From the Guidelines
Pediatric rectal prolapse should be initially managed with conservative measures, including manual reduction of the prolapse, addressing constipation, and improving toileting habits, as most cases resolve with these measures within 1 year 1.
Initial Management
Initial management of pediatric rectal prolapse should focus on conservative measures, including:
- Manual reduction of the prolapse using gentle pressure with a lubricated gloved finger to replace the prolapsed tissue
- Addressing constipation through dietary modifications (increased fiber and fluids), stool softeners like polyethylene glycol (Miralax 0.5-1.5 g/kg/day), and establishing regular toileting routines
- Improving toileting habits, such as avoiding prolonged straining and squatting during defecation
Indications for Surgical Treatment
Surgical intervention is reserved for recurrent or persistent cases unresponsive to conservative management, with indications including:
- Signs of shock or gangrene/perforation of prolapsed bowel, which require immediate surgical treatment 1
- Bleeding, acute bowel obstruction, or failure of non-operative management, which require urgent surgical treatment 1
- Recurrent or persistent cases unresponsive to conservative management, with options including linear cauterization, Thiersch procedure (anal encirclement), or rectopexy 1
Non-Operative Management
Non-operative management (NOM) may be attempted in patients with incarcerated rectal prolapse without signs of ischemia or perforation, using techniques such as:
- Submucosal adrenaline injections
- Topical application of granulated sugar
- Topical application of hypertonic solutions of sugar
- Submucosal infiltration of hyaluronidase
- Elastic compression wrap However, NOM should not delay surgical treatment, and surgery should be performed when NOM fails and manual reduction is not successful, to avoid ischemia and perforation 1
Underlying Conditions
Underlying conditions like cystic fibrosis, neurological disorders, or malnutrition should be evaluated and addressed, as these can contribute to rectal prolapse in children 1. Parents should seek immediate medical attention if the prolapse cannot be reduced or if there are signs of tissue strangulation.
From the Research
Definition and Prevalence
- Pediatric rectal prolapse is a common and often self-limited condition in infancy and early childhood 2
- It can occur in children and adolescents, with various underlying conditions contributing to its development, such as constipation, gastrointestinal infectious and non-infectious etiologies, cystic fibrosis, malnutrition, neurogenic, anatomic, lead points, and abuse 3
Management Options
- Medical management is the initial approach, addressing the underlying condition associated with rectal prolapse along with attempted manual reduction 3, 4
- Sclerotherapy with ethanol or 5% phenol can be effective local treatments for medically refractory disease 4
- Surgical options include perianal procedures, perineal procedures, and transabdominal rectopexy, with the latter being the favored treatment for disease refractory to local treatment 4
- Transabdominal rectopexy with sigmoidectomy may be preferred in the pediatric population for postoperative recurrences 4
Treatment Outcomes
- Medical therapy is highly effective in most patients, with bowel management programs being particularly successful 4
- Sclerotherapy has a resolution rate of 54%, with 33% resolving with sclerotherapy alone and 21% resolving after a subsequent surgical procedure 5
- Surgical intervention (sclerotherapy, rectopexy, transanal resection) resolved rectal prolapse in most children (63%) 5
- Patients who underwent initial surgical management had an adjusted odds ratio of 8.0 for resolution of prolapse compared to patients who underwent sclerotherapy initially 5
Factors Influencing Treatment
- Younger patients (<5 years) are more likely to be initially treated with medical management alone 5
- Patients with a psychiatric diagnosis are more likely to be offered either sclerotherapy or surgery upfront 5
- Markers of severity (bleeding, need for manual reduction) are not associated with initial therapy offered 5