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H E M O R R H O I D S

A N D R E C T A L

P R O L A P S E

Although disparate topics, these two different patho-logic entities are commonly misdiagnosed by bothlayperson and physician alike. The inclusion of both top-ics in a single chapter allows us to examine their similari-ties and emphasize their differences. In the process, wehope to clarify common misconceptions regarding theseanal/rectal disorders. We think you will see there is noone common profile particular to either diagnosis.

C H A R L E S N . H E A D R I C K

M I C H A E L J . S T A M O S

34

CASE 1RECTAL PROLAPSE

A 33-year-old white female, who was gravida 0, para 0, pre-sented with a chronic history of constipation and straining.She also gave a history of bright red blood per rectum andpassage of mucus and “tissue” with each bowel movement.She denied any rectal pain. The prolapsed tissue reducedspontaneously at the completion of each bowel movement.She described these symptoms as lasting for the previous 4months. She gave no history of any anal intercourse,trauma, or other significant past medical history. There hadbeen no previous anorectal or abdominal surgery and shehad no significant family history. Social history revealed thatshe did not smoke and was unmarried. Questions regardingher bowel habits revealed that she moved her bowels, atbest, every other day, and occasionally every 3 days. Therehad been no history of laxative use in the past.

Physical examination revealed a healthy appearingyoung female. Her abdominal examination revealed a thin,

scaphoid abdomen. Examination of the perianus revealedsome slight effacement of the anus. There was normal cu-taneous sensation, somewhat diminished spinchter tone,and a good voluntary squeeze. There were no intra-analmasses. Anoscopy revealed prominent rectal mucosal foldswith small internal hemorrhoids. These were moderatelyerythematous and with occasional superficial ulceration.Flexible sigmoidoscopy revealed a large rectal vault withmoderate inflammation extending to the mid-rectum. Shewas also noted to have a redundant sigmoid colon. The re-mainder of her examination was normal.

The patient was asked to reproduce her symptoms bysitting on the toilet and straining. The result revealed a 3-to 5-cm circumferential prolapse that demonstrated circu-lar, concentric folds consistent with rectal prolapse, orprocidentia. The prolapse reduced spontaneously.

At the end of her consultation, the patient was coun-seled regarding her diagnosis. She was advised to increasethe fiber in her diet and to take bulk fiber agents. A bar-ium enema was ordered to evaluate the remainder of the

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colon. The air contrast enema revealed a normal mucosaloutline without diverticula and a very redundant sigmoidcolon. Subsequently, her bowel regimen improved to onebowel movement a day with only occasional straining dur-ing defecation. She continued to prolapse, however, witheach bowel movement. Surgery was indicated because ofher continued symptoms and the risk of sphincter dam-age. An abdominal approach was recommended as herbest option. She underwent laparotomy, sigmoid resec-tion, low rectal dissection, and rectopexy. Her postopera-tive recovery was uneventful.

CASE 2RECTAL PROLAPSEIN AN ELDERLY PATIENT

A 79-year-old white female who was gravida 4, para 4, pre-sented with a history of constipation, stating that her rec-tum “falls out.” She had a long history of taking laxativeproducts (senna, herbal tea, cascara, and magnesiumproducts). She was especially concerned because shesometimes moved her bowels without warning and soiledher undergarments. Other pertinent history revealed thatshe had coronary artery disease and medically controlledhypertension. She had previously undergone an abdomi-nal hysterectomy and oophorectomy as well as an inciden-tal appendectomy.

Physical examination revealed a moderately obesewhite female with lower midline abdominal scars. Rectalexamination revealed both hemorrhoidal and rectal pro-lapse. The prolapse was easily reducible, but came backout with a moderate increase in intra-abdominal pressure.Digital examination revealed a diminished sphincter tone.Some soilage of stool and mucus was noted on her under-garments. Preoperative workup included contrast enemaand flexible sigmoidoscopy. Anal manometry revealed alow-resting sphincter pressure.

The patient was deemed to be at high risk of an ab-dominal operation, and a perineal approach was recom-mended. The patient subsequently underwent perinealrectosigmoidectomy under spinal anesthesia. Postopera-tively, the patient did well. Her prolapse was cured andshe had perceptible improvement in her continence.

CASE 3HEMORRHOIDAL PROLAPSE

A 43-year-old Hispanic male with a history of straining andconstipation came in complaining of bright red blood perrectum. He denied pain. He was found to have prolapse re-vealing radial folds (hemorrhoidal prolapse) and anemia of8 g Hb. Preoperative workup included a colonoscopy, whichwas normal, followed by surgical hemorrhoidectomy.

CASE 4THROMBOSED EXTERNALHEMORRHOID

A 25-year-old male came in complaining of anal swellingand a sudden onset of pain. The patient recently had se-vere gastroenteritis with diarrhea. Physical examinationrevealed a thrombosed external hemorrhoid. Treatmentconsisted of excision in the office under local anesthesia.

GENERAL CONSIDERATIONSHemorrhoidal disease is very common. The num-ber of over-the-counter remedies available is proofenough. Hemorrhoids are actually present in every personand have a normal physiologic function. They cushion thefecal bolus as it is expelled from the rectal reservoir andcontribute to normal continence. Poor diet and hygiene,increases in intra-abdominal pressure, and family historymay contribute to the development of abnormal hemor-rhoids, which usually manifest as enlargement and/or in-flammation. Hemorrhoids are classified as internal or ex-ternal, based on their relationship to the dentate line.Distal to this junction of mucous membrane and anodermthere is normal somatic sensation. Proximal to this line,there is a transitional zone, measuring from 1 to 1.5 cm, inwhich sensation is lessened as the somatic sensory appara-tus is diminished. It is in this zone, proximal to the dentateline, where internal hemorrhoids reside (Fig. 34.1). Symp-tomatic internal hemorrhoids may cause discomfort, pro-lapse, or even hemorrhage without pain to the individual(painless bleeding). External hemorrhoids rarely bleed,but may cause significant pain (Case 4) associated withthrombosis. Hemorrhoids may also bridge this anatomicboundary (mixed type) (Fig. 34.2).

Hemorrhoids have no sexual predilection, and span therange of ages. Certain conditions may predispose towardthe formation of hemorrhoids: constipation, chronic diar-rhea, and pregnancy. The most common causes of consti-pation are inadequate fluid intake, poor diet (low fiber in-take), and infrequent exercise. There are also a number ofmedications that can cause constipation (calcium channelblockers, tricyclic antidepressants, diuretics).

Hemorrhoidal prolapse constitutes a special situationin hemorrhoidal disease. The tissue has enlarged enoughto be partially expelled during defecation. A grading sys-tem is used to describe enlarged internal hemorrhoids: (1)grade I—enlarged hemorrhoidal tissue, (2) grade II—hemorrhoidal tissue that prolapses with straining butspontaneously reduces, (3) grade III—hemorrhoidal pro-lapse that requires manual replacement, and (4) gradeIV—unreducible prolapse. Anatomic orientation is alsohelpful as one person may have coexisting grades of hem-orrhoids. Left, right, anterior, posterior, and lateral are the

FIGURE 34.1 Internal hemor-rhoids, by definition, are lined bymucosa and rise above the den-tate line. External hemorrhoidsare lined by anoderm (skin).

FIGURE 34.2 The hemorrhoidalplexus may engorge and form col-laterals to develop into a combinedinternal/external hemorrhoid.

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labels used to describe hemorrhoidal location. The typicaldistribution of hemorrhoids include left lateral, right ante-rior, and right posterior columns.

True rectal prolapse, or procidentia, can be confusedwith prolapse of hemorrhoids or mucosal prolapse. In truerectal prolapse, there is a full thickness prolapse. The rec-tum actually turns “inside out,” similar to an intussuscep-tion. This situation connotes a loss of pelvic support andcarries with it a risk of incontinence (Case 2)—eitherthrough stretching of the pudendal nerve or direct physi-cal trauma to the sphincter complex.

Unlike hemorrhoidal disease, rectal prolapse is morecommon in women (Cases 1 and 2) (6:1 female/male) andcan occur at any age (even in the newborn). Historically, itwas thought to be associated with multiparous, elderly fe-males, but may also occur in a young male or a nulliparousyoung female (Case 1). Doctors and patients alike may beconfused by the symptoms and sensations of this ailmentand frequently attribute them to hemorrhoids.

DIAGNOSISDiagnosis of these anorectal problems is based on acareful history and thorough physical examination. Ancil-lary tests such as air contrast barium enema and analmanometry may be helpful after the diagnosis is secure.

History taking for anal/rectal disorders can be veryhelpful in making a diagnosis. Particular attention shouldbe directed toward the patient’s diet, bowel habits, anddescription of any symptoms. This should include the av-erage number of bowel movements per day or week, thepresence of straining or any sensation or prolapse, theamount of time spent on the toilet, and the characteristicsof any blood found during the movement. Associated ab-dominal complaints and concurrent usage of medicationshould also be discussed. Additionally, prior anorectal, ab-dominal, or pelvic surgery should be detailed, with partic-ular attention given to vaginal childbirth, episiotomies,and/or tears.

As with any anal/rectal disorder, the following elementsare essential to a good examination: (1) inspection of theperianus, including rudimentary sensory examination, (2)

digital examination to evaluate the canal for masses, tender-ness, and sphincter tone, (3) anoscopy to examine the analcanal visually, (4) flexible sigmoidoscopy to visually examinethe rectum and lower colon, and (5) when prolapse is sus-pected, visual examination of the anus and perineum duringstraining, preferably while sitting or squatting.

External hemorrhoids are visible on simple inspection,and in the noninflamed state simply may appear as fleshyskin covered protrusions (tags). They may become in-flamed and edematous or may thrombose. Thrombosis(usually an acute event brought on by straining, constipa-tion, or diarrhea), is typically very painful (Case 4). A firmtender mass is palpated adjacent to the anal canal. Themass may have a dark, bluish appearance. The overlyingskin is usually normal although central ulceration is notuncommon due to pressure necrosis. The tenderness is lo-calized to the thrombosis itself, unlike an abscess.

Internal hemorrhoids can only be appreciated ade-quately by visualization, either by inspection if prolapsedor by anoscopy. Palpation is unreliable in the diagnosis ofinternal hemorrhdoids.

Rectal prolapse can be difficult to diagnose. Eventhough the patient may report frequent prolapse, repro-ducing the event in the doctor’s office may be difficult.Frequently, the experience can be embarrassing for thepatient and even the physician. Often, the patient can onlyproduce the prolapse while squatting and straining. Abathroom adjacent to the examination room is helpful forthis part of the examination. When the prolapse is repro-duced, it may protrude 1–2 cm or up to 15–20 cm. Rarely,a patient will present with an incarcerated prolapse, whichshould be treated as a surgical emergency.

Although flexible sigmoidoscopy is usually adequate, amore thorough colonic examination (colonoscopy, air con-trast enema) may be helpful. Rarely, a tumor can act as a“bedpost” for intussusception or prolapse. Laboratorystudies are not helpful in making the diagnosis, althoughthe presence of anemia should mandate a full colonicevaluation.

DIFFERENTIAL DIAGNOSISThe main difficulty in diagnosing these conditionsis in distinguishing them from one another. True rectalprolapse produces circumferential mucosal folds whilehemorrhoidal prolapse yields radial folds (Figs. 34.3 and

K E Y P O I N T S

• Hemorrhoids present in every person and have a normalphysiologic function

• Hemorrhoids classified as internal or external, based on rela-tionship to dentate line

• Symptomatic internal hemorrhoids may cause discomfort,prolapse, or even hemorrhage without pain to the individual(painless bleeding)

• External hemorrhoids rarely bleed, but may cause significantpain associated with thrombosis

K E Y P O I N T S

• As with any anal/rectal disorder, the following elements areessential to good examination: inspection of perianus, digital ex-amination, anoscopy, and flexible sigmoidoscopy

• Internal hemorrhoids can only be appreciated adequately byvisualization, either by inspection if prolapsed or by anoscopy

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34.4). Likewise, true rectal prolapse does not include thedentate line, leaving a deep sulcus outside of the pro-lapsed tissue.

Other tumors may also prolapse through the analcanal and be mistaken for hemorrhoids. Rectal polyps, tu-mors, and hypertrophied anal papillae are the most com-mon. These are readily identified by anoscopy or proc-tosigmoidoscopy.

TREATMENTSuccessful treatment of hemorrhoids requires an ac-curate diagnosis and elimination of other perianal diseaseas the cause of the patient’s complaints. Since hemor-rhoids are a normal part of human anatomy, they will in-variably be present but may not be contributing to the pa-tient’s problems. Indeed, other pathology (e.g., analfissures, proctitis) frequently will exacerbate existing hem-orrhoids. Failure to appreciate and treat the primary dis-ease process will likely lead to failure of therapy.

Internal hemorrhoids may be treated medically, withoffice treatments, or with surgery. The decision rests on

the symptomatology and physical examination. For com-plaints of minor bleeding associated with bowel move-ments (“outlet bleeding”), dietary counseling and fibersupplementation (psyllium) may be adequate, althoughflexible sigmoidoscopy is mandatory to eliminate a distalcolon or rectal cancer as the possible cause of the bleed-ing. For prolapse, or bleeding associated with prolapse,additional treatment is required. A variety of office treat-ments may be used, although sclerotherapy and rubberband ligation are the most commonly employed. All ofthese office based treatments are “fixation” techniques.They work primarily by creating scar tissue locally that“fixes” the mucosa overlying the hemorrhoid to the under-lying internal sphincter muscle. Surgical treatment, in-cluding laser treatment, is reserved for more severe dis-ease (Case 3) and for patients with associated externalhemorrhoids that are not amenable to office treatment.Laser hemorrhoidectomy is identical to standard surgicalhemorrhoidectomy in every parameter studied. Its onlyapparent advantage is in marketing. The disadvantage issolely in cost.

External hemorrhoids may also be treated medicallyor with surgery. Topically applied creams may help shrink

FIGURE 34.3 True rectal prolapse. Note the circumferential mucosal folds and the sulcus outside theprolapse (fixation of the dentate line).

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edematous and inflamed tissue, but office surgery is some-times required to solve an acute painful process such asthrombosis (Case 4). On rare occasions, circumferentialthrombosis is best treated in the operating room withanesthetic blockade.

As a rule of thumb, it should be remembered thatmost hemorrhoidal problems can be solved without surgi-cal intervention.

Treatment for procidentia, unfortunately, does notenjoy the same success rate as hemorrhoidectomy. Oncediagnosed, the solution is surgical, but the choices for re-pair are numerous. They fall into three basic categories:(1) anal encirclement procedures (Thiersch), (2) perinealapproaches (Altmeier or Delorme), and (3) abdominal ap-proaches.

Historically, the circlage, or Thiersch procedure, hasbeen around the longest. The prolapse is reduced andmaintained by reinforcing the external sphincter mecha-nism with a permanent material placed outside of thesphincter mechanism and underneath the skin. The recur-rence and infection rates are high. It is now reserved forthe very infirm.

Perineal solutions have enjoyed a resurgence in popu-larity, particularly among the elderly patient population,since the operation is performed under regional anesthe-sia. It involves resection or plication of the redundantbowel via the anal canal. Although this does not treat anyunderlying cause of the problem, the recurrence rate issomewhat lower than an encircling procedure and the op-eration is quite safe.

The abdominal approach has the lowest recurrencerate but also the greatest morbidity. Evaluation of theanatomy is more complete and the operation can be com-bined with a resection, rectopexy, or very low dissection.Most versions include a very low dissection in order tocreate a plane of scarring in the retrorectal space. Therisks are the same as for low anterior resection. Choice ofoperation is based on an individual’s activity, experience,and preference of the surgeon.

It should be noted that the pathophysiology of proci-dentia is not completely understood. A weakening of thepelvic floor leads to the intussusception or prolapse, butthe role of bowel function and motility is not fully appreci-ated as a precursor to this event.

FIGURE 34.4 Hemorrhoidal or mucosal prolapse. Note the radial folds and absence of rectal wall(muscle) within the prolapse.

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FOLLOW-UPHemorrhoid disease and symptoms tend to recur intime if the inciting cause is not altered. The more conserv-ative the therapy, the more likely the onset of recurrentsymptoms. Follow-up should therefore emphasize avoid-ance of constipation and include dietary counseling.

Postoperative follow-up, however, should be done in arigorous fashion to avoid the preventable complications—stenosis, prolonged pain, and constipative bowel habit.Counseling the patient on high fiber diet, hygiene, andpain control should be done both in the pre- and postop-erative phase. Postoperative examinations should be doneevery 2 weeks until adequate healing has taken place toavoid postoperative stricture and stenosis. This may lastup to 12 weeks. Additional informational exchanges canalso take place on the telephone to eliminate anxiety andanswer simple questions.

Rectal prolapse operations all carry a significant inci-dence of recurrence, perineal operations more so thanabdominal operations. Although the exact cause of pro-lapse is unknown, avoidance of constipation and strainingis felt to be important. Fecal incontinence is common inpatients with prolapse (Case 2), and improvement is seenin approximately 50% of patients following operation.However, optimal function may take up to 6 months toachieve.

SUGGESTED READINGS

Corman ML: Rubber band ligation of hemorrhoids. Arch Surg112:1257, 1977

Simplified technical description of the most common tech-nique used for internal hemorrhoid treatment.

Huber FT, Stein H, Siewert JR: Functional results after treat-ment of rectal prolapse with rectopexy and sigmoid resec-tion. World Surg 19:138, 1995.

Prospective study looking not just at anatomic but also func-tional results.

Loder KM, Kamm MA, Nicholls RJ, Phillips RKS: Hemor-rhoids: pathology, pathophysiology and aetiology. Br J Surg81:946, 1994

Comprehensive review focusing on pathophysiology.

Williams JG, Madoff RD: Perineal repair for rectal prolapse.Prob Gen Surg 9:732, 1992

Outlines perineal approach and options.

QUESTIONS

1. Internal hemorrhoids?A. Typically cause pain associated with bowel

movements.B. Are universally present.C. Are most appropriately treated with the laser.D. Are readily diagnosed on digital examination.

2. Rectal prolapse?A. Can be difficult to differentiate from internal

hemorrhoids.B. Is best treated surgically.C. Can lead to fecal incontinence.D. May be treated via an abdominal approach.E. All of the above.

(See p. 604 for answers.)

K E Y P O I N T S

• Successful treatment of hemorrhoids requires accurate diag-nosis and elimination of other perianal disease as the cause ofpatient complaint; since hemorrhoids are normal humananatomy, will invariably be present, but may not be contribut-ing to patient’s problem

• Rule of thumb: majority of hemorrhoidal problems can besolved without surgical intervention