What are the signs of a strangulated rectal prolapse?

Signs of Strangulated Rectal Prolapse

Immediate surgical treatment is required when a rectal prolapse shows signs of gangrene, perforation, or shock, as these indicate strangulation requiring emergency intervention. 1

Key Clinical Signs of Strangulation

Strangulated rectal prolapse presents with several characteristic findings that require urgent recognition:

• Color changes: Dark purple or black discoloration of the prolapsed tissue indicating ischemia or necrosis
• Edema: Significant swelling of the prolapsed segment
• Irreducibility: Inability to manually reduce the prolapse despite gentle attempts
• Pain: Severe pain disproportionate to simple prolapse
• Systemic signs: Hemodynamic instability, fever, or signs of sepsis

Physical Examination Findings

When evaluating a suspected strangulated rectal prolapse, look for:

• Irreducible, edematous rectal tissue protruding from the anus 2
• Discoloration suggesting compromised blood supply
• Tenderness on gentle palpation
• Possible bleeding or mucous discharge 3
• Absence of normal pink, moist mucosal appearance

Laboratory and Imaging Indicators

In cases of suspected strangulation, certain laboratory findings may support the diagnosis:

• Elevated white blood cell count
• Increased C-reactive protein levels 2
• Signs of systemic inflammatory response

While imaging is not always necessary for diagnosis, it may be helpful in complicated cases to assess the extent of involvement.

Management Algorithm

1. Initial assessment: Evaluate for signs of strangulation (discoloration, irreducibility, severe pain)

2. If no signs of ischemia or perforation:

   • Attempt gentle manual reduction under mild sedation or anesthesia 1

3. If signs of strangulation present OR manual reduction fails:

   • Proceed to immediate surgical intervention 1
   • Administer empiric antimicrobial therapy due to risk of bacterial translocation 1

4. Surgical approach:

   • For hemodynamically stable patients without peritonitis: Choose between abdominal and perineal procedures based on patient characteristics and surgeon expertise 1
   • For patients with peritonitis: Abdominal approach recommended 1
   • For hemodynamically unstable patients: Open abdominal approach strongly recommended 1

Important Considerations and Pitfalls

• Do not delay surgical management in hemodynamically unstable patients with complicated rectal prolapse 1
• Avoid forceful reduction attempts which may cause further tissue damage or perforation
• Be aware that strangulation can occur rapidly and may be the first manifestation of rectal prolapse in some patients 4
• Watch for rare but serious complications such as perforation with evisceration of other viscera through the necrotic mucosa 5

Surgical Options

The surgical approach depends on patient stability and extent of strangulation:

• Perineal rectosigmoidectomy (Altemeier procedure) is often the intervention of choice for strangulated rectal prolapse 2
• In severe cases with significant strangulation, resection with primary anastomosis or diverting stoma may be necessary 1, 6

Early recognition of strangulation signs and prompt surgical intervention are critical to prevent progression to gangrene, perforation, and potentially life-threatening sepsis.