

Causes of rectal prolapse includes:

• Increased abdominal pressure
  • Constipation – most common reason
  • Coughing, intractable
  • Emesis, intractable
  • Iatrogenic – high ventilatory pressure
• Idiopathic
• Allergy
  • Cow’s milk protein
• Anatomic
  • Cloacal anomaly
  • Hirschsprung’s disease
  • Imperforate anus
  • Short gut syndrome
• Diarrhea illness
  • Inflammatory bowel disease
• Infection
  • Bacteria – Clostridium difficile, Salmonella, Shigella
  • Viral – Cytomegalovirus
  • Parasitic
• Intussception with lead point
  • Peutz-Jegher syndrome with polyp
  • Rectal polyps
  • Ulcerative colitis with pseudopolys
• Malnutrition
  • Celiac disease
  • Cystic fibrosis – very common before newborn screening but less common currently
• Neurologic
  • Meningomyelocoele
  • Psychological – studies show a large number of patients with concomitant psychological problems and rectal prolapse
    • Autism
    • Defecation dysfunction
    • Psychiatric illness
• Other
  • Bladder stone
  • Ehler-Danlos syndrome
  • Medications
  • Pelvic masses
  • Solitary rectal ulcer syndrome
  • Trauma

Questions for Further Discussion
1. What causes constipation? A review can be found here

2. What is different or the same for hemorrhoid and rectal prolapse presentations? A review can be found here
3. What treatment and followup would you recommend if you saw this child 2-3 days later?

Related Cases

Disease: Rectal Prolapse | Anal and Rectal Diseases | Pelvic Support Problems | Constipation

Symptom/Presentation: Abdominal Pain | Mass or Swelling

Specialty: Emergency Medicine | Gastroenterology | Surgery

Age: Toddler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Constipation and Anal and Rectal Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Cares K, El-Baba M. Rectal Prolapse in Children: Significance and Management. Curr Gastroenterol Rep. 2016;18(5):22. doi:10.1007/s11894-016-0496-y

Cares K, Klein M, Thomas R, El-Baba M. Rectal Prolapse in Children: An Update to Causes, Clinical Presentation, and Management. Journal of Pediatric Gastroenterology and Nutrition. 2020;70(2):243-246. doi:10.1097/MPG.0000000000002546

Saadai P, Trappey AF, Langer JL. Surgical Management of Rectal Prolapse in Infants and Children. Eur J Pediatr Surg. 2020;30(05):401-405. doi:10.1055/s-0040-1716725

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa