Is rectal prolapse more common in patients with chronic diverticulitis?

Association Between Chronic Diverticulitis and Rectal Prolapse

There is an increased incidence of rectal prolapse in patients with chronic diverticulitis, with complications such as rectal prolapse occurring at a younger age in adolescents and adults with diverticular disease. 1

Epidemiological Relationship

• Rectal prolapse is a rare condition with an incidence of approximately 2.5 per 100,000 inhabitants, with a prevalence of 1% in adults over 65 years, and a women:men ratio of 9:1 1
• Chronic diverticulitis is associated with several complications affecting the lower gastrointestinal tract, including rectal prolapse 1
• Diverticular disease can lead to chronic constipation, which is a known risk factor for rectal prolapse 1

Pathophysiological Connection

• Chronic diverticulitis can cause persistent inflammation and weakening of the colonic and rectal wall structures 2
• Complications of chronic constipation associated with diverticular disease include rectal prolapse, hemorrhoids, and intestinal perforation 1
• The weakening of pelvic floor muscles due to chronic straining in patients with diverticulitis-related constipation may contribute to rectal prolapse development 2

Clinical Presentation

• Rectal prolapse presents as a circumferential, full-thickness intussusception/protrusion of the rectum through the anus 1
• Patients with rectal prolapse typically present with:
  • Lower abdominal pain 1
  • Constipation 1
  • Hematochezia (bloody stools) 1
• Differential diagnosis between rectal prolapse and prolapsed hemorrhoids is essential:
  • Rectal prolapse involves a concentric protrusion 1
  • Prolapsed hemorrhoids present as radial bulging and prolapse of discrete anal cushions 1

Diagnostic Approach

• Diagnosis of rectal prolapse is primarily based on patient history, symptoms, and clinical examination 1
• In patients with suspected complicated rectal prolapse, laboratory tests should include:
  • Complete blood count 1
  • Serum creatinine 1
  • Inflammatory markers (C-reactive protein, procalcitonin, lactates) 1
• Imaging studies may include:
  • Contrast-enhanced abdomino-pelvic CT scan to detect possible complications 1
  • Defecography may be helpful in diagnosing rectal diverticulum associated with pelvic organ prolapse 3

Management Considerations

• Treatment approach depends on whether the rectal prolapse is complicated or uncomplicated 1
• Non-operative management (NOM) techniques for reducible prolapse include:
  • Manual reduction with the patient in Trendelenburg position 1
  • Application of sugar or hypertonic solutions to reduce edema 1
  • Elastic compression wrap to force edema fluid out of the prolapse 1
• Surgical intervention is indicated when:
  • Non-operative management fails 1
  • Manual reduction is unsuccessful 1
  • There are signs of ischemia or perforation 1

Surgical Options

• The choice between abdominal and perineal procedures should be based on:
  • Patient characteristics 1
  • Surgeon's expertise 1
  • Presence of peritonitis or hemodynamic instability 1
• Perineal techniques include:
  • Anal encirclement (Thiersch procedure) 1
  • Mucosal sleeve resection (Delorme's procedure) 1
  • Perineal proctosigmoidectomy (Altemeier's procedure) 1
• Abdominal procedures include:
  • Suture rectopexy 1
  • Mesh rectopexy (various techniques) 1
  • Resection rectopexy with or without mesh 1

Special Considerations

• Rectal diverticula are extremely rare compared to colonic diverticula (0.08% of all diverticulosis) but can be associated with rectal prolapse 3
• Case reports have documented successful treatment of rectal diverticulum with rectal prolapse using robotic ventral mesh rectopexy 3
• Delorme's procedure has been reported as a minimally invasive surgical technique to successfully address isolated rectal diverticulum complicated with rectal prolapse and outlet obstruction 4

Prevention Strategies

• Preventive measures for patients with diverticulitis to reduce risk of rectal prolapse include:
  • Aggressive treatment of chronic constipation 1
  • Increasing water and fiber in the diet 1
  • Using osmotic laxative treatment when necessary 1
  • Regular monitoring for early signs of rectal prolapse 1