Complete rectal prolapse is a relatively rare but serious disorder most often seen in infants or elderly individuals. It is more common in women than men.1·2 Factors that predispose to complete rectal prolapse in the elderly include chronic constipation, obstetrical injury, extremely deep cul-de-sac of Douglas, lack of normal fixation of the rectum to the anterior sacrum, neurological disease, and weakness of the external rectal sphincter.3
There are three types of rectal prolapse or procidentia: Type I or false prolapse, in which the rectal mucosa protrudes for 1-3 cm beyond the anal sphincter; Type II, in which there is intussusception of all three layers of the rectum through the anal opening; and Type III or complete rectal prolapse, in which there is both a protrusion of all three layers of the rectum through the anal sphincter and a sliding hernia of the pouch of Douglas.4
The single most important cause of rectal prolapse in the aged is persistent, prolonged, and marked straining at stool.4·5 During straining, the anterior rectal wall tends to descend following the stool.6 When the rectum is not firmly fixed to its sacral bed, the normal posterior curve of the rectum is lost and the rectum assumes a straight course from the pelvic brim to the anal canal, so that the increased intraabdominal pressure created by prolonged straining causes the rectum to invaginate upon itself and extrude through the anal opening.2 The presenting complaints of the patient with rectal prolapse can be seen in Figure 1.
Since complete rectal prolapse is most common in aged women with chronic constipation, nurses employed in nursing homes, geriatric units, rehabilitation facilities, and public health nursing agencies should know how to prevent, diagnose, and provide emergency treatment for the disorder for this large segment of the population.
In taking a geriatric patient's health history, the nurse should suspect impending or previous rectal prolapse in any patient who complains of chronic constipation with bloody or mucoid rectal drainage and a feeling of incomplete evacuation following defecation, especially if the patient was multiparous.
Examination of a patient with complete rectal prolapse will reveal a large red mass protruding through the anal sphincter, and the diagnosis will be obvious. However, in some elderly females with chronic constipation, the nurse may observe only a bulging of rectal mucosa through the anal opening when the patient performs the Valsalva maneuver, which may reflect a "pre-prolapsed" state.6
When only a small amount of tissue protrudes through the anal orifice, the nurse can differentiate mucosal prolapse from complete procidentia in the following manner:
(1) In complete procidentia, the mucosal folds are concentric, the anus is in normal anatomical position, and there is a sulcus between the anus and protruding bowel tissue.
(2) In mucosal prolapse, the mucosal folds are radial, the anus is inverted, and there is no sulcus or groove between the anus and protruding tissue. 1
PRESENTING COMPLAINTS OF PATIENTS WITH RECTAL PROLAPSE
PREOPERATIVE WORKUP FOR GERIATRIC PATIENTS WITH RECTAL PROLAPSE
When rectal prolapse is recurrent, the bowel may eventually remain permanently extruded, with ulceration of the rectal mucosa and, occasionally, strangulation and gangrene of the protruding bowel.7 Therefore, upon discovering rectal prolapse, the nurse should summon a physician to examine the patient and institute definitive treatment. While waiting for the physician to arrive, the nurse should reassure the patient (and any family members who are present) that she is in no immediate danger and that the prolapse can be reduced. Understandably, patients are frightened by the occurrence of rectal prolapse, since the event is usually interpreted as "losing my insides" and concerns a body area with which shameful feelings are often associated.
While waiting for the physician to arrive, the nurse should assist the patient to assume the knee-chest position, if she is capable of doing so, and should place a water- or saline-soaked cloth over the protruding bowel to protect it from drying. Having the patient assume the knee-chest position causes her abdominal viscera to fall cephalad, which may pull the extruded bowel back through the anus, reducing the prolapse (R. Jamieson, personal communication, June 27, 1979).
Unfortunately, once the rectum has prolapsed, the event tends to recur, due to progressive weakening of rectal attachments to the sacrum, lengthening of the rectum, stretch or pressure injury to perineal nerves, and resulting laxity of perineal muscles.8 Further, repeated rectal prolapse often leads to fecal incontinence, with associated problems of skin breakdown.9 In order to prevent complete sphincter denervation, continuous fecal incontinence, and ulceration of rectal mucosa and peri-anal skin, surgery is advised for the purpose of correcting the underlying causes of rectal prolapse.
Since the patient with rectal prolapse is usually an older individual, a careful preoperative workup is required to identify any degenerative changes or chronic illnesses that would increase her surgical risk. As part of the geriatric patient's preoperative preparation, the nurse should take a more detailed health history than that taken during the initial interview. A painstaking review of systems should be made at this time, since older persons sometimes suffer multiple disorders and the diversity of their illnesses leads them to ignore warning signs of new disorders when these signs can be mistaken for symptoms of an earlier disorder. 10 For example, angina may be interpreted as indigestion, bone pain may be interpreted as rheumatism, ischemic leg pain may be interpreted as muscle cramps, and pulmonary congestion may be interpreted as a "slight cold."
Since an intensive preoperative workup is required for most geriatric patients, the nurse should decrease the patient's and family's anxiety by explaining the purpose and procedure for each test and by remaining with the patient during the more stressful tests.
When the patient's condition permits major surgery to repair prolapse, the tests, listed in Figure 2 are usually performed preoperatively.
If tests reveal that the patient with rectal prolapse is a poor surgical risk, the Thiersch procedure, or encirclement of the anal orifice with a silver wire, may be performed under local anesthesia as a palliative measure. Unfortunately, the Thiersch procedure does not restore continence in the incontinent patient and there is a high incidence of prolapse, fecal impaction, infection, and rectovaginal fistula among patients in whom this procedure has been used.1·4
For the patient whose physical condition permits general anesthesia and intra-abdominal surgery, either a Teflon sling or a polyvinyl sponge may be inserted to fix the rectum to the hollow of the sacrum. Then when the patient strains, the rectum is pushed against the sacrum rather than being telescoped into itself and pushed through the anus.12
In the United States, the Ripstein procedure is most often used to correct complete rectal prolapse. In this operation, the upper half of the rectum is mobilized from the sacrum and lifted up. A 2 cm X 5 cm band of Teflon or Marlex mesh is placed around the rectum and sutured to the sacral fascia at the sacral promontory. The sling thus created will hold the rectum against the sacrum.2
In Great Britain, the procedure most often used to repair rectal prolapse consists of mobilizing the rectum down to the anorectal ring, sewing a piece of polyvinyl (Ivalon) sponge to the front of the sacrum, lifting and fixing the rectum to this sponge by wrapping the lateral edges of sponge around the rectum so that they just fail to meet anteriorally, and suturing the pelvic peritoneum over the suspended rectal segment. 1
Following surgical repair of rectal prolapse by either procedure, the patient should be observed for the following complications: hemorrhage, bowel obstruction, pelvic abscess, fecal impaction, and recurrent prolapse.
Because rectal prolapse is a serious disorder that progresses from episodic to continuous prolapse and leads to fecal incontinence, it must be treated with surgical procedures that have serious consequences in some patients. Efforts should be made to prevent prolapse in any patient predisposed toward its occurrence.
Nurses who care for geriatric females can identify patients with previous or impending rectal prolapse through detailed histories, repeated physical examinations, and careful observation of the patient's bowel habits. A rigorous bowel program should be instituted to prevent constipation for patients at risk of prolapse. The program should include a high-bulk diet, liberal fluid intake, and establishment of a regular daily habit time for defecation. Since the patient who lives at home must maintain her own bowel program with only intermittent supervision by the nurse and, perhaps, some assistance from family members, both patients and caregivers should be taught specific details of meal planning and bowel training.
Patients should be taught that dietary fiber includes such indigestible substances as cellulose, pectin, and lignin, which resist breakdown by digestive enzymes; that fiber absorbs water and increases stool bulk; and that increased stool bulk stimulates peristalsis and bowel emptying.
Since cooking tends to break down cellulose, uncooked fruits and vegetables are better sources of bulk than cooked foods.13 Although it has been determined that the diet of the average American provides about 4 gm of fiber per day, authorities do not agree about how much additional dietary fiber is needed to prevent constipation in the inactive individual.14 The following guideline has been suggested by Burkitt: the dietary intake of fiber is sufficient if the feces are soft and they float, but more fiber is needed if stools are hard and they sink. 13 The nurse should stress that cereal fiber is generally a more effective stool softener than the fiber in fruits and vegetables. However, 40% rather than 100% bran cereal should be used, since 100% bran may irritate a sensitive intestinal lining or cause impaction in some elderly individuals.15
In addition to dietary fiber, the chemical constituents of certain foods, such as prunes, have a laxative effect in some individuals. Highly sugared foods stimulate defecation by increasing fermentation in the gut, with formation of small-chain acids that exert an osmotic effect, drawing fluid into the gut lumen, distending the bowel, and stimulating defecation.16 Constipation can also be relieved by the addition of fat to the diet, since increased fat in the duodenum causes increased secretion of cholecystokinen, which increases secretion of bile into the duodenum. The high salt content of bile acts as a saline cathartic, drawing water into the bowel, distending the bowel, and stimulating peristalsis and bowel emptying.17
If the patient has normal cardiac and renal function, she should be taught that a fluid intake of from 2,000cc to 2,500cc will help to keep the stool soft.18 The nurse should advise the patient and caregiver to space this fluid intake throughout the daylight hours, to make it easier for the patient to drink a large volume of liquids without diminishing her appetite for foods at mealtime.
When advising a patient to select the same time each day to attempt defecation, the nurse should explain that from 20 to 40 minutes after eating, the presence of food in the stomach generates mass movements of the colon (gastrocolic reflex), making this an optimum daily habit time. She should also explain that the gastro-colic reflex is stronger after a large hot meal than a small cold meal, so a regular habit time may be easier to establish following a regular hot breakfast or supper than following a regular cold lunch.
Since the optimal physiological position for defecation is the squat, those patients who must use a built-up toilet seat because of limited hip flexion or diminished quadriceps strength should be advised to elevate their feet on a foot rest and bend forward on the toilet seat when attempting a bowel movement. 19 If a high bulk diet, high fluid intake, and establishment of a daily habit time fail to relieve constipation in an elderly individual, the physician may order a bulk-forming laxative, like psyllium hydrophilic mucilloid (Metamucil) or a stool softener like dioctyl sodium sulfosuccinate (Colace) to facilitate stool transit through the colon.
If, in spite of increased fluid intake, increased dietary fiber, and a stool softener, the patient occasionally develops fecal impaction, the nurse or family member may have to resort to gentle digital removal of impacted stool. However, a physician's order should be obtained before manually removing stool from a patient with a history of rectal prolapse, since the patient might have other rectal pathology that would necessitate extreme care in tissue manipulation. In teaching a family member to remove a fecal impaction, the nurse should stress the importance of lubricating the gloved finger liberally before insertion, gently breaking up the fecal mass before evacuation, and removing feces gently, from the lower rectum only.18
In the event that surgery cannot be performed to prevent or correct rectal prolapse and the patient is cared for at home, both the patient and her caregivers should be taught what to do in the event that prolapse recurs. If the patient is severely debilitated, she should be helped to a side-lying position and the protruding rectal mass should be covered with a moist cloth until the patient can be seen by a physician. The nurse should explain that although a sterile dressing is not required for this purpose, the cloth should be clean and, preferably, of cotton material.
If the patient can follow directions and is not debilitated or dyspneic, she should be assisted to the knee-chest position and the protruding rectal tissue covered with a clean, moist cloth. In the event that the forward pull of abdominal viscera does not reduce the prolapse, and if the physician approves, the caregiver may exert very gentle pressure on the prolapsed tissue with the moist cloth to guide the protruding tissue through the relaxed sphincter. Reduction of the prolapse in this manner can save the patient an uncomfortable and expensive trip to the/ hospital emergency room or an expensive home visit by her physician. The patient's attending physician should be notified of repeated episodes of prolapse, since palliative surgical intervention may become necessary.
Since each instance of rectal prolapse predisposes to recurrence of the event, and surgical treatment for prolapse is frequently unsuccessful, nursing interventions should be directed toward preventing the underlying causes of prolapse in predisposed individuals.
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