[size=20px]A 4 year old boy with constipation has recurring episodes of rectal prolapse with bowel movements that frequently require manual reduction. A trial of laxatives improved the constipation but the prolapse persists. Which of the following would be the best next step?

 

A Continued observation

 

B injection sclerotherapy

 

C Altmeier procedure

 

D posterior sagittal rectopexy

 

E laparoscopic rectopexy​[/size]

B

B

B

A

B

correct answer

B injection sclerotherapy

​

While rectal prolapse in children may be associated with anatomic abnormalities (such as sacrococcygeal flattening or straightening of the rectum) or other conditions (such as cystic fibrosis or malnutrition), the single most common cause in the United States is constipation. In the developing world, enterobiasis (pinworm) is associated with persistent rectal prolapse. Rectal prolapse may be defined as either mucosal or full thickness. In children mucosal prolapse is more common.

 

In the US first line treatments consist of aggressive management of the constipation with laxatives, dietary changes and improving toilet related behaviors (avoiding prolonged sitting). In cases where this mangement fails, further interventions may be appropriate.

 

Injection sclerotherapy is achieved by placing a sclerosing agent (hypertonic saline / glucose, alcohol, and others) in the submucosal space to initiate an inflammatory response that allows the mucosa to adhere. This procedure is typically performed transanally under anesthesia. It is relatively benign with minimal complications and can be repeated if necessary. It may be combined with a perianal modified Thiersch wire and linear cauterizations of the mucosa. Laparoscopic rectopexy has been the next most common procedure when sclerotherapy fails and has good reported outcomes. A posterior sagittal approach is possible, but is associated with a higher recurrence rate and complications such as wound infections. An Altmeier approach or transanal resectional therapy is usually reserved for full thickness prolapse in adults, but variations have been successful in children.

 

While all the choices listed are potential treatments, a systematic review and survey of pediatric surgeons suggested that injection sclerotherapy would be the best next step followed by laparoscopic rectopexy. It should be noted that injection sclerotherapy in patients with prolapse secondary to other conditions (e.g., after ARM repair, spina bifida) is usually best treated by other modalities. Continued observation in this case would not be recommended given the persistence of the issue.