Update Course Rewind: 2020 Colorectal Part 2

Published: 2021-03-24

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Rod — host
Eunice Huang — guest
Beth Remey — guest
Sean St. Peter — guest

Chapters

0:01Introduction and First Case Presentation — Introduction to the update course rewind format and presentation of a 3.5-year-old with episodic rectal prolapse requiring manual reduction in the emergency room.
2:26Conservative Management Basics — Review of anatomical factors in pediatric rectal prolapse, differential diagnosis, and initial conservative management including constipation treatment and proper toileting technique.
3:51Sclerotherapy as First-Line Surgical Option — Discussion of sclerotherapy technique and indications for patients failing conservative management, including specific injection protocol.
5:10Systematic Review Evidence and Treatment Algorithm — Review of two Journal of Pediatric Surgery publications examining sclerotherapy agents and operative procedures, leading to a recommended treatment algorithm with ethyl alcohol sclerotherapy followed by laparoscopic rectopexy.
8:36Multidisciplinary Approach and Psychological Factors — Case presentation highlighting the role of behavioral therapy, pelvic floor physical therapy, and addressing anxiety/depression in patients with rectal prolapse, followed by closing remarks.

Key claims

2:26Majority of pediatric rectal prolapse cases do not need surgery — Rod
2:33Most common reasons for rectal prolapse are constipation, sitting on the potty too long, or sitting on it incorrectly — Rod
2:44Rectal prolapse happens in kids because they have a very weak pelvic floor and the rectum is very low, so it tends to pop out easily if you strain hard enough — Eunice Huang
2:55Physical exam must distinguish rectal prolapse from intussusception, polyps, and rectal hemorrhoids — Rod
3:13Treatment includes managing constipation, teaching appropriate sitting on the potty with a smaller seat and step stool, and limiting time on toilet — Eunice Huang
3:39Parents should be taught how to safely reduce a prolapse to avoid incarceration — Rod
4:11Sclerotherapy is simple, innocuous, and can provide a window of a couple months without prolapse that helps younger kids see it less frequently — Sean St. Peter
4:30Sclerotherapy protocol uses 5 ccs of Sotradechol injected in 4 quadrants — Sean St. Peter
5:10A systematic review included 27 publications with 900 patients: 300 underwent sclerotherapy (8 studies, 3 sclerosing agents) and 600 underwent operative management (22 studies, 17 procedures) — Eunice Huang
5:46The large volume of different operative procedures indicates uncertainty about which is the best procedure for rectal prolapse — Eunice Huang
5:56Transabdominal procedures have a pretty high success rate for correcting prolapse — Eunice Huang
6:51The most popular sclerosing agent is alcohol and it is pretty effective — Rod
7:04Alcohol is easy to obtain in the hospital setting — Rod
7:14Complication rate with sclerotherapy is mostly negligible, complications are acute, and there is minimal risk of long-term problems — Eunice Huang
7:41Underlying diseases, especially cystic fibrosis, should be ruled out in patients with rectal prolapse — Eunice Huang
7:51Small children in the potty training phase should receive appropriate medical management and constipation treatment — Eunice Huang
8:04If conservative management fails, sclerotherapy with ethyl alcohol is the recommended first option — Rod
8:11Sclerotherapy can be done up to 3 times with an estimated cumulative success rate of a little bit over 80% — Rod
8:12If sclerotherapy fails, laparoscopic rectopexy is the recommended operative approach because it has the lowest complication rate and highest success rate — Rod
9:34Patients with rectal prolapse may have anxiety that creates a feedback loop where prolapse becomes an emotional release for evacuating stool — Eunice Huang
9:34Pelvic floor therapy is useful in strengthening pelvic floor musculature and leads to more durable outcomes after sclerotherapy — Eunice Huang
9:20Patients with rectal prolapse may necessitate a multidisciplinary team approach including behavioral therapy and physical therapy — Rod

Cases discussed

1:123.5-year-old male with episodic rectal prolapse
4:0110-year-old female with chronic recurrent rectal prolapse despite medical therapy
8:4212-year-old male with rectal prolapse and psychiatric comorbidities

Open questions

Which specific operative procedure is best for pediatric rectal prolapse when sclerotherapy fails?
What is the optimal number of sclerotherapy attempts before proceeding to operative management?
How should behavioral therapy and pelvic floor therapy be integrated into the treatment algorithm for patients with anxiety or depression?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Pediatric Rectal Prolapse: When Conservative Management Fails and What Comes Next

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Exists as a Distinct Problem

Rectal prolapse in children is not simply a smaller version of the adult disease. The anatomy is fundamentally different: children have a weak pelvic floor and a low-lying rectum, making the tissue prone to prolapse with any significant straining 2:44. Most cases resolve with behavioral modification and constipation management, but a subset of patients — those who fail conservative therapy despite appropriate medical treatment — present a genuine clinical dilemma. As one discussant put it, the available options are limited and the situation is distressing to families [q2]. The challenge is knowing when to escalate and which intervention to choose from a bewildering array of published techniques.

The Core Clinical Problem

The typical patient is a young child, often in the potty-training phase, who experiences episodic full-thickness rectal prolapse requiring manual reduction 2:33. The most common drivers are constipation, prolonged toilet sitting, or improper positioning on an adult-sized toilet 2:33. But a minority continue to prolapse despite addressing these factors. The question becomes: when does this warrant procedural intervention, and what should that intervention be?

Before escalating, the differential must be confirmed. Physical exam should distinguish true rectal prolapse from intussusception, polyps, and rectal hemorrhoids 2:55. Underlying systemic disease — particularly cystic fibrosis — must be ruled out 7:41.

How Conservative Management Works

First-line treatment targets the mechanical and behavioral factors. Constipation management is foundational 3:13 7:51. Proper toileting technique matters: a smaller toilet seat prevents the child from falling through, a step stool ensures upright positioning, and time on the toilet should be limited — no iPad for half an hour of straining 3:13. Parents should be taught how to safely reduce a prolapse at home to avoid incarceration 3:39. For many children, this is sufficient. The majority of pediatric rectal prolapse cases do not require surgery 2:26.

When Conservative Management Fails: The Evidence Base

For patients who fail conservative therapy, the literature offers little consensus. A systematic review of 27 publications encompassing 900 patients found that 600 underwent operative management across 22 studies describing 17 different procedures 5:10. As one discussant noted, "anytime you see that large volume of procedures, you know that we're not exactly sure which is the best procedure" [q6]. Transabdominal procedures show high success rates for correcting prolapse 5:56, but the heterogeneity of approaches reflects genuine uncertainty.

Sclerotherapy occupies a middle ground. The same systematic review included 300 patients treated with sclerotherapy across 8 studies using 3 sclerosing agents 5:10. A focused review of sclerotherapy publications identified ethyl alcohol as the most popular agent, and it is effective 6:51 7:04. The appeal is practical: sclerotherapy is simple, the complication rate is mostly negligible, complications are acute rather than chronic, and there is minimal risk of long-term problems 7:14.

The Recommended Algorithm

Based on the available evidence, the discussants propose a stepwise approach. After ruling out underlying disease and confirming the diagnosis, small children in the potty-training phase should receive appropriate medical management and constipation treatment 7:41 7:51. If conservative management fails, sclerotherapy with ethyl alcohol is the recommended first option 8:04. The technique described uses 5 ccs of Sotradechol injected in 4 quadrants 4:30. Sclerotherapy can be repeated up to 3 times, with an estimated cumulative success rate slightly over 80% 8:11.

One discussant described a low threshold for sclerotherapy in younger children: the procedure is simple and innocuous, and sometimes patients just need a window of time without prolapse to break the cycle [q4][q5] 4:11. If sclerotherapy fails after three attempts, laparoscopic rectopexy is the recommended operative approach because it has the lowest complication rate and highest success rate 8:12.

The Multidisciplinary Dimension

A subset of patients have psychological and behavioral factors that perpetuate the prolapse. One discussant described patients in whom anxiety creates a feedback loop: prolapse becomes an emotional release mechanism for evacuating stool 9:34. In these cases, pelvic floor physical therapy is useful for strengthening musculature and leads to more durable outcomes after sclerotherapy 9:34. Behavioral therapy may be necessary to address the underlying anxiety. These patients may require a multidisciplinary team approach including both behavioral therapy and physical therapy 9:20.

When to Involve Pediatric Surgery

Refer when conservative management — constipation treatment, proper toileting technique, and behavioral modification — has been optimized and the patient continues to prolapse. The timing matters: early referral allows sclerotherapy to be offered before the family and child become demoralized by repeated emergency room visits for manual reduction. If the patient has underlying systemic disease, particularly cystic fibrosis, involve surgery early in the diagnostic workup 7:41. If there is diagnostic uncertainty — distinguishing prolapse from intussusception or polyps — refer for examination under anesthesia if needed 2:55.

Takeaways from this story

Ethyl alcohol sclerotherapy (up to 3 attempts, >80% cumulative success) is first-line intervention after conservative management fails.
Laparoscopic rectopexy has the lowest complication rate and highest success rate when sclerotherapy fails.
Pelvic floor physical therapy strengthens musculature and improves durability of sclerotherapy outcomes.
Rule out cystic fibrosis in all pediatric rectal prolapse patients before escalating treatment.

Pediatric Rectal Prolapse: From Potty Training to Sclerotherapy

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · Teaching arc · AI-written, human-reviewed

Anatomy explains the vulnerability

Pediatric rectal prolapse is fundamentally an anatomical problem. Children have a very weak pelvic floor and the rectum sits very low, making it prone to prolapse with straining 2:44. This is not a structural defect requiring urgent correction — it is a developmental stage that most children outgrow. The clinical challenge is managing the distress it causes families while the pelvic floor matures.

Conservative management targets the mechanics of straining

Most cases resolve with attention to toileting mechanics and constipation 2:26. Treatment includes managing constipation, teaching appropriate sitting on the potty with a smaller seat and step stool, and limiting time on the toilet 3:13. The seat must be small enough that the child does not fall through; the stool positions them upright rather than dangling; the time limit prevents prolonged straining 3:13. Parents should be taught how to safely reduce a prolapse to avoid incarceration 3:39. These are not minor adjustments — they address the mechanical forces that produce prolapse in an anatomically vulnerable child.

Sclerotherapy buys time for maturation

When conservative measures fail, sclerotherapy offers a low-risk intervention that can break the cycle. The protocol uses 5 ccs of Sotradechol injected in 4 quadrants 4:30, though alcohol is the most popular sclerosing agent and is easy to obtain in the hospital setting 6:51. The value is not permanent cure but a window of months without prolapse, particularly in younger children 4:11. Sclerotherapy can be repeated up to 3 times with an estimated cumulative success rate of a little bit over 80% 8:11. The complication rate is mostly negligible, complications are acute, and there is minimal risk of long-term problems 7:14. This risk profile makes it the appropriate first procedural step.

Surgical heterogeneity signals clinical uncertainty

A systematic review included 27 publications with 900 patients: 300 underwent sclerotherapy (8 studies, 3 sclerosing agents) and 600 underwent operative management (22 studies, 17 procedures) 5:10. The large volume of different operative procedures indicates uncertainty about which is the best procedure for rectal prolapse 5:46. When the literature offers 17 different operations, you are not choosing between good and better — you are navigating genuine equipoise. Transabdominal procedures have a pretty high success rate for correcting prolapse 5:56, and if sclerotherapy fails, laparoscopic rectopexy is the recommended operative approach because it has the lowest complication rate and highest success rate 8:12.

Psychological factors require multidisciplinary thinking

Some patients develop a feedback loop where prolapse becomes an emotional release for evacuating stool 9:34. Anxiety drives straining, straining produces prolapse, and prolapse becomes the mechanism by which the child relieves both physical and emotional pressure. Pelvic floor therapy is useful in strengthening pelvic floor musculature and leads to more durable outcomes after sclerotherapy 9:34. These patients may necessitate a multidisciplinary team approach including behavioral therapy and physical therapy 9:20. Treating the prolapse without addressing the anxiety that perpetuates it produces only temporary relief.

The algorithm starts with exclusion

Underlying diseases, especially cystic fibrosis, should be ruled out in patients with rectal prolapse 7:41. Small children in the potty training phase should receive appropriate medical management and constipation treatment 7:51. If conservative management fails, sclerotherapy with ethyl alcohol is the recommended first option 8:04. The physical exam must distinguish rectal prolapse from intussusception, polyps, and rectal hemorrhoids 2:55 — treating the wrong diagnosis is worse than delaying treatment of the right one. The most common reasons for rectal prolapse are constipation, sitting on the potty too long, or sitting on it incorrectly 2:33, and these should be addressed before any procedural intervention.

Takeaways from this story

Proper toileting setup—smaller seat, step stool, time limits—addresses the mechanical forces producing prolapse in anatomically vulnerable children.
Sclerotherapy with alcohol can be repeated up to 3 times with cumulative success over 80% and minimal long-term complication risk.
When systematic reviews show 17 different procedures across 22 studies, you're navigating equipoise, not choosing between established best practices.
Anxiety can create a feedback loop where prolapse becomes an emotional release mechanism, requiring behavioral therapy alongside procedural treatment.

Pediatric Rectal Prolapse: From Operative Urgency to Staged Minimalism

How thinking and practice on this topic have changed over time, as told in this episode. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · How the thinking changed · AI-written, human-reviewed

The former surgical reflex

Rectal prolapse in children once drove a direct path to the operating room. The distress was visible — parents watching their child's rectum externalize, emergency room visits for manual reduction, the social disruption of an unpredictable anatomical event. The surgical literature reflected the urgency: 17 different operative procedures across 22 studies, a proliferation that itself signals uncertainty 5:10. Transabdominal approaches carried high success rates for correcting the prolapse 5:56, and when a problem presents dramatically, the impulse to fix it definitively is reasonable. The thinking was straightforward: if the anatomy fails, repair the anatomy.

What shifted the calculus

Two publications in the Journal of Pediatric Surgery reframed the problem by systematically reviewing outcomes across the treatment spectrum. The first examined 900 patients: 300 treated with sclerotherapy across 8 studies using only 3 agents, versus 600 undergoing operative management across 22 studies employing 17 different procedures 5:10. That disparity — three sclerosing agents versus seventeen operations — made the uncertainty explicit 5:46. The second publication isolated sclerotherapy outcomes and found ethyl alcohol both effective and widely available 6:51 7:04. More importantly, it documented that sclerotherapy complications were acute, negligible, and carried minimal long-term risk 7:14. The evidence didn't prove sclerotherapy superior; it proved surgery was being used where a lower-stakes intervention could buy time.

The anatomical insight mattered too. Pediatric rectal prolapse occurs because children have weak pelvic floors and a low-lying rectum that externalizes easily under strain 2:44. This is not structural failure requiring reconstruction — it is developmental immaturity that resolves as the pelvis matures. Constipation, prolonged toilet sitting, and improper positioning create the mechanical conditions for prolapse 2:33 3:13. Addressing those factors became the foundation, not an afterthought.

Current practice architecture

The algorithm now runs through escalating tiers, each with a defined failure threshold. First: rule out cystic fibrosis and other underlying disease 7:41. Confirm the diagnosis — distinguish prolapse from intussusception, polyps, hemorrhoids 2:55. For young children in the potty-training phase, medical management of constipation and proper toileting technique (smaller seat, step stool, time limits) constitute first-line treatment 3:13 7:51. Parents learn to reduce prolapse safely to prevent incarceration 3:39.

When conservative management fails, sclerotherapy with ethyl alcohol is the recommended first intervention 8:04. The protocol: 5 cc of sotradecol injected in four quadrants 4:30. It can be repeated up to three times with a cumulative success rate just over 80% 8:11. The rationale is not that sclerotherapy cures the problem permanently, but that it provides a window — often a few months — during which younger children experience fewer episodes and the feedback loop of anxiety and straining can be interrupted 4:11. Only after sclerotherapy fails does the algorithm advance to laparoscopic rectopexy, chosen for its lowest complication rate and highest success rate among operative options 8:12.

What remains contested

The multidisciplinary layer is still being defined. Some patients develop a psychological feedback loop: anxiety triggers straining, prolapse becomes an emotional release mechanism for stool evacuation, and the cycle reinforces itself 9:34. Pelvic floor physical therapy strengthens musculature and appears to make sclerotherapy outcomes more durable 9:34, but the evidence base for when to deploy behavioral therapy, how to identify the subset of patients who need it, and which interventions work remains thin 9:20. The algorithm addresses anatomy and mechanics cleanly; it addresses the psychological component only by acknowledging it exists.

The other unresolved question is operative timing. Sclerotherapy can be repeated three times, but no consensus defines when persistence becomes futility. Some surgeons have a low threshold for starting sclerotherapy early, viewing it as innocuous and potentially head-starting resolution in younger children 4:11. Others may see three failed sclerotherapy attempts as prolonging a problem that rectopexy would resolve definitively. The 17 operative procedures in the literature suggest that even among surgeons committed to operating, no single technique has emerged as standard 5:10 5:46. Laparoscopic rectopexy is recommended now, but the recommendation rests on comparative complication rates, not on long-term durability data that would settle whether earlier operation prevents years of conservative management.

The shift is from viewing rectal prolapse as a structural defect requiring surgical correction to viewing it as a developmental and behavioral problem where surgery is the last resort, not the definitive answer. The former approach was not wrong — it reflected the tools and framing available. The current approach reflects better evidence about what low-risk interventions can accomplish and clearer recognition that time and maturation solve many cases surgery would not.

Takeaways from this story

Sclerotherapy with ethyl alcohol (up to 3 attempts, >80% cumulative success) now precedes operative intervention for failed conservative management.
The 17 different operative procedures across 22 studies signal ongoing uncertainty about which operation is optimal for pediatric rectal prolapse.
Sclerotherapy complications are acute and negligible with minimal long-term risk, unlike operative approaches.
Pelvic floor physical therapy may improve sclerotherapy durability, but the role of behavioral intervention remains incompletely defined.

Topic overview

A pediatric surgery discussion reviewing management of rectal prolapse in children, covering both medical and surgical approaches. The speakers present a treatment algorithm starting with conservative management (constipation treatment, proper toileting technique), progressing to sclerotherapy with ethyl alcohol (up to 3 attempts, ~80% cumulative success), and finally laparoscopic rectopexy for refractory cases. The discussion emphasizes the importance of ruling out underlying conditions like cystic fibrosis and highlights the potential need for multidisciplinary care including behavioral therapy and pelvic floor physical therapy, particularly in patients with anxiety or depression.

Key takeaways

Most pediatric rectal prolapse resolves with constipation management and proper toileting technique; surgery rarely needed. (2:26)
Ethyl alcohol sclerotherapy (up to 3 attempts) achieves >80% cumulative success with minimal complications. (6:51)
Laparoscopic rectopexy is preferred operative approach after failed sclerotherapy due to highest success and lowest complications. (8:12)
Rule out cystic fibrosis and other underlying conditions in all pediatric rectal prolapse cases. (7:41)
Multidisciplinary care including pelvic floor PT and behavioral therapy improves outcomes, especially with anxiety component. (9:20)

Keywords

rectal prolapse Hirschsprung disease constipation intussusception rectal hemorrhoids cystic fibrosis depression anxiety sclerotherapy laparoscopic rectopexy manual reduction pelvic floor therapy Sotradechol ethyl alcohol Children's Hospital at Vanderbilt

Hashtags

#PediatricSurgery #RectalProlapse #ColorectalSurgery #PediatricGastroenterology

Transcript

Click "Show Transcript" to view the full text (9901 characters)

Hey there, listeners. Did you miss our annual pediatric surgery update course? It's a virtual conference that we put on every year to talk about groundbreaking research, practice changing articles, guidelines. Well, don't worry, because you can watch it on our website, or You can listen to this podcast where I'm gonna break down our favorite sessions from years past. And we've got a lot of content that we can bring to you. So, enjoy what we're gonna call our update course, rewind. If you listened to last week's episode, Doctor Megan Durham talked us through a couple of interesting cases of Hirschsprung disease. Well, for this week, we're gonna talk about something else, rectal prolapse. So, I'm gonna talk a little bit about rectal prolapse. This is a relatively unusual problem, but we recently had two systematic reviews that came out. That's Doctor Eunice Huang from Children's Hospital at Vanderbilt. 3.5 year old male presents with episodic rectal prolapse, has had Several episodes of circumferential prolapse, um, that spontaneously reduced, but then recently the prolapse required manual reduction in the emergency room, which was what prompted the mother to seek further evaluation. So, think to yourself, how would you manage this patient? I think this is like a nightmare in clinic, honestly, this is the patient that no one wants to see, right? I mean, rectal prolapses. I it's very distressing to the patient and the family, and we don't really have a lot of, of great options. That's Doctor Beth Remey from Cincinnati Children's Hospital. If it's a patient that I've never met before, I typically will address, you know, concerns about the constipation first and sort of prove or disprove whether or not this patient is significantly constipated. Um, I think if they are constipated, that's like the easier patient to deal with, but every once in a while, you get a kid who is well managed on whatever their regimen is, and they're still prolapsing, and then I think the question is, what do you do? Well, first, let's go back and review some basics about rectal prolapse. So remember that by and large, majority of these do not need surgery, and similar to adults. The most common reasons are going to be things like constipation or sitting on the potty too long or sitting on it incorrectly. But there is a difference with kids. It, it happens in kids because of the anatomy of children. They have a very weak pelvic floor and the rectum is very low and so it tends to pop out easily if you strain hard enough. Now the physical exam is key here because you really want to make sure you distinguish. A rectal prolapse versus an intestusoception versus polyps, versus rectal hemorrhoids. And then, for most of these patients, your treatment is probably gonna be about the same. If you treat their constipation and teach them how to sit appropriately in the potty, so sometimes that actually entails getting them a smaller seat, so they're not falling through the, the toilet, and then also giving them a step so that they're sitting properly upright, and that they don't spend a lot of time on it. They're not getting an iPad where they're sitting there for half an hour straining. So a lot of medical management as far as managing constipation in the pediatric patient. But then there's also some teachable moments for the parents, because you want to show them how to safely reduce a prolapse to avoid any incarceration that this patient may be at risk for. So what if you have a patient, as Beth was talking about, who has been appropriately managed, there's no other medical issues associated with them, and then they have persistent problems. So let's take a 10 year old female who presents with chronic recurrent rectal prolapse despite medical therapy for constipation. So what would be the next best option for management? I've got a low threshold for starting with sclerotherapy because it's, it's simple, it's innocuous, and then sometimes they just need that head start, particularly in that last case with a younger kid. They just need that window of a couple of months to not have a prolapse, and then they start seeing it less frequently. That's Dr. Sean St. Peter from Children's Mercy Hospital in Kansas City, and here's his sclerotherapy recipe 5 ccs of Sotradechol and inject it in 4 quadrants and then If there's a little left in between. Sclerotherapy was definitely very popular with our audience, but there are so many options as far as surgical approaches if the sclerotherapy isn't very successful. That's when Doctor Huang tried to break it down a little bit with a publication from the Journal of Pediatric Surgery that is linked in the description. So, if you want to open it up, you can read along while she talks you through it. So recently, there was a systematic review that came out that looked at um um a conglomeration of publications. And so a couple of things I wanted to point out, there are 27 publications included and um it spanned, uh, uh, you know, obviously across the whole world in terms of all these publications. Um, there was, um, out of these 900 patients. 300 of them were vascular therapy and so you notice this there were 8 studies and only 3 sclerosclerosing agents involved. In the 600 patients that underwent operative management, there are 22 studies and 17 procedures. So anytime you see that large volume of procedures, you know that we're not exactly sure which is the best procedure for this, uh, for this pathology. So, um. Um, so if you look at in terms of actually operative procedures for this, um, there are many different options, but they do, um, have some, uh, fairly high success rate, um, and to Mark's point about the transabdominal procedures, what has been published have shown that they, they have pretty high success rate of being, um, um, correcting the, um, the, uh, prolapse. Now, if you are gonna use sclerotherapy, which sclerotherapy do you use? Doctor Huang had another JPS article for that. So there was a second publication also from JPS from 2019 that looked at just a uh a review of publications on skill therapy for rectal prolapse in children. I've linked that article as well, so you should be able to scroll down and open up the entire thing to read. When you do, you'll notice that the most popular slourishing agent is actually alcohol, and it's pretty effective too, if you continue to read through the article. Probably really easy to obtain in the hospital setting as well. But there's another reason that we should consider the sclerotherapy. And then the best part about using sclerotherapy as initial um procedure is that the complication rate is uh really mostly negligible and they're, they're acute and there's not really any, um, there's a very minimal risk of long-term problems with sclero therapy. Those two publications combined helped create a treatment algorithm that I've also attached to this podcast. So you can go ahead and open it up. So, if you have a patient with a rectal prolapse, you should rule out underlying diseases, especially cystic fibrosis, you should make sure that it is a rectal prolapse and not a polyp or a hemorrhoid or something else. If it's a small child that is in the potty training phase, certainly having appropriate management, medical management of, of how you'd, um, do potty training. Is appropriate, and, um, and then make sure they're not constipated and treat that appropriately. Now, if that fails, sclerotherapy is the recommended first option with ethyl alcohol. You can do that up to 3 times. There's an estimated cumulative success rate of a little bit over 80%, but if the patient fails that, then the next step is a laparoscopic rectopexy. That's the recommended operative approach, because it has the lowest complication rate. And the highest success rate. Now we're gonna change gears a little bit. Here is a new case presentation from Doctor Huang. 12 year old male presents with chronic recurrent rectal prolapse, refractory to medical therapy. He's seeing you for consideration of surgical treatment. He has also been diagnosed with depression and anxiety, which are being treated with medications. What should you inform his patient, his parents about this? The discussion with the parents. It can vary so much because there's so much that we want to talk to them about and inform them. Obviously, as surgeons, you know, the surgical expectations and the approach. But Doctor Huang was pointing at something else, behavioral therapy and physical therapy. And even addressing the psychology of rectal prolapse, because what you may find is these patients with rectal prolapse may necessitate a multidisciplinary team approach. Partially, it's, it's a feedback loop, so they are anxious, and they have uh rectal prolapse and it becomes this sort of um for one of my patients, it was sort of a an emotional release for her to actually prolapse herself and evacuate stool and so it was important that in addition to cleo therapy, I, I was able to help her, um, uh, support her through, through the, um, the, the anxiety component of that and the pelvic floor, um, Therapy was very useful in strengthening um the pelvic floor musculature such that once you perform the scope therapy, then uh they're likely to have a, a more durable outcome from that procedure. So there you have it, a condensed version of one of our favorite talks from the 2020 pediatric surgery update course. Did you find it useful? Or maybe this is a repeat for you because you were at our update course. Or maybe you missed it, you enjoyed this, and you wanna be a part of the 2021 update course. Well, mark your calendar, August 20th, there's gonna be more information on the event to come, and you can hear about it here, you can follow us on social media. But until next time, I'm Rod from Cincinnati Children's. Remember, knowledge should be free.

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