34 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 CHARLES N. HEADRICK M I C H A E L J . S TA M O S A lthough disparate topics, these two different pathologic entities are commonly misdiagnosed by both layperson and physician alike. The inclusion of both topics in a single chapter allows us to examine their similarities and emphasize their differences. In the process, we hope to clarify common misconceptions regarding these anal/rectal disorders. We think you will see there is no one common profile particular to either diagnosis. CASE 1 RECTAL PROLAPSE A 33-year-old white female, who was gravida 0, para 0, presented with a chronic history of constipation and straining. She also gave a history of bright red blood per rectum and passage of mucus and “tissue” with each bowel movement. She denied any rectal pain. The prolapsed tissue reduced spontaneously at the completion of each bowel movement. She described these symptoms as lasting for the previous 4 months. She gave no history of any anal intercourse, trauma, or other significant past medical history. There had been no previous anorectal or abdominal surgery and she had no significant family history. Social history revealed that she did not smoke and was unmarried. Questions regarding her bowel habits revealed that she moved her bowels, at best, every other day, and occasionally every 3 days. There had been no history of laxative use in the past. Physical examination revealed a healthy appearing young female. Her abdominal examination revealed a thin, scaphoid abdomen. Examination of the perianus revealed some slight effacement of the anus. There was normal cutaneous sensation, somewhat diminished spinchter tone, and a good voluntary squeeze. There were no intra-anal masses. Anoscopy revealed prominent rectal mucosal folds with small internal hemorrhoids. These were moderately erythematous and with occasional superficial ulceration. Flexible sigmoidoscopy revealed a large rectal vault with moderate inflammation extending to the mid-rectum. She was also noted to have a redundant sigmoid colon. The remainder of her examination was normal. The patient was asked to reproduce her symptoms by sitting on the toilet and straining. The result revealed a 3to 5-cm circumferential prolapse that demonstrated circular, concentric folds consistent with rectal prolapse, or procidentia. The prolapse reduced spontaneously. At the end of her consultation, the patient was counseled regarding her diagnosis. She was advised to increase the fiber in her diet and to take bulk fiber agents. A barium enema was ordered to evaluate the remainder of the 245 2 4 6 C O L O N , R E C T U M , A N D A N U S colon. The air contrast enema revealed a normal mucosal outline without diverticula and a very redundant sigmoid colon. Subsequently, her bowel regimen improved to one bowel movement a day with only occasional straining during defecation. She continued to prolapse, however, with each bowel movement. Surgery was indicated because of her continued symptoms and the risk of sphincter damage. An abdominal approach was recommended as her best option. She underwent laparotomy, sigmoid resection, low rectal dissection, and rectopexy. Her postoperative recovery was uneventful. CASE 2 RECTAL PROLAPSE IN AN ELDERLY PATIENT A 79-year-old white female who was gravida 4, para 4, presented with a history of constipation, stating that her rectum “falls out.” She had a long history of taking laxative products (senna, herbal tea, cascara, and magnesium products). She was especially concerned because she sometimes moved her bowels without warning and soiled her undergarments. Other pertinent history revealed that she had coronary artery disease and medically controlled hypertension. She had previously undergone an abdominal hysterectomy and oophorectomy as well as an incidental appendectomy. Physical examination revealed a moderately obese white female with lower midline abdominal scars. Rectal examination revealed both hemorrhoidal and rectal prolapse. The prolapse was easily reducible, but came back out 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 undergarments. Preoperative workup included contrast enema and flexible sigmoidoscopy. Anal manometry revealed a low-resting sphincter pressure. The patient was deemed to be at high risk of an abdominal operation, and a perineal approach was recommended. The patient subsequently underwent perineal rectosigmoidectomy under spinal anesthesia. Postoperatively, the patient did well. Her prolapse was cured and she had perceptible improvement in her continence. CASE 3 HEMORRHOIDAL PROLAPSE A 43-year-old Hispanic male with a history of straining and constipation came in complaining of bright red blood per rectum. He denied pain. He was found to have prolapse revealing radial folds (hemorrhoidal prolapse) and anemia of 8 g Hb. Preoperative workup included a colonoscopy, which was normal, followed by surgical hemorrhoidectomy. CASE 4 THROMBOSED EXTERNAL HEMORRHOID A 25-year-old male came in complaining of anal swelling and a sudden onset of pain. The patient recently had severe gastroenteritis with diarrhea. Physical examination revealed a thrombosed external hemorrhoid. Treatment consisted of excision in the office under local anesthesia. H GENERAL CONSIDERATIONS emorrhoidal disease is very common. The number of over-the-counter remedies available is proof enough. Hemorrhoids are actually present in every person and have a normal physiologic function. They cushion the fecal bolus as it is expelled from the rectal reservoir and contribute to normal continence. Poor diet and hygiene, increases in intra-abdominal pressure, and family history may contribute to the development of abnormal hemorrhoids, which usually manifest as enlargement and/or inflammation. Hemorrhoids are classified as internal or external, based on their relationship to the dentate line. Distal to this junction of mucous membrane and anoderm there is normal somatic sensation. Proximal to this line, there is a transitional zone, measuring from 1 to 1.5 cm, in which sensation is lessened as the somatic sensory apparatus is diminished. It is in this zone, proximal to the dentate line, where internal hemorrhoids reside (Fig. 34.1). Symptomatic internal hemorrhoids may cause discomfort, prolapse, or even hemorrhage without pain to the individual (painless bleeding). External hemorrhoids rarely bleed, but may cause significant pain (Case 4) associated with thrombosis. Hemorrhoids may also bridge this anatomic boundary (mixed type) (Fig. 34.2). Hemorrhoids have no sexual predilection, and span the range of ages. Certain conditions may predispose toward the formation of hemorrhoids: constipation, chronic diarrhea, and pregnancy. The most common causes of constipation are inadequate fluid intake, poor diet (low fiber intake), and infrequent exercise. There are also a number of medications that can cause constipation (calcium channel blockers, tricyclic antidepressants, diuretics). Hemorrhoidal prolapse constitutes a special situation in hemorrhoidal disease. The tissue has enlarged enough to be partially expelled during defecation. A grading system is used to describe enlarged internal hemorrhoids: (1) grade I—enlarged hemorrhoidal tissue, (2) grade II— hemorrhoidal tissue that prolapses with straining but spontaneously reduces, (3) grade III—hemorrhoidal prolapse that requires manual replacement, and (4) grade IV—unreducible prolapse. Anatomic orientation is also helpful as one person may have coexisting grades of hemorrhoids. Left, right, anterior, posterior, and lateral are the FIGURE 34.1 Internal hemorrhoids, by definition, are lined by mucosa and rise above the dentate line. External hemorrhoids are lined by anoderm (skin). FIGURE 34.2 The hemorrhoidal plexus may engorge and form collaterals to develop into a combined internal/external hemorrhoid. 2 4 8 C O L O N , R E C T U M , A N D A N U S labels used to describe hemorrhoidal location. The typical distribution of hemorrhoids include left lateral, right anterior, and right posterior columns. True rectal prolapse, or procidentia, can be confused with prolapse of hemorrhoids or mucosal prolapse. In true rectal prolapse, there is a full thickness prolapse. The rectum actually turns “inside out,” similar to an intussusception. This situation connotes a loss of pelvic support and carries with it a risk of incontinence (Case 2)—either through stretching of the pudendal nerve or direct physical trauma to the sphincter complex. Unlike hemorrhoidal disease, rectal prolapse is more common in women (Cases 1 and 2) (6:1 female/male) and can occur at any age (even in the newborn). Historically, it was thought to be associated with multiparous, elderly females, but may also occur in a young male or a nulliparous young female (Case 1). Doctors and patients alike may be confused by the symptoms and sensations of this ailment and frequently attribute them to hemorrhoids. K E Y P O I N T S • Hemorrhoids present in every person and have a normal physiologic function • Hemorrhoids classified as internal or external, based on relationship 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 significant pain associated with thrombosis D DIAGNOSIS iagnosis of these anorectal problems is based on a careful history and thorough physical examination. Ancillary tests such as air contrast barium enema and anal manometry may be helpful after the diagnosis is secure. History taking for anal/rectal disorders can be very helpful in making a diagnosis. Particular attention should be directed toward the patient’s diet, bowel habits, and description of any symptoms. This should include the average number of bowel movements per day or week, the presence of straining or any sensation or prolapse, the amount of time spent on the toilet, and the characteristics of any blood found during the movement. Associated abdominal complaints and concurrent usage of medication should also be discussed. Additionally, prior anorectal, abdominal, or pelvic surgery should be detailed, with particular attention given to vaginal childbirth, episiotomies, and/or tears. As with any anal/rectal disorder, the following elements are essential to a good examination: (1) inspection of the perianus, including rudimentary sensory examination, (2) digital examination to evaluate the canal for masses, tenderness, and sphincter tone, (3) anoscopy to examine the anal canal visually, (4) flexible sigmoidoscopy to visually examine the rectum and lower colon, and (5) when prolapse is suspected, visual examination of the anus and perineum during straining, preferably while sitting or squatting. External hemorrhoids are visible on simple inspection, and in the noninflamed state simply may appear as fleshy skin covered protrusions (tags). They may become inflamed and edematous or may thrombose. Thrombosis (usually an acute event brought on by straining, constipation, or diarrhea), is typically very painful (Case 4). A firm tender mass is palpated adjacent to the anal canal. The mass may have a dark, bluish appearance. The overlying skin is usually normal although central ulceration is not uncommon due to pressure necrosis. The tenderness is localized to the thrombosis itself, unlike an abscess. Internal hemorrhoids can only be appreciated adequately by visualization, either by inspection if prolapsed or by anoscopy. Palpation is unreliable in the diagnosis of internal hemorrhdoids. Rectal prolapse can be difficult to diagnose. Even though the patient may report frequent prolapse, reproducing the event in the doctor’s office may be difficult. Frequently, the experience can be embarrassing for the patient and even the physician. Often, the patient can only produce the prolapse while squatting and straining. A bathroom adjacent to the examination room is helpful for this part of the examination. When the prolapse is reproduced, it may protrude 1–2 cm or up to 15–20 cm. Rarely, a patient will present with an incarcerated prolapse, which should be treated as a surgical emergency. Although flexible sigmoidoscopy is usually adequate, a more thorough colonic examination (colonoscopy, air contrast enema) may be helpful. Rarely, a tumor can act as a “bedpost” for intussusception or prolapse. Laboratory studies are not helpful in making the diagnosis, although the presence of anemia should mandate a full colonic evaluation. K E Y P O I N T S • As with any anal/rectal disorder, the following elements are essential to good examination: inspection of perianus, digital examination, anoscopy, and flexible sigmoidoscopy • Internal hemorrhoids can only be appreciated adequately by visualization, either by inspection if prolapsed or by anoscopy T DIFFERENTIAL DIAGNOSIS he main difficulty in diagnosing these conditions is in distinguishing them from one another. True rectal prolapse produces circumferential mucosal folds while hemorrhoidal prolapse yields radial folds (Figs. 34.3 and 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 2 4 9 FIGURE 34.3 True rectal prolapse. Note the circumferential mucosal folds and the sulcus outside the prolapse (fixation of the dentate line). 34.4). Likewise, true rectal prolapse does not include the dentate line, leaving a deep sulcus outside of the prolapsed tissue. Other tumors may also prolapse through the anal canal and be mistaken for hemorrhoids. Rectal polyps, tumors, and hypertrophied anal papillae are the most common. These are readily identified by anoscopy or proctosigmoidoscopy. S TREATMENT uccessful treatment of hemorrhoids requires an accurate diagnosis and elimination of other perianal disease as the cause of the patient’s complaints. Since hemorrhoids are a normal part of human anatomy, they will invariably be present but may not be contributing to the patient’s problems. Indeed, other pathology (e.g., anal fissures, proctitis) frequently will exacerbate existing hemorrhoids. Failure to appreciate and treat the primary disease process will likely lead to failure of therapy. Internal hemorrhoids may be treated medically, with office treatments, or with surgery. The decision rests on the symptomatology and physical examination. For complaints of minor bleeding associated with bowel movements (“outlet bleeding”), dietary counseling and fiber supplementation (psyllium) may be adequate, although flexible sigmoidoscopy is mandatory to eliminate a distal colon or rectal cancer as the possible cause of the bleeding. For prolapse, or bleeding associated with prolapse, additional treatment is required. A variety of office treatments may be used, although sclerotherapy and rubber band ligation are the most commonly employed. All of these office based treatments are “fixation” techniques. They work primarily by creating scar tissue locally that “fixes” the mucosa overlying the hemorrhoid to the underlying internal sphincter muscle. Surgical treatment, including laser treatment, is reserved for more severe disease (Case 3) and for patients with associated external hemorrhoids that are not amenable to office treatment. Laser hemorrhoidectomy is identical to standard surgical hemorrhoidectomy in every parameter studied. Its only apparent advantage is in marketing. The disadvantage is solely in cost. External hemorrhoids may also be treated medically or with surgery. Topically applied creams may help shrink 2 5 0 C O L O N , R E C T U M , A N D A N U S FIGURE 34.4 Hemorrhoidal or mucosal prolapse. Note the radial folds and absence of rectal wall (muscle) within the prolapse. edematous and inflamed tissue, but office surgery is sometimes required to solve an acute painful process such as thrombosis (Case 4). On rare occasions, circumferential thrombosis is best treated in the operating room with anesthetic blockade. As a rule of thumb, it should be remembered that most hemorrhoidal problems can be solved without surgical intervention. Treatment for procidentia, unfortunately, does not enjoy the same success rate as hemorrhoidectomy. Once diagnosed, the solution is surgical, but the choices for repair are numerous. They fall into three basic categories: (1) anal encirclement procedures (Thiersch), (2) perineal approaches (Altmeier or Delorme), and (3) abdominal approaches. Historically, the circlage, or Thiersch procedure, has been around the longest. The prolapse is reduced and maintained by reinforcing the external sphincter mechanism with a permanent material placed outside of the sphincter mechanism and underneath the skin. The recurrence and infection rates are high. It is now reserved for the very infirm. Perineal solutions have enjoyed a resurgence in popularity, particularly among the elderly patient population, since the operation is performed under regional anesthesia. It involves resection or plication of the redundant bowel via the anal canal. Although this does not treat any underlying cause of the problem, the recurrence rate is somewhat lower than an encircling procedure and the operation is quite safe. The abdominal approach has the lowest recurrence rate but also the greatest morbidity. Evaluation of the anatomy is more complete and the operation can be combined with a resection, rectopexy, or very low dissection. Most versions include a very low dissection in order to create a plane of scarring in the retrorectal space. The risks are the same as for low anterior resection. Choice of operation is based on an individual’s activity, experience, and preference of the surgeon. It should be noted that the pathophysiology of procidentia is not completely understood. A weakening of the pelvic floor leads to the intussusception or prolapse, but the role of bowel function and motility is not fully appreciated as a precursor to this event. H E M O R R H O I D S K E Y P O I N T S A N D R E C T A L P R O L A P S E 2 5 1 SUGGESTED READINGS • Successful treatment of hemorrhoids requires accurate diagnosis and elimination of other perianal disease as the cause of patient complaint; since hemorrhoids are normal human anatomy, will invariably be present, but may not be contributing to patient’s problem Corman ML: Rubber band ligation of hemorrhoids. Arch Surg 112:1257, 1977 • Rule of thumb: majority of hemorrhoidal problems can be solved without surgical intervention Huber FT, Stein H, Siewert JR: Functional results after treatment of rectal prolapse with rectopexy and sigmoid resection. World Surg 19:138, 1995. H Simplified technical description of the most common technique used for internal hemorrhoid treatment. Prospective study looking not just at anatomic but also functional results. FOLLOW-UP emorrhoid disease and symptoms tend to recur in time if the inciting cause is not altered. The more conservative the therapy, the more likely the onset of recurrent symptoms. Follow-up should therefore emphasize avoidance of constipation and include dietary counseling. Postoperative follow-up, however, should be done in a rigorous fashion to avoid the preventable complications— stenosis, prolonged pain, and constipative bowel habit. Counseling the patient on high fiber diet, hygiene, and pain control should be done both in the pre- and postoperative phase. Postoperative examinations should be done every 2 weeks until adequate healing has taken place to avoid postoperative stricture and stenosis. This may last up to 12 weeks. Additional informational exchanges can also take place on the telephone to eliminate anxiety and answer simple questions. Rectal prolapse operations all carry a significant incidence of recurrence, perineal operations more so than abdominal operations. Although the exact cause of prolapse is unknown, avoidance of constipation and straining is felt to be important. Fecal incontinence is common in patients with prolapse (Case 2), and improvement is seen in approximately 50% of patients following operation. However, optimal function may take up to 6 months to achieve. Loder KM, Kamm MA, Nicholls RJ, Phillips RKS: Hemorrhoids: pathology, pathophysiology and aetiology. Br J Surg 81:946, 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.)