Externer Rektumprolaps

Ätiologie, Pathogenese und Diagnostik
Leitthema
  • 20 Downloads

Zusammenfassung

Als Rektumprolaps wird die teleskopartige Einstülpung des Rektums in distal gelegene Rektumabschnitte bezeichnet. Es findet sich eine deutliche Häufung der Erkrankung beim weiblichen Geschlecht und eine zweigipflige Altersverteilung – bei Kindern und bei Patienten über 50 Jahren. Die genaue Pathogenese und Ätiologie des Rektumprolapses sind unklar. Als ätiologische Faktoren werden Bindegewebsstörungen, Myopathien und Neuropathien diskutiert. Hinsichtlich der Pathogenese werden v. a. 2 unterschiedliche Konzepte zur Entstehung des Rektumprolapses in Betracht gezogen: die Gleithernientheorie und die Interpretation der Entstehung eines Rektumvollwandprolapses als sequenzielle, fortschreitende Entwicklung eines zunächst inneren Rektumprolapses. Diese pathophysiologischen Erklärungen der Prolapsentstehung basieren aber v. a. auf klinischen Beobachtungen und nicht auf kausal nachzuweisenden Zusammenhängen. Insgesamt dürfte die Entstehung des Rektumprolapses multifaktoriell sein und auf einer Kombination aus funktionellen Störungen und anatomischen Veränderungen basieren. Die relative Relevanz der einzelnen pathophysiologischen und pathomorphologischen Komponenten beim betroffenen Individuum bleibt oft nicht schlüssig erklärbar; vielmehr erscheint es wahrscheinlich, dass jeder Patient ein individuelles Pathomechanismusprofil aus den unterschiedlichen ätiologischen Faktoren aufweist. Grundlage der Diagnostik eines Rektumprolapses sind eine detaillierte Anamneseerhebung und eine gezielte klinische Untersuchung. Ein externer Rektumprolaps kann meist bereits klinisch diagnostiziert werden. Die Defäkographie als weiterführende diagnostische Maßnahme hilft bei der Detektion häufig bestehender morphologischen Begleitpathologien.

Schlüsselwörter

Rektumvollwandprolaps Intussuszeption Oxford-Klassifikation Defäkographie Stuhlentleerungsstörung 

External rectal prolapse

Etiology, pathogenesis and diagnosis

Abstract

Rectal prolapse refers to the invagination of the rectum into distal rectal segments. There is a marked accumulation of the condition in the female gender and a bimodal age distribution in children and in patients over 50 years. The exact pathogenesis and etiology of rectal prolapse are unclear. Tissue disorders, myopathies and neuropathies are discussed as etiological factors. With respect to the pathogenesis, there are two main concepts for the development of the rectal prolapse: the hernia theory and the interpretation of a rectal full-thickness prolapse as a sequential, progressive development of an initially internal rectal prolapse; however, these pathophysiological theories are mainly based on clinical observations. Overall, the development of rectal prolapse is likely to be multifactorial and based on a combination of functional disorders and anatomical changes. The relative relevance of the individual pathophysiological and pathomorphological components in the affected individual often remains unclear, but it seems likely that each patient has an individual pathomechanism profile due to various etiological factors. The basis of the diagnosis of a rectal prolapse is a detailed medical history and a targeted clinical examination. An external rectal prolapse can usually be diagnosed clinically. Defecography as a further diagnostic measure has a high priority because of the frequent coexistence of morphological pathological disorders.

Keywords

External rectal prolapse Intussusception Oxford classification Defecography Defecation disorder 

Notes

Einhaltung ethischer Richtlinien

Interessenkonflikt

K.E. Matzel gibt an, ärztlicher Berater für Medtronic zu sein. C. Handtrack und M. Brunner geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Literatur

  1. 1.
    Altomare DF, Pucciani F (2008) Rectal prolapse: diagnosis and clinical management, S 1–19CrossRefGoogle Scholar
  2. 2.
    Antao B, Bradley V, Roberts JP, Shawis R (2005) Management of rectal prolapse in children. Dis Colon Rectum 48:1620–1625CrossRefPubMedGoogle Scholar
  3. 3.
    Beer-Gabel M, Carter D (2015) Comparison of dynamic transperineal ultrasound and defecography for the evaluation of pelvic floor disorders. Int J Colorectal Dis 30:835–841CrossRefPubMedGoogle Scholar
  4. 4.
    Belizon A, Levitt M, Shoshany G, Rodriguez G, Pena A (2005) Rectal prolapse following posterior sagittal anorectoplasty for anorectal malformations. J Pediatr Surg 40:192–196CrossRefPubMedGoogle Scholar
  5. 5.
    Bordeianou L, Paquette I, Johnson E, Holubar SD, Gaertner W, Feingold DL, Steele SR (2017) Clinical practice guidelines for the treatment of rectal prolapse. Dis Colon Rectum 60:1121–1131CrossRefPubMedGoogle Scholar
  6. 6.
    Broden B, Snellman B (1968) Procidentia of the rectum studied with cineradiography. A contribution to the discussion of causative mechanism. Dis Colon Rectum 11:330–347CrossRefPubMedGoogle Scholar
  7. 7.
    Brunner M, Roth H, Gunther K, Grutzmann R, Matzel KE (2018) Ventral rectopexy with biological mesh: short-term functional results. Int J Colorectal Dis 33(4):449–457CrossRefPubMedGoogle Scholar
  8. 8.
    Cares K, El-Baba M (2016) Rectal prolapse in children: significance and management. Curr Gastroenterol Rep 18:22CrossRefPubMedGoogle Scholar
  9. 9.
    Choi JS, Hwang YH, Salum MR, Weiss EG, Pikarsky AJ, Nogueras JJ, Wexner SD (2001) Outcome and management of patients with large rectoanal intussusception. Am J Gastroenterol 96:740–744CrossRefPubMedGoogle Scholar
  10. 10.
    Dvorkin LS, Gladman MA, Epstein J, Scott SM, Williams NS, Lunniss PJ (2005) Rectal intussusception in symptomatic patients is different from that in asymptomatic volunteers. Br J Surg 92:866–872CrossRefPubMedGoogle Scholar
  11. 11.
    Freeman NV (1984) Rectal prolapse in children. J R Soc Med 77(Suppl 3):9–12PubMedPubMedCentralGoogle Scholar
  12. 12.
    Freimanis MG, Wald A, Caruana B, Bauman DH (1991) Evacuation proctography in normal volunteers. Invest Radiol 26:581–585CrossRefPubMedGoogle Scholar
  13. 13.
    Gonzalez-Argente FX, Jain A, Nogueras JJ, Davila GW, Weiss EG, Wexner SD (2001) Prevalence and severity of urinary incontinence and pelvic genital prolapse in females with anal incontinence or rectal prolapse. Dis Colon Rectum 44:920–926CrossRefPubMedGoogle Scholar
  14. 14.
    Hetzer FH, Andreisek G, Tsagari C, Sahrbacher U, Weishaupt D (2006) MR defecography in patients with fecal incontinence: imaging findings and their effect on surgical management. Radiology 240:449–457CrossRefPubMedGoogle Scholar
  15. 15.
    Hotouras A, Murphy J, Abeles A, Allison M, Williams NS, Knowles CH, Chan CL (2014) Symptom distribution and anorectal physiology results in male patients with rectal intussusception and prolapse. J Surg Res 188:298–302CrossRefPubMedGoogle Scholar
  16. 16.
    Hussein AM, Helal SF (2000) Schistosomal pelvic floor myopathy contributes to the pathogenesis of rectal prolapse in young males. Dis Colon Rectum 43:644–649CrossRefPubMedGoogle Scholar
  17. 17.
    Kairaluoma MV, Kellokumpu IH (2005) Epidemiologic aspects of complete rectal prolapse. Scand J Surg 94:207–210CrossRefPubMedGoogle Scholar
  18. 18.
    Karasick S, Spettell CM (1999) Defecography: does parity play a role in the development of rectal prolapse? Eur Radiol 9:450–453CrossRefPubMedGoogle Scholar
  19. 19.
    Karulf RE, Madoff RD, Goldberg SM (2001) Rectal prolapse. Curr Probl Surg 38:771–832CrossRefPubMedGoogle Scholar
  20. 20.
    Keane DP, Sims TJ, Abrams P, Bailey AJ (1997) Analysis of collagen status in premenopausal nulliparous women with genuine stress incontinence. Br J Obstet Gynaecol 104:994–998CrossRefPubMedGoogle Scholar
  21. 21.
    Madiba TE, Baig MK, Wexner SD (2005) Surgical management of rectal prolapse. Arch Surg 140:63–73CrossRefPubMedGoogle Scholar
  22. 22.
    Madoff RD, Mellgren A (1999) One hundred years of rectal prolapse surgery. Dis Colon Rectum 42:441–450CrossRefPubMedGoogle Scholar
  23. 23.
    Maglinte DD, Bartram CI, Hale DA, Park J, Kohli MD, Robb BW, Romano S, Lappas JC (2011) Functional imaging of the pelvic floor. Radiology 258:23–39CrossRefPubMedGoogle Scholar
  24. 24.
    Malik M, Stratton J, Sweeney WB (1997) Rectal prolapse associated with bulimia nervosa: report of seven cases. Dis Colon Rectum 40:1382–1385CrossRefPubMedGoogle Scholar
  25. 25.
    Marceau C, Parc Y, Debroux E, Tiret E, Parc R (2005) Complete rectal prolapse in young patients: psychiatric disease a risk factor of poor outcome. Colorectal Dis 7:360–365CrossRefPubMedGoogle Scholar
  26. 26.
    Marshman D, Percy J, Fielding I, Delbridge L (1987) Rectal prolapse: relationship with joint mobility. Aust N Z J Surg 57:827–829CrossRefPubMedGoogle Scholar
  27. 27.
    Mellgren A, Schultz I, Johansson C, Dolk A (1997) Internal rectal intussusception seldom develops into total rectal prolapse. Dis Colon Rectum 40:817–820CrossRefPubMedGoogle Scholar
  28. 28.
    Moschcowitz A (1912) The pathogenesis, anatomy, and cure of prolapse of the rectum. Surg Gynecol Obstet 15:7–21Google Scholar
  29. 29.
    Nigro ND (1966) An evaluation of the cause and mechanism of complete rectal prolapse. Dis Colon Rectum 9:391–398CrossRefPubMedGoogle Scholar
  30. 30.
    O’Brien DP (2007) Rectal prolapse. Clin Colon Rectal Surg 20:125–132CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Pilkington SA, Nugent KP, Brenner J, Harris S, Clarke A, Lamparelli M, Thomas C, Tarver D (2012) Barium proctography vs magnetic resonance proctography for pelvic floor disorders: a comparative study. Colorectal Dis 14:1224–1230CrossRefPubMedGoogle Scholar
  32. 32.
    Poncelet E, Rock A, Quinton JF, Cosson M, Ramdane N, Nicolas L, Feldmann A, Salleron J (2017) Dynamic MR defecography of the posterior compartment: comparison with conventional X‑ray defecography. Diagn Interv Imaging 98:327–332CrossRefPubMedGoogle Scholar
  33. 33.
    Shorvon PJ, McHugh S, Diamant NE, Somers S, Stevenson GW (1989) Defecography in normal volunteers: results and implications. Gut 30:1737–1749CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Siafakas C, Vottler TP, Andersen JM (1999) Rectal prolapse in pediatrics. Clin Pediatr (Phila) 38:63–72CrossRefGoogle Scholar
  35. 35.
    Snellman B (1961) Complete prolapse of the rectum. Dis Colon Rectum 4:199CrossRefGoogle Scholar
  36. 36.
    Sun WM, Read NW, Donnelly TC, Bannister JJ, Shorthouse AJ (1989) A common pathophysiology for full thickness rectal prolapse, anterior mucosal prolapse and solitary rectal ulcer. Br J Surg 76:290–295CrossRefPubMedGoogle Scholar
  37. 37.
    Todd IP (1963) Prolapse of the rectum. Dis Colon Rectum 6:94–97CrossRefPubMedGoogle Scholar
  38. 38.
    van Iersel JJ, Formijne Jonkers HA, Verheijen PM, Broeders IA, Heggelman BG, Sreetharan V, Futterer JJ, Somers I, van der Leest M, Consten EC (2017) Comparison of dynamic magnetic resonance defaecography with rectal contrast and conventional defaecography for posterior pelvic floor compartment prolapse. Colorectal Dis 19:O46–O53CrossRefPubMedGoogle Scholar
  39. 39.
    Wassef R, Rothenberger DA, Goldberg SM (1986) Rectal prolapse. Curr Probl Surg 23:397–451CrossRefPubMedGoogle Scholar
  40. 40.
    Wijffels NA (2012) Rectal prolapse enlightment of the obscure. http://www.werkgroepcoloproctologie.nl/pdf/RPETO.pdf
  41. 41.
    Wijffels NA, Collinson R, Cunningham C, Lindsey I (2010) What is the natural history of internal rectal prolapse? Colorectal Dis 12:822–830CrossRefPubMedGoogle Scholar
  42. 42.
    Yiou R, Delmas V, Carmeliet P, Gherardi RK, Barlovatz-Meimon G, Chopin DK, Abbou CC, Lefaucheur JP (2001) The pathophysiology of pelvic floor disorders: evidence from a histomorphologic study of the perineum and a mouse model of rectal prolapse. J Anat 199:599–607CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Zafar A, Seretis C, Feretis M, Karandikar S, Williams SC, Goldstein M, Chapman M (2017) Comparative study of magnetic resonance defaecography and evacuation proctography in the evaluation of obstructed defaecation. Colorectal Dis 19:O204–O209CrossRefPubMedGoogle Scholar
  44. 44.
    Zorenkov D, Otto S, Bottner M, Hedderich J, Vollrath O, Ritz JP, Buhr H, Wedel T (2011) Morphological alterations of the enteric nervous system in young male patients with rectal prolapse. Int J Colorectal Dis 26:1483–1491CrossRefPubMedGoogle Scholar

Copyright information

© Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2018

Authors and Affiliations

  1. 1.Klinik für Allgemein- und ViszeralchirurgieUniversitätsklinikum der Friedrich-Alexander-UniversitätErlangenDeutschland

Personalised recommendations