Update Course Rewind: 2020 Colorectal Part 2

Rectal prolapse is a relatively unusual problem in pediatric surgery.

Children develop rectal prolapse because of their anatomy: they have a very weak pelvic floor and the rectum is very low, so it tends to pop out easily if they strain hard enough.

Conservative treatment includes managing constipation, teaching proper toilet sitting with a smaller seat so children don't fall through, providing a step for proper upright posture, and limiting time on the toilet without distractions like iPads.

Sclerotherapy has a low threshold for use because it is simple, innocuous, and can provide a window of a couple months without prolapse that allows younger children to see less frequent episodes.

Dr. Sean St. Peter's sclerotherapy technique uses 5 ccs of Sotradechol injected in 4 quadrants with any remaining volume injected in between.

A systematic review in the Journal of Pediatric Surgery included 27 publications with 900 patients: 300 underwent sclerotherapy (8 studies, 3 sclerosing agents) and 600 underwent operative management (22 studies, 17 different procedures).

The large number of different operative procedures (17 procedures across studies) indicates uncertainty about which is the best procedure for rectal prolapse.

Transabdominal procedures have a pretty high success rate for correcting rectal prolapse based on published data.

Alcohol as a sclerosing agent is probably really easy to obtain in the hospital setting.

The complication rate of sclerotherapy is mostly negligible, complications are acute, and there is minimal risk of long-term problems.

Patients with rectal prolapse should be evaluated to rule out underlying diseases, especially cystic fibrosis.

Some patients with rectal prolapse and anxiety develop a feedback loop where prolapse becomes an emotional release mechanism for evacuating stool.

Pelvic floor therapy is useful in strengthening pelvic floor musculature and, when combined with sclerotherapy and support for anxiety, leads to more durable outcomes.