The more complete form of prolapse by true invagination is rarely seen, save in adults, and in consequence of some serious preëxistent condition, such perhaps as complete laceration of the perineum in the female, paralysis of the sphincter from previous accident, or from the existence of spinal-cord disease. Here and in extreme cases several inches of bowel may be extruded from the anus, and to an extent scarcely permitting spontaneous or even individual restoration. So complete a form is permitted only by some previous lesion of the pelvic floor, while the mesorectum and even the mesosigmoid become gradually stretched and useless. The lower portion of the rectum is by far the more muscular, and such a condition requires that its intrinsic muscles yield also with those around them.
Prolapse is a condition of general and usually slow development rather than of abrupt onset. It is made known by the presentation at the anus of the bright-red mucosa of the rectum, where it pouts and protrudes, forming a tumor of varying size, with more or less tender surface, which, with gentle coaxing pressure, is easily made to return within the rectum. It can usually be made to appear by straining effort on the part of the patient. Boys with phimosis, who are in consequence made to strain every time they urinate, will frequently present minor degrees of the condition, perhaps oftener than when the rectum itself is at fault, as the act is so frequently repeated. The oftener such protrusion occurs the more relaxed becomes the anus and the more irritated the presenting surface, until ulceration and even keratosis may result. Chronic constipation of children or adults will also produce the same effect. The presence of hemorrhoidal tumors or of polypi, or even of parasites, causes the same result.
The most pronounced and complete types of invagination produce a condition in which reduction is perhaps not possible and procidentia is constant. There may form here a pouch around the rectum, containing loops of bowel, bladder, or ovary, or there may even occur a perirectal hernia.
While patients nearly always become more or less accustomed to the condition it nevertheless is distressing in proportion to its size and the individual’s temperament.
Treatment.
—Treatment depends entirely upon the nature and extent of the condition. Mild forms occurring in young children may be easily obviated by attention to their stools, by circumcision if needed, or by the use of a five-grain capsule of ergotin inserted as a suppository, it having the effect of invigorating the involuntary muscle and stimulating the sphincter. Cases not amenable to the milder methods become surgical and the treatment is then apportioned to the extent of the lesion. If connected with hemorrhoids or other tumors it becomes a part of their treatment and is to be dealt with at the same time. Occurring apparently independently the milder forms will often yield to the proper use of caustics. The actual cautery being preferable, it is applied in streaks up and around the rectum, in such a way that, when the ulcers thus formed cicatrize, the rectum shall be shortened by cicatricial contraction as by a series of loops drawn up to shorten it. When permitted by rupture of the perineum and more or less combined perhaps with cystocele, repair of the perineum, rather than attention to the rectal condition itself, will be demanded, while the latter may be combined with an operation for rectocele by excision of an elliptical portion of the vaginal mucosa and the approximation of its edges into a line of sutures. This will reduce the capacity of both the vagina and the rectum and a double indication be thus met. Acute inflammation sometimes follows exposure of a prolapsed rectum and it may slough, thus leading to spontaneous recovery, the process not being without its dangers of thrombosis and septic infection. This procedure may be imitated by a surgical excision of the entire prolapsed portion, always with great caution so that if peritoneal surfaces be exposed they be protected from infection. It has been possible in many instances to completely excise the protruding portion, and then to apply a double row of sutures similar to those used in intestinal resection, only with attention first to the peritoneal rather than the mucous surface, in such a way as to excise several inches of the prolapsed bowel and thus meet the indication. Nevertheless cases where this can be done are exceptional.
Pratt has suggested a temporary purse-string suture of the anus, effected by a curved needle, completely circumscribing the anal opening, but kept between the skin and the mucous membrane, to be brought out through the same puncture at which it was inserted. The finger of an assistant being passed into the anus, the suture is now tied around it. This may be used as supplementary to linear cauterization above mentioned.
Numerous methods of proctopexy, or elevation and fixation, have been devised. Fowler, for instance, made an incision half-way between the anus and the point of the coccyx, and after separating the rectum from the latter and the sacrum inserted two fingers in the rectum, holding it up while its posterior wall was forced into the external wound and there held by heavy sutures of kangaroo tendon. By further incision he brought out the ends of these sutures on each side of the coccyx and tied them across the bone, thus by traction bringing the rectum up into position.
Colopexy has been practised as a more radical measure for the same purpose. As advised by Bryant the abdomen is opened by an incision parallel to Poupart’s ligament on the left side and one inch above it, and the prolapse is reduced by firmly pulling the rectum upward. It is then secured to the peritoneum about it, and is held by quilting sutures, which include the entire muscular coat of the bowel. Save in exceptionally favorable cases one or the other of these methods may be considered preferable to the complete amputation above described.