A 3 year old previously presents to the ED with the chief complaint of “purple donut coming out of his butt” – seriously. It happened after he was going to the potty. The parents are understandably freaked out, and the child initially appeared mildly uncomfortable – but now is acting normally. His past history is unremarkable aside from constipation. He strains to have bowel movements and sometimes goes 3-4 days without pooping. Otherwise his growth and development have been normal. On exam he is well hydrated with normal heart and lungs, and no abdominal tenderness or masses. His rectal exam is normal.
What happened?
This is a case of rectal prolapse
Why is his exam now normal?
The prolapse spontaneously reduced when he calmed down
OK, so you haven’t shown a picture yet, but what does it look like?
You can click on the image here to get a look at what a typical case of pediatric rectal prolapse looks like. Trust me when I say the Google image search rabbit hole goes really deep…
Background
Rectal prolapse occurs when some or all of the rectal mucosa extrudes through the external anal sphincter. There is an equal male/female prevalence and it most often occurs in the first 4 years of life, with the peak age approximately at age 1 year. It is rare in children without predisposing factors, which we’ll get to in a moment. There are 2 types – Type I which is mucosae only, and Type II involves the full thickness of the muscular rectal wall. Type I is much more common. In general it is thought that increased sigmoid mobility, lower levator ani tone, and absence of the valves of Houston (seen in 3/4 children <12 months) contribute to the increased incidence in early childhood. It is felt to occur as a result of intussusception of the upper rectum and rectosigmoid colon. It can occur again if the underlying cause is not addressed. The overall prognosis is good, and 90% of children that prolapse between age 6 months and 3 years and receive proper treatment have no longterm problems. Though prolapse can recur it rarely does so after age 6 years. Cases presenting after age 4 years usually occur in association with neurologic or musculoskeletal defects and are much more likely to benefit from surgery.
Risk Factors
A retrospective review of over 4 dozen children found that prolapse was secondary to chronic constipation in 28 percent, diarrheal disease in 20%, CF in 11% in 11 percent, and to neurologic or anatomic conditions in 24%. The other 17% have no easily identifiable cause. Other risks may include conditions that predispose to increased intraabdominal pressure such as protracted coughing (eg, pertussis), excessive vomiting, and straining with urination (eg, phimosis). One-fourth of CF patients may have rectal prolapse. Before newborn screening rectal prolapse often lead to a CF diagnosis. Nevertheless, it is reasonable to pursue outpatient workup for CF if there are concerns, as newborn screening may not pick up all genotypes, or if the child was not born in the US. Children with CF who are on pancreatic enzymes have a lower incidence of prolapse. Though it is often a concern of parents on history rectal prolapse is not immediately suggestive of sexual abuse – though history should include discussion about risk factors nevertheless. In the developing world malnutrition is the most cited cause, perhaps secondary to the mucosal edema brought on by hypoproteinemia and increased incidence of diarrheal illnesses.
Clinical Presentation
The diagnosis is pretty obvious if the rectal tissue is still prolapsed. and the mom’s description from above is pretty apt based on my experience in the ED. This dark red/purple mass may or may not bleed. Though the child may be frightened, the prolapsed tissue itself is not painful. It is important to palpate the tissue to check for muscular rings. The DDx includes ileocecal intussusception (currant jelly stools), prolapsed rectal polyp and rectal hemorrhoids.
Treatment
Always evaluate and treat the likely cause if the tissue has spontaneously reduced. Miralax is great for constipation, Pulmonologists are great for CF. If it is still “out” then manual reduction will need to be attempted. You will need gloves, lubricant, gauze, and tape and perhaps sedation and/or analgesia depending on the age of the child. I think that PO versed is a great PO reduction agent. Here are the steps:
- Place the child prone in the knee-chest position on the examination table or the parent’s lap.
- Lubricate your gloves
- Apply gentle, firm, consistent pressure to the prolapsed mucosa. I place hands at the 3 and 9 o’clock positions. Some experts note that a finger placed in the rectum may aid in reduction.
- Continue applying pressure for 5-15 minutes – at which point most should reduce
- Do a digital rectal exam afterwards to assure that your reduction was successful
- If the rectal tissue prolapses on its own quickly, apply a pressure dressing by placing lubricated gauze over the anus, and taping it in place, then taping the buttocks together for several hours (at least 2-3). This may need to be done while the child is observed in the ED.
- It is is very large and/or hard to reduce you can apply table sugar to draw fluid out of the mucosal tissue osmotically – or consult a pediatric surgeon, as reduction under anesthesia may be necessary
After successful reduction you can teach parents how to perform reduction at home. Surgical options have been explored for recurrent cases, but non have been proven to be superior. Local pain and mucosal bleeding are the most common complications in cases that reduce spontaneously or that are manually reduced. Prolonged exposure to the air and/or failure to reduce can lead to ulceration, venous obstruction, and thrombosis.
