Rectal prolapse is the protrusion of either partial mucosal or full-thickness rectal wall through the external anal sphincter. ^, In the pediatric population, most commonly in children younger than 4 years old, anatomic factors likely account for the increased occurrence of this diagnosis. ^, These factors include a more vertical course of the rectum, a more mobile sigmoid colon, and looser attachment of the rectal mucosa to the muscle layers. ^, Additional anatomic differences that may contribute to an increased incidence in children include a flatter coccyx, poor levator support, and absent Houston’s valves (in most children younger than 1 year of age). ^, Chronic constipation is the most common predisposing condition associated with rectal prolapse in developed countries, followed by diarrheal disease, cystic fibrosis, and neurologic conditions. Outside of developing countries, the primary associated predisposing conditions include parasitic disease, malnutrition, and diarrheal illnesses. While constipation is the most common predisposing factor for rectal prolapse, patients should be evaluated for reversible causes, such as thyroid hormone issues or celiac disease.

The primary treatment strategy for rectal prolapse should include manual reduction of the prolapse as soon as possible, followed by identification and treatment of the underlying predisposing condition. If no underlying predisposing condition for rectal prolapse can be identified, empiric treatment with stool softeners and avoiding straining is often adequate to achieve resolution in most cases. It is estimated that approximately 20% of patients will experience refractory rectal prolapse that does not respond to conservative management.

A wide variety of procedural treatment strategies exist. In general, less-invasive options should be pursued prior to more aggressive surgical interventions. Sclerotherapy is the injection of sclerosing agent into the submucosal space above the dentate line to create fibrosis and an inflammatory reaction that fixes the rectal mucosa in place. Sclerosing agents shown to be effective in treating rectal prolapse include 98% ethyl alcohol, 50% dextrose solution, 15% saline, and others. ^{, , , ,} Sclerotherapy has shown success in resolving rectal prolapse in up to 65% of patients and in some clinical series and success has been shown to increase with multiple injections. However, there are no standardized protocols or evidence-based guidelines around sclerotherapy for rectal prolapse, and some cases with successful resolution after sclerosis would likely have eventually resolved without treatment. In cases recalcitrant to conservative management, sclerotherapy may be a good first-line procedural treatment. ^,

Thiersch’s cerclage, or anal encirclement with the use of a suture, has also been described as a procedural treatment for rectal prolapse. Like sclerotherapy, the technical components vary significantly in the literature. Although initially described with a wire, a current version of the technique is performed with an absorbable or nonabsorbable suture. Thiersch’s cerclage can also be combined with linear cautery. Linear cautery, or the placement of linear lines of cautery along the rectal mucosa, is thought to increase the inflammatory reaction and aid with creation of fibrosis. ^{, ,}

More invasive surgical management includes rectopexy with or without rectal resection. ^{, , ,} Surgical rectopexy, through a variety of approaches, fixes the rectum to the presacral fascia. This can be performed via abdominal laparoscopy, exploratory laparotomy, or through a posterior sagittal approach. Recurrence of rectal prolapse in retrospective series usually ranges from 0% to 5%. ^{, , ,} While many procedures exist to manage rectal prolapse, in general conservative, nonprocedural treatment with management of any underlying predisposing conditions should be pursued as first-line therapy.

For a small portion of patients with rectal prolapse, conservative management and local surgical approaches ( Fig. 35.1 ) (e.g., sclerotherapy, cerclage) fail. For these patients, surgical approach options include laparoscopic rectopexy and open rectopexy. ^{, , ,} However, laparoscopic rectopexy is more minimally invasive and is performed with two operating ports and a port for the laparoscope. ^, The rectum is mobilized and sutured to the periosteum of the sacral promontory in multiple locations with nonabsorbable suture ( Fig. 35.2 ). Open posterior rectopexy is another technique for rectal prolapse and may be performed when other approaches fail. ^{, ,} Through a posterior sagittal incision, the coccyx is removed, the muscular hiatus is narrowed, and the rectum is suspended from the cut edge of the sacrum so that it can no longer prolapse ( Fig. 35.3 ). This maneuver reestablishes the levator ani suspensory mechanism and narrows the anorectal hiatus. Due to the increased risk of recurrence with posterior surgical approaches, the laparoscopic approach is the favored initial choice for surgical intervention. ^, Surgical repair for rectal prolapse should be reserved for patients with failure of at least two sclerotherapy treatments, and constipation should be well managed. A proposed algorithm for the management of rectal prolapse is included ( Fig. 35.4 ).

This two-year-old child developed persistent rectal prolapse. The prolapse occurred several times daily and was not responsive to medical management. The child underwent submucosal sclerotherapy with 5% morrhuate sodium and the prolapse resolved.

This child developed rectal prolapse that was refractory to conservative treatment and a laparoscopic rectopexy was done. The retrorectal space and sacral promontory are exposed (A). The left ureter ( arrow ) is also identified in (A) and (B). In (B) the first rectopexy silk suture has been placed through the serosa of the rectum and the inferior aspect of the sacral promontory. In (C) the second suture has been placed and will be tied. This patient recovered and his symptoms resolved.

(A) A cut-away sagittal view illustrates the failure of the rectal suspensory mechanism to hold the rectum within the pelvis. (B) The posterior sagittal incision is depicted. (C) The coccyx has been removed and the posterior rectal wall exposed. (D) The pelvic diaphragm is closed posterior to the reduced rectum. The rectum is sutured laterally to the pelvic diaphragm. The rectum is further suspended from the cut edge of the sacrum.

A and D adapted from Ashcraft KW, Amoury RA, Holder TM. Levator repair and posterior suspension for rectal prolapse. J Pediatr Surg . 1977;12:241–245; B and C from Ashcraft KW. Atlas of Pediatric Surgery . WB Saunders; 1994. p. 217.

Proposed algorithm for the management of rectal prolapse.

Adapted from Rentea RM et al. Pediatric rectal prolapse. Clin Colon Rectal Surg . 2018;31(2):108–116. https://doi.org/10.1055/s-0037-1609025 .

Perineal abscess is a superficial, soft tissue infection in the perianal area, with the presence of pus. It is seen most commonly in infants less than 12 months old and presents as a tender mass in the perianal region ( Fig. 35.5 ). The exact pathogenesis for perianal abscess is unknown, but there are many proposed mechanisms for their origin. One possibility includes infection of abnormally deep anal crypts. ^, These crypts are typically located proximal to the dentate line and produce mucus. Greater than 90% of patients with perianal abscesses are male, suggesting a role for androgen contributing to their development. It is important to differentiate between perianal abscess in infants versus in older children. Crohn disease should be considered in the differential for perirectal abscesses, more complex ischiorectal abscesses, and fistula-in-ano in older children and adolescents.

Perianal abscesses are often seen in male infants. The abscess typically presents as a fluctuant, tender mass in the perianal region. Incision and drainage are the initial management if conservative measures have failed.

Perianal abscess typically begins with redness, swelling, and tenderness near the anal opening that generally leads to eventual spontaneous drainage without intervention. It is estimated that 30%–80% of abscesses resolve without recurrence. For nonfluctuant perianal lesions, initial nonoperative management with warm compresses and sitz baths, with or without antibiotics, is the preferred management strategy. ^, Patients with large abscesses, fever, or significant discomfort are candidates for incision and drainage. Needle aspiration of large perianal abscesses has also been described, but data in pediatric patients are limited ( Fig. 35.6 ).

(A) CT image of a complex ischiorectal abscess ( asterisk ) in an adolescent with Crohn disease. Note the rectum ( arrow ) is markedly compressed. (B) This contrast study identifies the large abscess cavity. A drain was positioned over the guide wire ( arrow ) and left in situ to drain the abscess cavity.

It is estimated that up to 50% of perianal abscesses may progress to fistula-in-ano. The typical history for this clinical scenario is a child with several episodes of perianal abscess in the same location ( Fig. 35.7 ). The fistula is commonly located lateral to the anus rather than in the midline. Once fistula-in-ano has developed, surgical intervention with rectal exam under anesthesia and fistulotomy is the standard approach if conservative management fails, although several series report spontaneous resolution with conservative management and time. ^{, ,} ( Fig. 35.8 ). This surgical approach should be carefully undertaken and performed only for superficial fistula tracts to preserve continence. The increased incidence of development of fistula-in-ano in patients who undergo incision and drainage of perineal abscess has also been demonstrated in the literature and should be considered when determining if a patient with a perineal abscess is appropriate for drainage procedure.

As many as half of perianal abscesses progress to a fistula-in-ano. In this photograph, the fistula is seen at 1 o’clock when the infant is in the lithotomy position.

(A) At the time of operation, a small, fine, malleable probe is inserted through the fistula and can usually be gently advanced until it is visualized to exit the base of the involved crypt. (B) An incision is then made along the probe and is deepened through the superficial portion of the external sphincter. (C) After complete unroofing of the tract, the incision is usually left open, which may provide some distress on the part of the parents, but usually does not cause much discomfort for the child.

For more complex fistula-in-ano, or cases where inflammatory bowel disease is suspected, large perineal wounds should be avoided. Any abscess associated with the fistula should be managed with minimal incisions to drain any fluid collections and be performed with seton placement through the fistulous tract. Current management for the infection after surgical management of fistula in Crohn disease varies, but consensus guidelines support biologic agents such as infliximab or adalimumab for induction and maintenance therapy, possibly in combination with immunomodulators such as azathioprine and 6-mercaptopurine. Seton removal typically occurs months after placement and when medical management is in place and drainage has minimized.

An anal fissure often develops when more solids are introduced into a child’s diet, resulting in firmer stool and often constipation. The exact etiology of anal fissures is unknown but constipation and increased internal anal sphincter pressure are considered contributing factors. This entity typically presents as a linear tear in the anoderm below the mucocutaneous junction distal to the dentate line. Most fissures are found in the posterior midline. They are accompanied by symptoms of pain with passage of stool and rectal bleeding. The pain and discomfort with defecation is thought to result in spasms of the sphincter complex, which leads to worsening constipation. This cycle can cause continued aggravation of the fissure, impeding healing. Symptoms may include a history of hematochezia, crying with bowel movements, and visualization of a split in the anoderm. Operative interventions such as lateral internal sphincterotomy or fissurectomy are rarely necessary, although reported success rates are high. Aggressive management of constipation with an osmotic stool softener and sitz baths are typically sufficient treatment to result in healing. It is important to continue medication for management of constipation after resolution of the fissure to minimize recurrence.

Topical 0.2% nitroglycerin ointment has been shown to have earlier symptomatic relief and fissure healing compared with classic conservative therapy, but late fissure recurrence in those initially cured can develop in up to 50%. Other medical therapies, such as topical glyceryl trinitrate, calcium channel blockers, and botulinum toxin (Botox) injection for acute and chronic anal fissures, may be attempted but provide only a slightly better chance of resolution than placebo. Chemical sphincterotomy using Botox can be trialed when all other nonoperative interventions have failed and constipation is managed appropriately.

An anal fissure in an older child or a teenager may be associated with Crohn disease. Immunomodulatory treatment of Crohn disease typically results in healing of the fissure. Topical application of tacrolimus ointment remains an unproven therapy with a potential for systemic toxicity and should be used only when traditional treatment options fail. In general, first-line therapy for management of anal fissure for patients with Crohn disease includes nonprocedural therapies including nitroglycerin, diltiazem, botulinum toxin, and local steroids. Partial lateral internal sphincterotomy should be performed only for those patients with highly symptomatic fissures associated with internal sphincter muscle hypertonicity that are also refractory to conservative measures. Diarrhea and rectal inflammation must not be present.

A perianal skin tag is typically a benign finding and is often seen in the case of a healed anal fissure ( Fig. 35.9 ). These are generally asymptomatic but, when large enough, can affect perianal hygiene. In these situations, local excision may be indicated with low morbidity.

This one-year-old infant developed an anal skin tag secondary to constipation. Due to its size, it was excised.

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