Pediatric rectal prolapse

　　Pediatric rectal prolapse can be divided into complete and incomplete types. The incomplete prolapse refers to the prolapse of only the mucosa, and the complete prolapse refers to the prolapse of all layers of the rectum at the same time. The main factors causing rectal prolapse in this disease are mainly three important factors:

　　One, systemic factors

　　Malnutrition, the disappearance of fat in the ischiorectal fossa, causes the rectum to lose the surrounding support and fixation effect, and the contraction force of the sphincter group is also weakened, making the rectum easy to prolapse from the anal orifice.

　　Two, local tissue anatomical factors

　　1, the curvature of the sacrum has not formed: The sacrum of infants and young children has not formed, the pelvis tilts forward insufficiently, the rectum is in a vertical position, and it is in a straight line with the anal canal. When the downward pressure in the abdominal cavity increases, the rectum has no support from the sacrum, and the pressure is directly applied to the anal canal, making it easy to slide down.

　　2, weak surrounding muscle support: The support force of the levator ani muscle and the pelvic floor muscles is weak.

　　3, mucosal relaxation: The rectal mucosa is relatively loose when attached to the muscular layer, and the mucosa is easy to slip off the muscular layer.

　　Three, promoting factors

　　Any condition that causes a long-term or sudden increase in intra-abdominal pressure can promote rectal prolapse. For example, chronic constipation, diarrhea, whooping cough, phimosis, bladder stones, and long-term chronic cough are often predisposing factors for rectal prolapse. Some diseases (such as lumbar sacral spinal cord meningocele) or injuries (including accidental and surgical injuries) that cause dysfunctions of the sphincter muscle and the muscles around the rectum or neurological disorders can lead to rectal prolapse when abdominal pressure increases.

　　Pediatric rectal prolapse can be complicated with strangulated rectal prolapse, incarceration, and rectal stenosis. The rectum prolapsed outside the anus is held by the sphincter muscle, and venous return is obstructed, causing the volume to continuously increase until the arterial vessels are compressed and cannot be returned to the anal canal. After incarceration, varying degrees of infection may occur, and the patient may have symptoms such as urgent need to defecate, significant anal distension, and other symptoms. At this time, the infection is often localized to the anal area. If the treatment is not proper, it is easy to cause the spread of infection, leading to submucosal, perianal, or ischiorectal pouch abscess.

　　During the initial stage of pediatric rectal prolapse, the mucosa may prolapse from the anal opening during defecation, automatically retract after defecation, and recur repeatedly. After repeated attacks, it is necessary to use hands to push it back after each defecation, and there is often a small amount of mucus. When crying, coughing, or exerting force, the intestine will prolapse. If the entire rectum prolapses and remains out for a long time without being复位, it can cause congestion, edema, ulceration, hemorrhage, making it difficult to复位, and sometimes it can also become incarcerated. The intestinal tract becomes purple and black, and there is a local intestinal tract blood circulation disorder. Even after复位, it is easy to develop rectal stenosis.

　　This disease is caused by the interaction of congenital and acquired factors. Enhancing the physical fitness of children, ensuring reasonable nutrition, and promoting the growth and development of children are the main preventive measures. The specific situation is as follows.

　　1. Treat diarrhea and infectious enteritis, chronic dysentery, and other diseases in a timely manner. Pay special attention to childhood diarrhea and dysentery.

　　2. Eat more vegetables to prevent constipation.

　　3. Develop good toilet habits, avoid long squatting in the toilet, and do not strain during defecation.

　　4. Take active preventive and therapeutic measures against whooping cough, chronic tracheitis, emphysema, and other diseases.

　　5. Pay attention to adequate rest.

　　6. Often perform anal muscle exercises to increase the function of the anal sphincter muscle.

　　In summary, the causes of rectal prolapse are diverse. It is of great significance to develop good habits in life to prevent the formation of this disease.

　　Children with rectal prolapse generally have normal blood, urine, and stool routine examinations. Anorectal examination may be performed as needed to confirm the diagnosis. When the patient squats and strains, the rectum prolapses, and part of the prolapse can be seen as a circular, red, smooth mass, with mucosal folds in a 'radiating' pattern. The prolapsed length is generally not more than 3 cm, and the finger palpation only touches two folded mucosal layers. During rectal palpation, the anal sphincter muscle feels weak and lacks contraction when the patient strains. If it is a complete rectal prolapse, the mucosal surface has 'concentric ring' folds. The prolapsed part is longer, and the prolapsed part is composed of two layers of intestinal wall folds, which are thicker to palpate. During rectal palpation, the anal orifice is expanded, and the anal sphincter muscle feels relaxed and weak. When the anal canal is not prolapsed, there is a ring-shaped deep groove between the anal orifice and the prolapsed intestinal tract.

　　Children with rectal prolapse should not eat too greasy or spicy food, and pay more attention to daily care. For children with habitual constipation or poor defecation, they should eat more vegetables and fruits rich in fiber in their daily diet to keep the stool soft, and do not defecate too forcefully or squat for too long during defecation.

　　Prolapse of rectum in children is caused by the interaction of congenital and acquired factors, manifested as the rectum and anal canal are inverted and prolapsed outside the anus. According to the clinical manifestations, the following methods of treatment are adopted.

　　1. Conservative treatment

　　If prolapse of rectum is secondary to diarrhea, constipation, bladder stones, etc., prolapse of rectum can usually be cured after the disease is cured. During the treatment, it is necessary to comprehensively improve the living habits of children, improve nutrition, and cultivate the habit of defecating at regular times (the defecation time should not be too long). The key to treating prolapse of rectum in children is to avoid defecating in a squatting position, and try not to flex the hip joint during defecation. For young infants, they can take a straight leg posture to defecate or urinate, while older children can defecate by sitting on a high toilet seat (or placing the toilet seat on a chair) or adopt a lateral or supine defecation posture. This can make the rectum less likely to prolapse. By persisting for 1 to 2 months, it can be cured. When the rectum prolapses after defecation, it should be immediately复位 by manual manipulation. If the intestine prolapses immediately after复位 or if it is always prolapsed outside, use a thick pad made of gauze to press on the anus after复位, and then use adhesive plaster to tighten and firmly stick the two buttocks together. Instruct the child to rest in bed for 1 to 2 weeks, persist in defecating in bed, and after the anus and rectum no longer prolapse, persist in half-squatting defecation. After 1 to 2 months, it can be cured most of the time.

　　2. Injection Therapy

　　The medication is injected into the submucosal layer of the rectum to cause adhesion between the mucosa and the muscular layer, or the medication is injected into the perirectal area to cause adhesion between the perirectal tissues and the rectum through stimulation by the medication, so that the rectum is fixed and no longer prolapsed, leading to recovery. Overuse of medication or the use of excessively irritating drugs can easily cause mucosal necrosis, and complications such as infection, abscess, and necrosis of the rectal wall can also occur due to improper injection, so caution should be exercised when using injection therapy. Medications commonly used for perirectal injection include 0.5% to 1.0% procaine, 95% ethanol solution, and 5% sodium laurate. Medications for submucosal rectal injection include 5% glycerol carbonate or 30% saline solution, with injection sites being on both sides of the rectum and the pre-sacral area. Two sites are chosen each time, and it is necessary to maintain a supine or high sitting position for defecation during the treatment period. Generally, a single injection is sufficient for recovery, but in a few cases, a repeat injection is required 7 to 10 days later.

　　3. Surgical Treatment

　　For those with incarcerated prolapse or blackened necrotic intestinal segments that cannot be replaced, local hot compresses, antibiotic wet compresses, and insertion of rectal tubes for exhaust lavage can be used to allow for spontaneous recovery or shedding. Otherwise, the prolapsed part must be excised while being sutured, or the electric knife can be used for excision, with a significant amount of bleeding, and there is a high risk of postoperative infection and stricture. For those with relaxed or weak anal sphincter contraction, recurrence can still occur after excision of the prolapsed part, such as after the formation of anal prolapse following myelomeningoceles. An anal sphincteroplasty must be performed. Patients can also use silver wire loops wrapped around the subcutaneous tissue around the anal opening, known as perianal ligation surgery. For some serious rectal prolapse children, rectal suspension surgery or operations such as sacroanal levator retraction can be considered based on their specific conditions.