Rectal prolapse traumatizes rectal neuromuscular microstructure explaining persistent rectal dysfunction.

Matthias Kraemer,Stephanie Rozsnoki,Saskia Mankewitz,David Kara,Werner Paulus

doi:10.1007/s00384-016-2649-8

Matthias Kraemer, Stephanie Rozsnoki + Show 3 more

Open Access

https://doi.org/10.1007/s00384-016-2649-8

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Abstract

PurposeInternal rectal prolapse is common and correlates with age. It causes a plug-like physical obstruction and is a major cause of defecation disorder. The progressive distortion of the prolapsing rectum likely causes secondary defects in the rectal wall, which may exacerbate rectal dysfunction. We undertook a prospective observational study to detect and quantify the neurologic and histopathologic changes in the rectal wall.MethodsWe examined dorsal and ventral rectal wall specimens from consecutive patients with internal rectal prolapse undergoing stapled transanal rectal resection (STARR). We subjected specimens to histopathologic and neuropathologic assessment, including immunohistochemistry. We also recorded patients’ clinical and demographic characteristics and sought correlations between these and the pathologic findings.ResultsWe examined 100 specimens. The severity of rectal prolapse and the extent of descent of the perineum correlated significantly with age. Concomitant hemorrhoidal prolapse was noted in all male patients and in 79 % of female patients. Muscular and neuronal defects were detected in 94 and 90 % of the specimens, respectively. Only four specimens (4 %) were free of significant structural defects.ConclusionRectal prolapse traumatizes the rectum causing neuromuscular defects. The tissue trauma is due to shearing forces and ischemia caused by the intussusception. This initiates a self-reinforcing vicious circle of physical and functional obstruction, further impairing rectal evacuation and causing constipation and incontinence. The correlation between extent of prolapse and age suggests that internal rectal prolapse can be considered a degenerative disorder. Neural and motor defects in the wall of the rectum caused by rectal prolapse are likely irreversible.

Highlights

The last decade has brought a better understanding of acquired degenerative disorders of the rectum as well as new treatment options
The correlation between extent of prolapse and age suggests that internal rectal prolapse can be considered a degenerative disorder
Neural and motor defects in the wall of the rectum caused by rectal prolapse are likely irreversible

Summary

Introduction

The last decade has brought a better understanding of acquired degenerative disorders of the rectum as well as new treatment options. In this context, internal rectal prolapse is recognized as a major cause of defecation disorder. The causal link between internal rectal prolapse and defecation disorder is largely accepted as a pathophysiologic concept known as obstructed defecation syndrome [1–12]. Imaging of patients with rectal prolapse— dynamic defecography—often reveals an extremely flaccid and dilated rectum. It would be unlikely that a markedly flaccid, dilated, and intussuscepting rectum still retains the sensorimotor integrity required for evacuation. A structurally normal rectum is unlikely to be flaccid enough to undergo intussusception

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