A 25 y.o. male with autism comes in with rectal pain
What is wrong?
Our patient had autism and had a rectal prolapse due to chronic constipation. Rectal prolapse occurs in a bimodal distribution. It occurs in children younger than one year but is most commonly encountered in older adults. Predisposing factors for rectal prolapse include, constipation, cystic fibrosis, celiac disease, pinworms and weakness of the pelvic floor.
Manual reduction is accomplished by several methods. Sugar can be used as a hygroscopic agent. Waller used saline-soaked gauze inserted 15 cm into the rectum which is left in place for several minutes. Often spasm of the sphincter limits success for while the bowel does not have nerve endings the sphincter does. This is why a perianal field block is useful.
Not as complicated as it looks: basically a ring block around the anus with 20-30 cc of lidocaine
The perianal block involves local anesthetic placed into the ischiorectal fat peripheral to the external sphincter blocking the levator. Pain from spasm of the anal sphincter is relieved in 2 minutes. This can be used for thrombosed hemorrhoids, anal fissures or retrieving foreign bodies in the rectum.
Two conditions mimic rectal prolapse: intussusception protruding through the anus and mucosal prolapse without colonic prolapse. To determine intussusception you have to put your finger into the anus and establish that a tube of bowel is within the anal ring. Hemorrhoids can also mimic rectal prolapse. Internal hemorrhoids can protrude through the anus causing mucosal prolapse. Since 75% of adults have hemorrhoids you will see this condition. The point of differentiation lies in the orientation of the mucosal folds. Internal hemorrhoids have radial folds while the colon has circular folds.
hemorrhoids have radial folds because they are a group of dilated veins.
Rectopexy is the treatment for recurrent prolapse.
Our patient was manually reduced using an anal field block and 20 mg of ketamine.He was admitted to colorectal surgery. He had a bowel movement the next day and prolapsed again but reduced it himself. He has elected to defer the repair.
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