2020年10月29日星期四

hemorrhoids and ibs,Anorectal series knowledge and question and answer-rectal prolapse (prolapse)

    Rectal prolapse is a disease in which the rectal mucosa, anal canal, full-thickness rectum, and part of the sigmoid colon move downwards and prolapse outside the anus. The disease can occur in all age groups, but it mostly occurs in young children, the elderly, chronically ill, frail, and weak. The incidence of females is higher than that of males due to factors such as large lower pelvic mouth and multiple births. The disease is characterized by the rectal mucosa and rectum repeatedly protruding outside the anus and accompanied by anal relaxation.

    Cause

    1. Etiology

    Such as long-term constipation, chronic diarrhea, dysuria caused by enlarged prostate, and chronic cough caused by chronic bronchitis

    Causes of rectal prolapse

    Other factors can cause rectal prolapse.

    (1) Factors of hypoplasia: children with immature sacrum development or adults with developmental defects, the sacrum has a small forward bending angle, the development is straight, the rectum runs vertically, the bladder or uterine lacuna is located higher, and the back of the rectum The supporting effect of the curved surface of the sacrum is lost, and it is easy to shift downward when the intra-abdominal pressure is increased.

    (2) Physical factors: Due to various reasons, persistent intra-abdominal hypertension causes the muscle groups, ligaments, fascia and other supporting tissues around the rectum or pelvic floor to become unbearable and relax. Such as urethral stricture, bladder stones, prostate enlargement and other concurrent dysuria, heavy physical labor, intractable constipation, chronic diarrhea, and multiple births can easily cause rectal prolapse.

    (3) Pathological factors: This is the most common cause of disease in the clinic. In a sense, prolapse is a complication or secondary disease. If you suffer from chronic wasting disease or malabsorption, malnutrition, internal hemorrhoids, rectal polyps, tumors protruding into the intestinal wall for a long time, old physical weakness, lumbosacral nerve damage, it is easy to cause the pelvic muscles and anal sphincter to decline and relax , Loss of support for the anal canal and rectum, loose rectal submucosa tissue, loss of adhesion and fixation between the mucosal layer and the muscle layer, causing the rectal mucosa to slide downward and shift.

    Two, 3 common causes of rectal prolapse

    1. The pelvic floor tissue is weak. Muscle relaxation in the elderly, excessive childbirth in women and perineal tears during childbirth, and hypoplasia in young children can cause hypoplasia and atrophy of the levator ani muscle and pelvic floor fascia, which cannot support the rectum in a normal position.

    2. Long-term intra-abdominal pressure increases. Factors such as long-term constipation, chronic diarrhea, dysuria caused by enlarged prostate, and chronic cough caused by chronic bronchitis can cause rectal prolapse.

    3. Anatomical factors. The curvature of the sacrococcyx in children is shallower than normal, and the rectum is vertical. When the intra-abdominal pressure increases, the rectum loses the support of the sacrum and is prone to prolapse. In some adults, the peritoneum at the anterior rectal depression is lower than normal. When the intra-abdominal pressure increases, the loops directly press on the front wall of the rectum and push it down, which easily leads to rectal prolapse.

    3. Pathogenesis

    There are currently two theories about the occurrence of rectal prolapse. One is the sliding hernia theory: rectal prolapse is considered to be the rectum

    Rectal prolapse

    Sliding hernia of pelvic depression and peritoneum. Under the pressure of abdominal viscera, the peritoneal wrinkle wall of pelvic depression gradually droops, pressing the anterior rectal wall covering the peritoneum into the ampulla of the rectum, and finally prolapses through the anus.

    The second is the theory of intussusception: when normal, the upper end of the rectum is fixed near the sacral promontory. Due to chronic cough, constipation, etc., the intra-abdominal pressure increases, and this fixed point is injured. Intussusception easily occurs at the junction of the sigmoid colon and rectum. Under the continuous action of factors such as increased pressure, the intestinal tube inserted into the rectum gradually increased. Due to the alternate intussusception and intussusception reduction, the rectal lateral ligaments and the levator ani muscle were injured, the intussusception gradually increased, and finally prolapsed through the anus. . Some people think that the above two theories are the same thing, but the degree is different. Sliding hernia is also a kind of intussusception, but it does not affect the entire circle of intestinal wall. The latter is full-layer nesting.

    Onset is slow. In the early stage, the lump only protrudes from the anus during defecation, and it can retract by itself after defecation. As the disease progresses, due to the lack of contractility of the levator ani muscle and anal sphincter, you need to use your hands to help you recover. In severe cases, it can also come out when coughing, sneezing, straining or walking, and it is not easy to recover. If it is not reset in time, edema, strangulation, and even necrosis may occur in the prolapsed bowel segment. In addition, there are often inexhaustible bowel movements and anal falling, soreness, and some may have lower abdominal pain and frequent urination. The pain is severe when incarcerated.

    Fourth, the cause of rectal prolapse in children

    There are two major causes of prolapse in children

    1. Congenital factors: related to the anatomical characteristics of children's rectum, that is, children's congenital factors are the imperfect development of the pelvic tissue structure, and the surrounding tissues supporting the rectum are relatively weak and not firmly fixed.

    2. Acquired factors: The pressure in the abdominal cavity has been increased for a long time, such as forced defecation, severe coughing, vomiting, frequent diarrhea; poor defecation habits, too long sitting in the potty, etc., can promote rectal prolapse. This situation might as well be an analogy. The cuff is regarded as an anus. If the clip is not firmly connected to the lining, the clip will easily come out of the cuff. This is the reason why anal prolapse occurs.

    The early manifestation of anal prolapse is only when there is a red, wet, and soft lump in the anus during defecation, and the lump quickly retracts into the anus after defecation. After repeated attacks, the lumps cannot be retracted immediately, and the lumps must be recovered with the help of hands. Due to frequent prolapse, the mucosa is stimulated by friction, mucus secretion increases, and the mucosa appears congestion, edema, bleeding, ulcers, and even necrosis.

    Causes of rectal prolapse in children

    Chinese medicine believes that children are prone to prolapse of the anus if the blood is not vigorous. Rectal prolapse is very common in children under 5 years of age. Due to the delicate physique of children, the development is not fully mature, the vitality is not strong, the sacrum is not fully curved, the submucosa of the rectum is relatively loose, the rectum lacks the support of the sacrum, and the rectum and pelvis Almost straight, that is, a vertical state, relatively active, not conducive to fixation, and increase the load of the anal sphincter, children are prone to malnutrition, pertussis, enteritis, diarrhea and other diseases.

    Long-term intra-abdominal pressure increases and loses the traction and fixation effect on the rectum, and rectal prolapse is prone to occur. This is the main reason why children are susceptible to rectal prolapse.

    Clinically, it is also common to cause the disease in children to defecate, urinate and sit for too long. With the development of the pelvis and the bending of the sacrum in children, most patients with rectal prolapse can often heal on their own, so non-surgical treatment is generally used.

    classification

    1. Classification of rectal prolapse

    Rectal prolapse can be divided into partial and complete according to the degree of prolapse.

    (1) Partial prolapse (incomplete prolapse): The prolapsed part is only the mucosa of the lower rectum, so it is also called mucosal prolapse. The prolapse length is 2 to 3 cm, generally not more than 7 cm, the mucosal wrinkle wall is radial, and the prolapsed part is composed of two layers of mucosa. There is no groove-like gap between the prolapsed mucosa and the anus.

    (2) Complete prolapse: Full-thickness prolapse of the rectum. In severe cases, the rectum and anal canal can be turned out to the outside of the anus. The prolapse length often exceeds 10cm, or even 20cm, in the shape of a pagoda, and the mucosal folds are arranged in a ring shape. The prolapsed part is composed of two folded intestinal walls, which are thick to the touch. There is a peritoneal space between the two intestinal walls.

    Second, rectal prolapse index

    In the past, rectal prolapse was divided into two types, complete rectal prolapse and incomplete rectal prolapse. In order to better guide clinical practice, the National Anorectal Conference in 1975 unified standards and divided rectal prolapse into three degrees. details as follows.

    Degree I prolapse: When defecation or increased abdominal pressure, the rectal mucosa protrudes out of the anus and the length is less than 3 cm. The prolapsed part can be absorbed by itself after defecation, and there is generally no obvious conscious symptoms.

    Second-degree prolapse: full-thickness rectal prolapse during defecation or increased abdominal pressure. The length is 4 to 8 cm. It cannot be repaid by itself. It needs to be repaid by hand. It is often accompanied by anal sphincter relaxation.

    Ⅲ degree prolapse: The anal canal, rectum, and part of the sigmoid colon protrude outside the anus when defecation or increase abdominal pressure, and the length is more than 8 cm. It is difficult to reset by hand. May be accompanied by anal sphincter relaxation, rectal mucosal erosion, hypertrophy, blood in the stool, fecal incontinence and other symptoms.

    symptom

    1. Common symptoms of rectal prolapse

    Common symptoms of rectal prolapse include insufficiency of stool; falling anus; lower abdominal distension and pain; frequent urination; rectal prolapse refers to the anal canal, rectum, and even

    Rectal prolapse

    The lower end of the sigmoid colon shifts downward. Only mucosal prolapse is called incomplete prolapse; full rectal prolapse is called complete prolapse. If the part is inside the anal canal or rectum, it is called prolapse or internal intussusception; if it is outside the anus, it is called external prolapse.

    Rectal prolapse is common in children and the elderly. In children, rectal prolapse is a self-limiting disease that can heal itself before the age of 5, so non-surgical treatment is the main treatment.

    Adult complete rectal prolapse is more serious. Long-term prolapse will cause pudendal nerve damage and cause anal incontinence, ulcers, perianal infection, rectal bleeding, and the risk of edema, stenosis, and necrosis of the prolapsed bowel. Surgical treatment should be the main treatment. Manual reduction; injection therapy; rectal suspension and fixation; prolapsed bowel resection; anal ring reduction.

    2. Early symptoms of rectal prolapse

    At first, I often have constipation, irregular bowel movements, and always feel full rectum and unclean bowel movements. The mass protrudes during defecation, but it can retract on its own. Long-term walking and exertion can be released, and often need to be sent back. Due to frequent prolapse and discharge of mucus contaminate underwear. Damage to the intestinal mucosa can also cause bleeding and diarrhea when ulcers occur. The anus and rectum feel sluggish. Symptoms of prolapse above the anus are often unchanged, mainly because the feeling of emptying is not completely after defecation, and the feeling of emptying is felt after total exertion. Prolapse repeatedly drops and retracts in the rectum, causing mucosal congestion and edema, and a large amount of mucus and bloody substances are often discharged from the anus. Patients often feel swelling and dragging of the pelvis and lumbosacral area, dull pain in the perineum and the back of the thigh.

    3. Typical anatomical features of rectal prolapse

    ①Rectal intussusception;

    ② Deep depression or deep douglas depression;

    ③The rectum and sacral promontory are not fixed;

    ④Straight up and long sigmoid colon;

    ⑤The pelvic floor and anal sphincter are weak;

    ⑥ There may be thyroid ectocele and other abnormalities. The ideal surgical method should correct these abnormalities as much as possible.

    diagnosis

    1. Three diagnostic criteria for rectal prolapse

    The diagnosis of rectal prolapse is divided into the following three criteria, as follows:

    Rectal prolapse

    1. Grading standard Ⅰ degree: the rectal mucosa prolapses outside the anus when defecation or increasing abdominal pressure.

    Degree II: Full-thickness rectum prolapses outside the anus when defecation or increased abdominal pressure.

    Degree III: When defecation or increased abdominal pressure, the anal canal and rectum or part of the sigmoid colon prolapse outside the anus. All kinds of prolapse diagnosis should indicate the prolapse length.

    2. Judgment of anal sphincter function in patients with rectal prolapse

    (1) Good function of anal sphincter: self-controlled defecation, strong contraction of sphincter, and good anus closure.

    (2) Anal sphincter dysfunction: usually mucus overflows outside the anus, sometimes loose stools cannot be controlled, sphincter contraction is weak, and the anal mouth is not tightly closed.

    (3) No anal sphincter function: usually gas and loose stool cannot be controlled, sometimes dry stool cannot be controlled, sphincter atrophy, anal inability to contract, and anus cannot be closed.

    3. Curative effect standard of rectal prolapse

    (1) Recovery: The symptoms of degree I prolapse disappear and the rectal mucosa no longer protrudes outside the anus; For degree II and third degree prolapse, the entire thickness of the rectum no longer prolapses outside the anus.

    (2) Improvement: The symptoms have basically disappeared, and the prolapse is significantly reduced.

    (3) Invalid: no obvious change after treatment.

    Second, the diagnosis of rectal prolapse

    1. Anal inspection: It can be found that there is a soft mass of intestinal mucosa prolapsed from the anus during defecation, and the intestinal mucosa prolapsed from the anus during defecation.

    2. Digital rectal examination: the doctor puts a finger into the patient's anus, which is a simple and very important clinical examination method to check the disease.

    3. Routine examination of hematuria and stool.

    4. Proctoscopy: the rectum is inspected using a proctoscope.

    5. Barium enema: check whether there is a long sigmoid colon.

    7. Defecography: It can be seen that the force row first appears in the rectum intussusception, and then develops into extrarectal prolapse.

    treatment

    The diagnosis of extrarectal prolapse is not difficult. The patient squats down to do a defecation movement and exerts force on the abdominal muscles, and the prolapse can appear. Part of the prolapse shows a round, red, smooth surface, and the mucous membrane is "radial" folds, soft, and retracts by itself after defecation. If it's over

    Rectal prolapse

    If it is complete, the prolapse is longer, the prolapse is pagoda-like or spherical, and ring-shaped rectal mucosal folds can be seen on the surface. On digital rectal examination, the sphincter muscles were loose and weak. If there is a small intestine in the prolapse, bowel sounds can sometimes be heard.

    Rectal mucosal prolapse needs to be differentiated from circular internal hemorrhoids. In addition to the different medical history, when the annular internal hemorrhoids prolapse, hyperemic hemorrhoids can be seen, which are plum-shaped, easy to bleed, and there is a normal mucosa that is sunken between the hemorrhoids. In digital rectal examination, the sphincter muscles contract strongly, while the rectal mucosa prolapses and relax, which is an important point of identification.

    Diagnosis of internal rectal prolapse is difficult, and defecography is needed to assist in the diagnosis. However, when the patient complains of obstruction and incomplete defecation in the rectal ampulla, the disease should be suspected.

    <1> Non-surgical treatment

    Most children with rectal prolapse can heal by themselves, so non-surgical treatment is the main treatment. That is, with the growth and development of children and the formation of sacral curvature, rectal prolapse will gradually disappear. If constipation is corrected, develop good bowel habits. Defecation time should be shortened and reset immediately after defecation

    Rectal prolapse

    . If the prolapse time is long, prolapse, congestion, or edema, you should take the prone or lateral position, immediately reset the prolapse, push the prolapse into the anus, and do a digital rectal examination after recovery, and push the prolapsed bowel above the sphincter. After manual reduction, cover the anus with gauze rolls, and then fix the two buttocks with tape to temporarily close the anus to prevent crying or increased abdominal pressure from recurring in a short time. If you have been sick for a long time, the above methods are still ineffective, and injection therapy can be used. Method: Inject carbolic acid vegetable oil into the rectal mucosa or a circle around the rectum, and inject 4 to 5 places, each injection, the total amount. The route of injection can be to inject the drug into the submucosa under direct vision through an anoscope to make the mucosa adhere to the muscle layer; or through the perianal skin, perform perirectal injection under digital rectal examination to make the rectum and the surrounding adhesion fixed.

    , surgical treatment

    Adult incomplete prolapse or mild complete prolapse, if the sphincter tension is normal or slightly weak, it can be treated like three female hemorrhoids resection or rubber band ligation, or sclerosing agent injection can be used. If the sphincter is loose, consider anal ring reduction or sphincteroplasty.

    The treatment of adult complete rectal prolapse is mainly based on surgery. There are four types of surgical approaches: transabdominal, transperineum, transabdominal perineum, and sacrum. The surgical method is better than mine, but each has its advantages and disadvantages and recurrence rate. No single surgical method can be used for all patients. Sometimes several surgical methods are needed for the same patient. In the past, surgery only paid attention to repairing the pelvic floor defect, and the recurrence rate was high. In recent years, the intussusception theory of rectal prolapse has been studied, and the surgery is focused on treating the rectum itself. The following operations are now used.

    1. Rectal suspension and fixation

    1. Ripstein operation: cut the peritoneum on both sides of the rectum through the abdomen, free the posterior wall of the rectum to the tip of the tailbone, and improve the rectum. Surround the upper rectum with a 5cm wide Teflon mesh sling, and fix it to the presacral fascia and periosteum under the sacral carina, and sew the edge of the sling to the rectum

    Rectal prolapse

    The front wall and its side walls are not repaired on the pelvic floor. Finally, suture the peritoneal incision on both sides of the rectum and all layers of the abdominal wall. The main point of this operation is to improve the pelvic depression, the operation is simple, there is no need to remove the intestine, and the recurrence rate and mortality are low. Currently, this operation is mostly used in the United States, Australia and other countries. But there are still certain complications, such as fecal impaction obstruction, presacral hemorrhage, stenosis, adhesive small bowel obstruction, infection and sling slippage. Gorden integrated the results of 1111 cases of rectal prolapse using Ripstein surgery. The recurrence rate was 2.3% and the complications were 16.6%. Tjandra (1993) treated 169 cases of rectal prolapse in 27 years, and performed 185 cases of operations, including 142 cases of Ripstein operation, 42 cases of postoperative constipation, of which 27 cases had constipation before operation and 15 cases were postoperative As a result, 7 cases had fecal obstruction after operation. 35% of patients undergoing Ripstein surgery are not satisfied with the effect, because the symptoms of intestinal dysfunction (constipation, diarrhea or alternate constipation and diarrhea) still persist. Therefore, he pointed out that for patients with constipation of rectal prolapse, bowel resection with or without fixation is better than Ripstein's procedure.

    2. Ivalon sponge implantation: This operation was first created by Well, so it is also called Well surgery, also known as posterior rectal suspension fixation. At present, this method is mostly used in the UK to treat adult complete rectal prolapse. Method: Free the rectum through the abdomen to the back wall of the anorectal ring, sometimes cut off the upper half of the rectal lateral ligament, suture the semicircular Ivalon sponge sheet into the sacral cavity with non-absorbable sutures, pull the rectum upward, and place it on the Ivalon sheet The front, or just wrap around with free rectal suture, not with sacrum, to avoid presacral bleeding. Suture the Ivalon sponge to the side wall of the rectum, and keep the anterior wall of the rectum open with a gap of about 2 to 3 cm wide to avoid narrowing the intestinal cavity. Finally, cover the sponge and rectum with pelvic peritoneum. The advantage of this method is straight

    Rectal prolapse

    The fixation of the intestine and sacrum makes the rectum harden and prevents the formation of intussusception. The mortality and recurrence rate are low. If there is an infection, the sponge piece becomes a foreign body and a fistula will form. The main complication of this operation is pelvic suppuration caused by the implantation of a sponge sheet. Prevention requirements: ①Sufficient colon preparations should be made before surgery; ②Antibiotic powder should be placed in the thin slices; ③High-dose broad-spectrum antibiotics should be used during the operation; ④Hemostasis thoroughly; ⑤If the conjunctiva is accidentally broken during the operation, It should not be implanted. If a pelvic infection occurs, the suspension sheet needs to be removed. There have been reports of no recurrence of rectal prolapse after removal. Marti (1990) collected literature and reported 688 Well operations, with an infection rate of 2.3%, a surgical mortality rate of 1.2%, and a recurrence rate of 3.3%.

    3. Suspend the rectum on the sacrum: In the early period, Orr fixed the rectum on the sacrum with two pieces of fascia lata, which is twice as prolapsed (generally, the folding should not exceed 5 layers). The fold of the intestinal wall must be down and the stitches must not be up. Each piece is about 2cm wide and about 10cm long. After the rectum is properly freed, one end of the fascia lata is sutured to the raised anterior and lateral wall of the rectum, and the other end is sutured to fix the sacral promontory to achieve the purpose of suspension. In recent years, it has been advocated to replace the fascia lata with nylon or silk bands or to remove two fascias from the anterior rectus sheath, and the effect is good. There have been two reports of Orr surgery in China, with a total of 31 cases, and the recurrence rate was 19.3%. In Shanghai Changhai Hospital, more than 20 cases of adult complete rectal prolapse were treated with silk suspending and immobilization of the rectum. The length of the prolapse was 8~26cm. The method was to sew two silk ribbons (1cm×12cm) with one end on the front wall of the rectum. On the side, the other end was sutured to the sacral carina and the fascia under the sacral carina. The posterior wall of the rectum was not separated. The first case of intestinal prolapse had a 26cm suspension and fixed it with a temporary sigmoid colostomy. After putting it back into the abdominal cavity, the postoperative effect was good. More than 20 cases were followed up for more than 10 years, and there was no recurrence.

    4. Anterior rectal wall folding: In 1953, Shen Kefei proposed an anterior rectal wall folding based on the pathogenesis of adult complete rectal prolapse. Method: Transabdominal free to improve rectum. Lift the lower part of the sigmoid colon up, in front of the upper end of the rectum and the lower end of the sigmoid colon

    Rectal prolapse

    The wall is folded and sutured in several layers from top to bottom or bottom to top, and each layer is sutured with 5-6 stitches intermittently with silk thread. Each folded layer can shorten the anterior wall of the rectum by 2 to 3cm, and every two layers are separated by 2cm. Once the length of the intestinal wall is folded, it can only pass through the serosamus layer. Folding the anterior wall of the rectum shortens and hardens the rectum, and fixes it with the sacrum (sometimes the rectal side wall is sutured and fixed to the presacral fascia), which not only solves the disease of the rectum itself, but also strengthens the fixation at the junction of the B and rectum Point, in line with the view of treating intussusception. Shanghai Changhai Hospital reported 41 cases, only 4 cases recurred (9.8%), 12 cases had complications, 7 cases of lower abdominal pain during urination, 2 cases of residual urine, 1 case each of abdominal abscess, wound infection and ventromedial neuritis.

    5. Nigro operation: Nigro believes that because the puborectalis muscle loses its contraction effect and cannot pull the rectum forward, the pelvic floor defect enlarges, the "anal right angle" disappears, and the rectum becomes vertical, causing the rectum to prolapse, so he advocates reconstruction Rectal sling. Nigro fixed the lower rectum posteriorly and laterally with a Teflon band, and pulled the rectum forward, and finally sutured the Teflon band to the pubic bone to establish an "anal right angle". After the operation, the sling can be touched on the digital rectal examination, but the sling has no contraction effect. The advantage of this surgery over sacral fixation is that the pelvic fixation is better, because it indirectly supports the bladder, it can still improve bladder function. Nigro reported more than 60 cases. After more than 10 years of follow-up, no recurrence occurred. This operation is more difficult. The main complications are bleeding and infection, which requires more experienced doctors.

    Second, prolapsed bowel resection

    1. Altemeir operation: Resection of the rectosigmoid colon through the perineum. Altemeir advocated a one-stage resection of the prolapsed bowel through the perineum. This operation is especially suitable for the elderly who are not suitable for transabdominal surgery, who have prolapsed for a long time, cannot be reset, or have intestinal necrosis.

    The advantages are: ① Entering from the perineum, anatomical variation can be seen clearly and easy to repair. ②No need for anesthesia

    Rectal prolapse

    Deep, the elderly are easy to tolerate deeply. ③At the same time, repair the sliding hernia and remove the lengthy intestine. ④ There is no need to transplant artificial fabrics to reduce the chance of infection. ⑤The mortality and recurrence rate are low. However, this method still has certain complications, such as perineal and pelvic abscess, and rectal stricture. Altemeir (1977) reported 159 cases and 8 relapses (5.03%). 1 case died. 47 cases of early complications, such as perineal abscess (6 cases), cystitis (14 cases), pyelonephritis (7 cases), atelectasis (7 cases), cardiac insufficiency (6 cases), hepatitis (4 cases) ), ascites (3 cases). 6 cases of late complications: pelvic abscess (4 cases), rectal stenosis (2 cases).

    2. Goldberg operation, transabdominal resection of the sigmoid colon + fixation: As the prolapsed bowel resection through the perineum has certain complications, Goldberg advocates that after the rectum is freed through the abdomen, the rectum should be improved, the side wall of the rectum and the sacral periosteum should be fixed and removed The lengthy sigmoid colon works well. In 1980, he summarized 103 cases in 20 years (1952~1977), and only 1 case died. During the follow-up, 9 cases had mucosal prolapse, and the recurrence cases were treated with carbolic acid vegetable oil injection or rubber band ligation, and the effect was good. Complications in 12 cases (12%): 3 cases each for colonic obstruction and small bowel obstruction, 1 case each for anastomotic fistula, wound dehiscence, severe presacral hemorrhage, fecal fistula, acute pancreatitis, and acute esophageal hiatal hernia.

    3. Anal circle reduction surgery: Place a 1.5cm wide fascial nylon mesh belt or silicone rubber mesh belt around the anal canal to reduce the anus to prevent rectal prolapse. Only suitable for the elderly and the physically weak. Method: Make a small cut at the front and back of the anus, and use curved vascular forceps to separate the subcutaneous edge through the anus to make the two cuts communicate. The nylon mesh belt is wound around the upper part of the anal canal through the incision and formed into a ring to allow an index finger to pass through the anus. Postoperative infection and fecal impaction are prone to occur, and the recurrence rate is high.

    4. PPH operation: This operation uses a special surgical instrument called "PPH anastomosis" to effectively treat rectal prolapse through circular resection of the rectal mucosa and submucosa tissue. Compared with traditional surgery, PPH surgery has the following advantages: short operation time (the entire operation process takes about 20-30 minutes), less postoperative pain, fast recovery time, short hospital stay (only 2 to 3 days after surgery), postoperative The advantages of fewer complications (such as anal stenosis, fecal incontinence, etc.) and low recurrence rate.

    Painless rectal prolapse surgery, technical advantages of PPH:

    1. Painless: the tissue is cut and anastomosed instantly, without touching the nerve cell gathering area.

    2. Safety: There is no need to remove the anal cushion, the normal function of the anus is preserved to the greatest extent, and complications such as anal stenosis and anal incontinence are avoided.

    3. No need to be hospitalized: Traditional surgical methods require 7-10 days of hospitalization, while PPH minimally invasive surgery does not require hospitalization.

    4. Small trauma and quick recovery: the circular stapling of the mucosa is a non-open wound, with less bleeding, eliminating the trouble of dressing change after surgery, and returning to normal life quickly.

    5. The recurrence rate is extremely low: as long as the patient pays attention to diet and does not drink alcohol after the operation, there is no recurrence in the return visit.

    6. Suitable for: Because of less damage, it is especially suitable for middle-aged and elderly people, white-collar workers who pay attention to efficiency, and those who have relapsed in traditional treatment, and patients with mild prolapse and rectal mucosal prolapse.

    <3> Laser treatment of rectal prolapse

    Laser surgical cutting method: according to the cause of prolapse and pathological changes for different surgical treatments.

    The surgical method is to pull the prolapse out of the anus, and then laser longitudinally incise the mucosa from about 2.5cm above the tooth line before the prolapse. Separate the mucosa at the incision margin from the muscle layer and then pull the incision to both sides to form a transverse incision. Excise the excess mucosa, suture the deep layer of the mucosa and the muscle layer, and finally suture the wound. The posterior laser treatment method is the same as incision and suture. After the operation, the prolapsed part is pushed back to the rectum.

    The advantage of laser resection is that the incision is clean and easy to operate. The surgical method is to pull the prolapse out of the anus, and then laser longitudinally incise the mucosa from about 2.5cm above the tooth line before the prolapse. Separate the mucosa at the incision margin from the muscle layer and then pull the incision to both sides to form a transverse incision. Excise the excess mucosa, suture the deep layer of the mucosa and the muscle layer, and finally suture the wound. The posterior laser treatment method is the same as incision and suture. After the operation, the prolapsed part is pushed back to the rectum.

    <4>, treatment options

    There are many treatment methods for rectal prolapse, and different treatments should be selected according to age, type of prolapse and general condition. Each type of surgery has its advantages and disadvantages and recurrence rate. There is no one type of surgery that can be used for all patients who need surgery. Sometimes several surgery methods are needed for the same patient. For example, Goligher used 10 surgical methods (153 times) for 152 cases of complete rectal prolapse; 78 cases of rectal prolapse in Hangzhou Kangtai Hospital also used 11 treatment methods before 1981. No matter what kind of surgery is used, the various factors that cause rectal prolapse should be removed as much as possible after the operation, so that the rectum and sigmoid colon fixed by the operation can be firmly adhered to the surrounding tissues.

    Children and elderly incomplete and complete anorectal prolapse should be treated with non-surgical treatment first. If it does not work, intrarectal submucosal injection can be used. Intra-abdominal surgery is rarely needed. Adult incomplete prolapse can be used injection therapy, mucosal longitudinal section and transverse suture. For adults with complete prolapse, it is safe to use intra-abdominal rectal fixation or suspension, with low complications, morbidity and mortality, and good results. Partial resection of the sigmoid colon and rectum is also effective, but there are more complications after surgery. Prolapse or intestinal necrosis that cannot be returned can undergo partial rectosigmoid resection through the perineum.

    <5> Acupuncture and moxibustion treatment of rectal prolapse

    1. Moxibustion treatment of rectal prolapse:

    (1) Acupoint selection. Main points: Baihui, Changqiang. Matching points: Dachangshu, Shangjuxu, Pishu, Shenshu, Qihai, Guanyuan.

    (2) Governing Law: Divided into two methods. One is moxa moxibustion and the other is ginger moxibustion. For moxa moxibustion, the main acupoints must be taken each time, with 2 to 3 matching acupoints, taken in turns. After the moxa roll is lit, aim at the acupoints at a distance of about 3 to 5 cm, so that the patient feels warm without burning. When applying moxibustion at Baihui point, you can use your left hand to separate your hair to expose the acupuncture points, and place your food and middle fingers on both sides of the moxibustion point. Generally, moxibustion for 5 to 7 minutes per acupoint, with the degree of local blush. Baihui point should be moxibustion followed by pecking moxibustion for 5 to 10 minutes. When pediatric moxibustion is applied, the time and temperature should be adjusted at any time to prevent burns. The method is applied once a day, 7 days as a course of treatment, and the course of treatment is intermittent for 3 days.

    2. Acupuncture treatment of rectal prolapse:

    (1) The main acupoints are divided into 2 groups. 1. Changqiang, Chengshan, Dachangshu, Qihaishu. 2. Baihui, Cilian.

    (2) Treatment The first group of points is used for acupuncture, and the second group of points is used for moxibustion. Take 2 to 3 points each time, the points can be used in turn. After acupuncture has gained qi, leave the needle for 20-30 minutes, and moxibustion with moxa sticks for 20 minutes per acupoint, once a day, 7 times as a course of treatment, with an interval of 3 to 5 days.

    3. Body acupuncture treatment of rectal prolapse:

    (1) The main acupoints: Changqiang and Huiyang. Distribution points: Chengshan, Baihui.

    (2) The main points of the treatment method are taken, and the matching points are added 1 each time. At Changqiang point, insert the needle from the depression of the tailbone tip, and pierce the needle up to 1.5 inches parallel to the sacrum, and pierce the needle point of Huiyang point 1.5 inches inward. After entering the needle quickly, press and lift slowly 9 times; use weak stimulation for matching points, Twist slowly 4 to 5 times. Keep the needle for 20 minutes. 1 time a day, 6 times as a course of treatment.

    <6> Food therapy for rectal prolapse

    Common dietary prescriptions:

    (1) Formula: 30 grams of Astragalus, 1 pig intestine. Production method: Wash the fresh pig intestines, repeatedly wash and deodorize them for later use. Then take the yellow test, collect and arrange the stilbene, wash it and wrap it with gauze, and boil it in cold water together with the spare pig intestine head, so that the large intestine head is boiled, discard the medicine residue, add salt, wine and other condiments before eating. Suitable for children with rectal prolapse.

    (2) Formula: 1 rice eel, 60 grams of lean pork, 30 grams of astragalus. Method of preparation: the rice field eel is cleaned and boiled with lean pork and astragalus. Add salt, sugar and rice wine, and eat after removing the astragalus. Suitable for adults with rectal prolapse.

    (3) Formula: 60 grams each of rice and millet. Production method: Wash rice and millet, add water and cook until half-cooked, then add 1 kg of soy milk, stir well and cook, and it is edible. Function: To invigorate the spleen and stomach, to replenish deficiency. Suitable for the young and old with rectal prolapse.

    <7> Medicinal recipes for rectal prolapse

    Mung bean, sticky rice and pig intestines: Put 50-60 grams of mung beans and 20-30 grams of glutinous rice into 250-300 grams of large intestine, tie both ends with thread, add water and boil for 2 hours to take out, cut into sections for seasoning. To serve with food. Indications of prolapse.

    Boiled large intestine with mung bean and glutinous rice: 50 grams each of mung beans and glutinous rice are put into 250 grams of pig large intestine, both ends are tied tightly with thread, put into a casserole, add appropriate amount of water and boil for 2 hours, and eat after overcooking. The function of clearing and reducing coke, reducing fire and dampness. Indications of senile prolapsed uterus or rectal part of redness, or combined with ulceration, bleeding, accompanied by short red urine, dry mouth and stuffy, fever; female leucorrhea increased, yellow and white with red.

    Astragalus and Atractylodes porridge: 30 grams of Astragalus, 15 grams of Atractylodes and Bupleurum, add an appropriate amount of water and decoct for 40 minutes, remove the residue and juice, add 100 grams of japonica rice and cook the porridge. Function to invigorate qi and invigorate the spleen, uplift the yang and raise depression. Indications of senile hypogastric deficiency, visceral sagging caused by weakness of the organs; symptoms of fatigue, shortness of breath and spontaneous sweating, especially when moving.

    Astragalus and Cornus Broth: 30g of Astragalus and 10g of Cornus, plus appropriate amount of water, fry for 30 minutes, remove the residue and extract the juice, add 100g of lean pork slices and cook thoroughly, seasoning. Drink soup and eat meat. Function to invigorate qi and uplift, nourish the kidney and invigorate the body. Indications of visceral ptosis of hypogastric deficiency; symptoms include fatigue, shortness of breath and laziness.

    Astragalus and Gorgon Boiled Pig Large Intestine: 150 grams of pig large intestine is slightly boiled in boiling water to remove the flavor. Add 30g each of Astragalus and Gorgon. Add appropriate amount of water and cook until the intestines are overcooked. Seasoning. Drink soup and eat intestines. Function to invigorate qi and invigorate the spleen, promote solidification. Indications of organ prolapse; symptoms of chronic diarrhea and prolapse of the anus.

    Astragalus and Astragalus and Red Dates Pot: 200g of fresh rice eel, slaughtered, remove the internal organs, cut into sections, put in a casserole with 30g Astragalus and 10 red dates, add appropriate amount of water and a little vegetable oil, cook over a small fire, and season. Drink soup and eat meat. Function to replenish qi and nourish blood, lift up. Indications for senile organ prolapse; symptoms include fatigue, dizziness, shortness of breath, backache, weakness, and pale complexion.

    <8> Classification treatment of rectal prolapse

    There are various treatments for rectal prolapse, and treatment should be based on the cause of the disease, the degree and type of prolapse.

    ① Children's rectal prolapse: Due to its physiological characteristics, the rectal prolapse of this group of people has a tendency to self-heal. Therefore, conservative treatment is mainly used and the accompanying systemic diseases are actively treated, such as whooping cough, diarrhea, and constipation. At the same time, acupuncture, massage and other therapies can be used, or topical medications can have a good effect. For older children who do not heal for years, surgery or injection therapy can also be used.

    ②Adult rectal mucosal prolapse: The injection therapy of injecting sclerosing agent should be the main method, or strong stimulation therapy such as acupuncture and moxibustion should be used. For the relaxation of the anal sphincter, rectal tightening or sphincter folding can be used.

    ③ Adult complete rectal prolapse: Both injection therapy and surgical therapy can be used, but appropriate methods should be selected for treatment according to the severity and type of prolapse.

    <9> Surgical methods for rectal prolapse

    During examination, mucus or fecal stains can be found in the underwear of the patient. Digital rectal examination can often find loose sphincter muscles and smooth mucous membranes. Ask the patient to take a squatting position and forcefully defecate downwards to make the rectum prolapse and facilitate diagnosis. If mucosal prolapse is seen about 4~5cm long and light red wrinkles or radial mucosa, it is diagnosed as double-folded mucosa on finger examination, soft in quality. For complete prolapse, you will see mucosal folds longer than 5 cm, in the form of circular grooves, thick fingers, and rectal cavity in the center of the prolapsed end.

    After the prolapse is reset, press the front wall with the fingers to increase the abdominal pressure of the patient, and the prolapse will not occur. However, if the back wall is compressed, the patient will defecate and exhale, and the prolapse can be repeated. Patients with internal prolapse often have constipation, poor defecation, incomplete defecation, and sometimes bloody mucus. Rectal prolapse is not seen during the examination, which makes the diagnosis difficult. The application of X-ray film photography technology for defecation imaging can show the prolapse and intussusception to establish the diagnosis.

    Rectal prolapse in children is mostly partial mucosal type. After actively improving the physique and treating the predisposing factors, most of them can heal themselves, so surgery is not necessary. If non-surgical treatment fails, sclerosing agent injection therapy can be considered, that is, phenol glycerol is injected into the rectal mucosa to fix the loose submucosal tissue. Alcohol can also be injected. It can also be embedded with perianal subcutaneous metal thread and removed after 3 weeks. It can also be embedded under the perianal skin with catgut. Only a few require major surgery similar to adult rectal prolapse.

    Adult rectal prolapse is mainly a complete full-thickness prolapse, so surgical treatment is often required, and there are many surgical methods, which can be roughly divided into the following categories:

    ①Prolapse of bowel resection;

    ②Resection or folding of prolapsed mucosa;

    ③ Anal ring contraction;

    ④Pelvic floor repair or strengthening;

    ⑤ Rectal suspension and fixation;

    ⑥ Improving or closing rectal bladder or rectal uterine depression surgery;

    ⑦Intestinal tube or mesenteric shortening;

    ⑧ Repair the sliding hernia of the perineum. There are trans-abdominal, trans-perineal, trans-abdominal-perineum, and trans-sacral approaches for surgery. Each of the above operations has its own advantages and disadvantages and recurrence rate. The surgical method should be determined according to the condition. Sometimes several surgical methods can be used to cure the same patient. For example, 10 surgical methods are used for 152 cases of complete rectal prolapse. 173 operations were performed. In the past, many surgeries only paid attention to repairing pelvic floor defects, and the recurrence rate was high; in recent years, it has been noted that intussusception is the main pathogenesis of rectal prolapse, and the surgical methods are mainly for the rectum itself.

    complication

    1. Bleeding: Occasionally, severe bleeding may occur due to isolated rectal ulcer.

    2. Anal incontinence: 16% to 20% have gas incontinence and 17% to 24% are completely incontinent. The causes of incontinence caused by rectal prolapse include:

    (1) Rectal prolapse produces substantial rectal dilation, causing the internal anal sphincter to continue to reflexly inhibit and relax, especially in the elderly due to weak puborectal muscles and the valve does not play a major role. Once the internal sphincter is dysfunctional, Cause incontinence;

    (2) Childbirth or long-term hard defecation can cause abnormal perineum decline, causing stretched damage to the pudendal nerve, and denervation and denervation of the pelvic striated muscle. Anorectal pressure measurement is helpful to understand the function of anal sphincter. The results of Zhang Lianyang et al.’s anal canal pressure measurement on patients with internal rectal prolapse indicate that there is a decrease in anal pressure. Among them, rectal mucosal prolapse has anal resting pressure. While the full-thickness rectal intussusception has a decrease in the resting pressure of the anal canal and cough pressure.

    3. Anal pain.

    health care

    1. Postoperative care for rectal prolapse

    After rectal prolapse, oral antibiotics are given to prevent and treat infectious complications for about 7 to 10 days.

    When given multivitamin preparations. Take 10ml of liquid paraffin every day after surgery to avoid prolonged squatting and exertion. If the abdominal pressure increases, it is not good for healing.

    Patients with rectal prolapse are given a low-fiber diet after surgery, and excessive intake of crude fiber food can easily damage the intestinal wall. After the operation, you should avoid eating strong irritating foods such as pepper and wine. To avoid congestion and edema affecting healing.

    Within 1 to 2 weeks of postoperative recovery, patients with rectal prolapse should reduce their activities and lie down and rest, which is extremely beneficial for a complete postoperative recovery. If the patient's activities are strengthened or other exercises after the operation can increase the abdominal pressure, the treatment surface can be separated, and blood can be emitted. Especially after laser surgery, the patient's pain is mild, and some even have no pain or discomfort, so it should be avoided.

    Patients are given a low-fiber diet after surgery, and excessive intake of crude fiber food can easily damage the intestinal wall. After the operation, you should avoid eating strong irritating foods such as pepper and wine. To avoid congestion and edema affecting healing.

    ●Oral antibiotics are given to prevent and treat infection complications for about 7-10 days after surgery, and multivitamin preparations are also given.

    ●Oral liquid paraffin 10mL daily after surgery to avoid prolonged squatting and exertion. If the abdominal pressure increases, it is not good for healing.

    ●In the 1 to 2 weeks of postoperative recovery, the patient should reduce activities and lie down and rest, which is extremely beneficial to a complete postoperative recovery.

    ●If the patient's activities are strengthened or other exercises after the operation can increase the abdominal pressure, the treatment surface will be separated, and blood may be emitted. Especially after laser surgery, the patient's pain is mild, and some even have no pain or discomfort, so it should be avoided.

    2. Postoperative care of rectal prolapse

    1. Observe the condition closely. Rest in bed on the day after the operation, and adopt a comfortable position; get out of bed the next day for proper activities, and gradually increase the amount of activity in the future, but avoid strenuous activities.

    2. Diet guidance: Fasting on the day after the operation, liquids can be taken the next day, after 3 days, change to general food, eat less fat, fat, and greasy things, avoid spicy, tobacco, alcohol, and stimulating products. Eat more nutritious and fiber-rich products. Digested things, such as fresh vegetables, fruits, and crude fiber foods.

    3. Defecation guidance After the operation, the patient is instructed to control the stool discharge within 2 to 3 days (to prevent bleeding and contaminate the wound). The first bowel movement should be injected with corkscrew or liquid paraffin into the anus to assist in defecation.

    4. Pain care: Postoperative local tissue damage, inflammatory edema of the wound, and a large amount of injections can cause varying degrees of pain or discomfort when falling. At this time, you should explain patiently, do a good job of psychological care, introduce benign information in time, and instruct patients to adopt relaxation therapies, such as listening to music, watching TV, and taking deep breaths, to distract and enable them to develop their potential for pain tolerance, and use analgesics when necessary.

    Nursing

    1. Life care of patients with rectal prolapse

    1. The patient should first actively treat various factors that cause rectal prolapse under the guidance of a doctor, and treat chronic cough, constipation and other inducements, and change the state of malnutrition. In the early stage of this disease, infants only need to eliminate the cause, or use tape to draw the hips together during defecation, which can help tighten the anus, and prolapse can be cured.

    2. The rectal prolapse should be reset immediately, and the caregiver or patient can gently lift it back by hand. If it is not easy to reset due to edema after prolapse, it is necessary to go to the hospital to reset under anesthesia. Need to lie still for half an hour after reduction, and take laxatives.

    3. Encourage patients to insist on doing auxiliary exercises, such as practicing contraction of the anus 2 times a day for 5-10 minutes each time to enhance the contraction ability of the anal sphincter.

    4. Disable the squatting position during defecation, and use the bedpan prone position to defecate on the bed to reduce the chance of prolapse.

    5. Some patients can also try the traditional Chinese medicine Buzhong Yiqi Decoction or acupuncture treatment, with the main methods of invigorating qi, lifting and strengthening astringent.

    6. For severe rectal prolapse or non-surgical long-term treatment ineffective, they should be advised to accept anal ring contraction or rectal suspension fixation and other operations.

    2. Dietary care of patients with rectal prolapse

    1. The diet of patients with rectal prolapse should be light, easy to digest, less scum, so as not to increase the frequency of defecation.

    2. Patients with habitual constipation or poor defecation should eat more vegetables and fruits that contain more fiber to keep their stool soft, and do not use too much force or squatting in the toilet during defecation. When an adult has stool, the posture should be reclining, not standing upright. Pay attention to diet to avoid constipation or diarrhea to prevent rectal prolapse.

    3. Patients should not eat irritating foods, such as spicy oil, mustard, chili, etc.; should not overeat greasy food; should not eat hairtails, crabs and other hair materials.

    prevention

    1. Preventive measures for rectal prolapse

    Patients with rectal prolapse should insist on physical exercises and strong abdominal muscle exercises in order to improve the body's deficiency of qi and blood and insufficient qi, which is of great practical significance for consolidating the curative effect and preventing rectal prolapse. Specific preventive measures include:

    (1) Actively remove various predisposing factors, such as coughing, sitting for a long time, diarrhea, long-term cough, enteritis and other diseases, especially infants and young children.

    (2) Pay attention to increasing nutrition, regular life, do not squat on the potty for a long time, develop the habit of defecation regularly, prevent dryness of the stool, and take a hot bath after going to bed and before going to bed to stimulate the contraction of the anal sphincter , Has a positive effect on the prevention of rectal prolapse.

    (3) For patients with habitual constipation or difficulty in defecation, in addition to eating more fiber-containing foods, do not use excessive force during defecation.

    (4) Women should take adequate rest during childbirth and after delivery to protect the normal function of the anal sphincter. If there is a prolapse of uterus and internal organs, treatment should be promptly.

    (5) Do anal gymnastics frequently to promote the movement of the levator ani muscle group, which has the effect of enhancing the function of the anal sphincter and has a certain effect on preventing this disease.

    2. Prevent rectal prolapse-anal function exercise

    Anal functional exercise is one of the important contents of anal self-care. It can not only effectively prevent and treat various common anorectal diseases, such as hemorrhoids, rectal prolapse, anal fissure, anal stenosis, anal incontinence, etc., but also for patients after anal surgery. Functional restoration has an extremely important role. Here are four simple and easy methods:

    1. Finger expansion exercise: apply a proper amount of lubricant to the index finger of the right hand, first press and knead the anus for 1 minute, then slowly extend into the anus for 2 knuckles, expand the anus in four directions forward, backward, left, and right for 3 minutes. Use even force and avoid The use of inappropriate violence can be done once after the toilet and before going to bed. It is especially suitable for patients after anal surgery and patients with anal canal stenosis and advanced anal fissure.

    2. Supine knee bending exercise: lying on your back, bend your knees, raise your head, stretch your right hand to your left knee, then relax and recover; then bend your knees and raise your head, stretch your left hand to your right knee, relax and recover. Exercise 30 times each time.

    3. Rapid contraction exercise: It can contract the anus quickly, 30 times per minute, 2-3 times a day.

    4. Anus lift exercise: sit quietly, relax, clamp the buttocks and thighs forcefully, close your eyes, lift the anus upward when you breathe in, close your breath after lifting the anus, and then relax the whole body when you breathe out. Practice 90 times each time. Three times a day, once after going to bed and before going to bed.

    Three, prevent rectal prolapse daily attention

    Patients with rectal prolapse should insist on physical exercises and strong abdominal muscle exercises to improve the body's deficiency of qi and blood and insufficient qi. This is of great practical significance for consolidating the curative effect and preventing rectal prolapse. Specific preventive measures are:

    ① Actively remove various predisposing factors such as coughing, sitting for a long time, standing for a long time, diarrhea, long-term coughing, enteritis and other diseases, especially infants and young children

    ②Patients with habitual constipation or difficulty defecation should not use excessive force when defecation besides eating more foods containing fiber

    ③Women should have enough rest during childbirth and postpartum to protect the normal function of the anal sphincter. If there is uterine ptosis and visceral ptosis, prompt treatment

    ④Do regular anal gymnastics to promote the exercise of the levator ani muscle group, which has the effect of enhancing the function of anal sphincter and has a certain effect on preventing rectal prolapse.

    ⑤Usually pay attention to increase nutrition and regularize your life. Do not squat on the potty for a long time to develop the habit of regular bowel movements. Prevent dry stools. After and before going to bed, you can use a hot bath to stimulate the contraction of the anal sphincter to prevent rectal prolapse. .

    harm

    As a kind of anorectal disease, rectal prolapse has many harms to human body and life. There are mainly the following four types:

    1. In the early stage of rectal prolapse, there is constipation, irregular bowel movements, and always feel full rectal fullness and poor bowel movements. The mass protrudes during defecation, but it can retract on its own.

    2. After the rectal prolapse gradually worsens, in addition to the prolapse of the anus during defecation, it can also cause the prolapse of the anus under the condition of a little abdominal pressure such as coughing or walking. It is often unable to retract on its own. It is necessary to hold the prolapsed mass by hand Into the anus. Excretion of mucus due to frequent prolapse will often contaminate underwear.

    3. Rectal prolapse can cause bleeding and diarrhea when the intestinal mucosa is damaged and ulcers occur. If the prolapsed mass cannot be retracted, inflammation and swelling are prone to occur, and pain will occur, which will further aggravate constipation.

    Fourth, the prolapse repeatedly drops and retracts in the rectum, causing mucosal congestion and edema, and a large amount of mucus and bloody substances are often discharged from the anus. Patients often feel swelling and dragging of the pelvis and lumbosacral area, dull pain in the perineum and the back of the thigh.

    In addition, rectal prolapse is more serious, long-term prolapse will cause pudendal nerve damage to cause anal incontinence, ulcers, perianal infection, rectal bleeding, prolapsed bowel edema, stenosis and necrosis.

    Diagnosis and differentiation of rectal prolapse

    In the early stage, after defecation, the mucous membrane protrudes from the anus and can retract on its own; later, it can’t recover on its own. You need to lift it up with your hands to reposition. There is often a little mucus flowing out of the anus. After defecation, there is a feeling of falling and incomplete defecation. Increased; then after coughing, sneezing, walking, standing for a long time or a little bit of force, you can come out. After prolapse, you can feel local swelling and pain in the lumbosacral area. The prolapsed mucosa has mucus secretion, and the mucosa is often irritated. Congestion, edema, erosion and ulcers occur, secretion of mucus that can be mixed with blood, irritates the perianal skin, and can cause itching. Due to the relaxation of the anal sphincter, incarceration rarely occurs. Once the incarceration occurs, the patient feels severe local pain. The tumor cannot be reset with a hand rest. The prolapse of the anal canal quickly appears swelling, congestion and cyanosis, and mucosal folds disappear. If treated in time, strangulation and necrosis can occur. When there is no prolapse, the physical examination shows that the anal mouth is spread out, and the digital examination often finds that the anal sphincter is loose and the contraction force is weakened. The rectal pedicled polyps and severe internal hemorrhoids prolapse should be excluded during the examination. The patient can be asked to squat hard. After the anal canal is completely prolapsed, the examination will be performed to determine the partial and complete prolapse. Clinically, it is divided into three degrees according to the degree of prolapse: one degree is rectal mucosal prolapse, second degree is full-thickness rectal prolapse, and third degree is rectal and sigmoid colon prolapse.

    Rectal prolapse can be divided into children rectal prolapse and adult rectal prolapse. The two types of patients differ greatly in their identification and diagnosis because of their age and physical conditions.

    Rectal prolapse in children is mostly partial mucosal type. After actively improving the physical fitness and treating the predisposing factors, it can heal itself, so it is not necessary. If non-surgical treatment fails, sclerosing agent injection therapy can be considered, that is, 5% phenol glycerol is injected into the rectal mucosa to fix the loose submucosa tissue. 95% alcohol can also be injected. Gabriel advocates embedding with perianal subcutaneous metal thread, which will be removed after 3 weeks. It can also be embedded under perianal skin with catgut. Only a few require major surgery similar to adult rectal prolapse.

    Adult rectal prolapse is dominated by complete full-thickness prolapse, so surgical treatment is often required, and there are many surgical methods. According to statistics, there are 54 types since Moschowitz in 1912, which can be roughly divided into the following categories:

    ①Prolapse of bowel resection;

    ②Resection or folding of the prolapsed mucosa;

    ③ Anal ring reduction surgery;

    ④Pelvic floor repair or strengthening;

    ⑤ Rectal suspension and fixation;

    ⑥ Improving or closing rectal bladder or rectal uterine depression surgery;

    ⑦Intestinal tube or mesenteric shortening;

    ⑧ Repair the sliding hernia of the perineum.

    There are trans-abdominal, trans-perineal, trans-abdominal-perineum, and trans-sacral approaches for surgery. Each of the above operations has its advantages and disadvantages and recurrence rate. The surgical method should be determined according to the condition. Sometimes several surgical methods can be used to cure the same patient. For example, Goligher used 10 surgical methods on 152 cases of complete rectal prolapse. 173 operations were performed. In the past, many surgeries only paid attention to repairing pelvic floor defects, and the recurrence rate was high. In recent years, it has been noted that intussusception is the main pathogenesis of rectal prolapse, and the surgical methods are mainly for the rectum itself.

    Frequently Asked Questions

    According to Zhangzhou Anorectal Hospital's comprehensive clinical experience in the treatment of rectal prolapse for many years, the following common questions and answers about rectal prolapse are summarized, and the details are as follows:

    1. Why are the elderly prone to rectal prolapse?

    1) Rectal prolapse in the elderly is mostly caused by old age and weakness, insufficient qi and blood, depression of qi, and lack of qi. "Deficiency" is the main cause of the elderly.

    2) Due to the deterioration of the body's tissues and muscle relaxation in the elderly, plus some chronic diseases, such as constipation, bronchitis, cough, enlarged prostate, dysuria, etc. Frequent increase in abdominal pressure, while the diaphragm muscles decrease, press the abdominal organs to push the sigmoid colon and rectum downward, and because the elderly are weak and weak, the sphincter muscles are relaxed, and the amount of fat in the pelvic rectal fossa and ischiorectal fossa is reduced. This is also easy for the elderly. One of the reasons for incomplete rectal prolapse.

    3) In the treatment of the elderly suffering from rectal prolapse, attention should be paid not only to local pathogenic factors, but also to the overall condition of the whole body.

    2. Why are children prone to rectal prolapse?

    1) Due to the delicate physique of the child, the development is not fully mature, the vitality is not strong, the sacrum is not curved, the submucosal tissue of the rectum is relatively loose, the rectum lacks the support of the sacrum, and the rectum and pelvis are almost straight, that is, the state of vertical, relatively active , Is not conducive to fixation, and increases the load of the anal sphincter, and is prone to malnutrition, pertussis, enteritis, diarrhea and other diseases in childhood.

    2) The long-term intra-abdominal pressure increases and loses the traction and fixation effect on the rectum, and rectal prolapse is prone to occur. This is the main reason why children are susceptible to rectal prolapse.

    3) Clinically, it is also common to cause the disease in children to defecate, urinate and sit for too long.

    4) With the development of the pelvis and the curvature of the sacrum in children, most patients with rectal prolapse can often heal on their own, so non-surgical treatment is generally used.

    3. How do patients with rectal prolapse self-regulate?

    1. Normally, physical exercise should be strengthened to enhance physical fitness. The patient does levator ani exercises daily to strengthen the contraction function of the anal sphincter.

    2. Treat chronic cough, bladder stones, enlarged prostate, chronic constipation and diarrhea, and other diseases that increase abdominal pressure in time, and avoid long-term increase in abdominal pressure.

    3. Treat chronic diarrhea, constipation, internal hemorrhoids, rectal polyps and other diseases in time.

    4. Children with malnutrition should be treated in time, and those who are weak after the illness and the elderly and infirm should take Qi-lifting and lifting drugs.

    5. Reposition in time after rectal prolapse.

    6. Adjust your bowel habits, don't squat in the toilet for a long time and defecate excessively.

    4. How to care for rectal prolapse in children?

    The early manifestation of anal prolapse is only when there is a red, wet, and soft lump at the mouth of the anus during defecation, and the lump quickly shrinks into the anus after defecation. After repeated episodes, the lumps cannot be retracted immediately, and the lumps must be restored with hands. Due to frequent weight loss, the mucosa is stimulated by friction, mucus secretion increases, and the mucosa appears hyperemia, edema, bleeding, ulcers, and even necrosis. The anal canal and rectum turn outwards and protrude out of the anus, which is called anorectal prolapse, or prolapse in short. It mostly occurs in children under 4 years old, but babies under 1 year old are rarely seen suffering from this disease. Most of the disease can heal on its own with age.

    5. How to eat rectal prolapse?

    After getting rectal prolapse, special attention should be paid to diet to avoid aggravating the symptoms of rectal prolapse. Then, patients with rectal prolapse should pay attention to the following 3 aspects in diet, which are introduced as follows:

    (1) Patients with rectal prolapse should have a light diet, easy to digest, and less scum, so as not to increase the frequency of defecation.

    (2) Patients with habitual constipation or poor defecation should eat more vegetables and fruits that contain more fiber to keep their stool soft, and do not use too much force or squatting in the toilet during defecation. When adults have bowel movements, the posture should be reclining, not standing upright. Pay attention to diet to avoid constipation or diarrhea and prevent rectal prolapse.

    (3) In addition, patients with rectal prolapse should also be careful not to consume too much spicy oil, mustard, chili and other irritating foods. Be careful not to eat too greasy things, and eat less octopus and crabs.

    6. How to avoid the occurrence of prolapse in children?

    According to experts from Zhangzhou Anorectal Hospital, there are 3 ways to avoid rectal prolapse in children. The specific introduction is as follows:

    1. To make children develop a good habit of defecation regularly every day, and avoid sitting on the potty for too long.

    2. Children with constipation should drink plenty of water and eat more fiber-rich foods.

    3. For children with cough and recurrent diarrhea, the primary disease should be actively treated to prevent the occurrence of prolapse. For those who cannot recover from frequent prolapse, they must go to the hospital for treatment. If the general conservative treatment is still ineffective, then surgery must be performed.

    7. Who is prone to suffer from rectal prolapse?

    Who are susceptible to rectal prolapse, and what are the reasons why they are susceptible to rectal prolapse? According to experts, infants and the elderly are prone to rectal prolapse. The causes of rectal prolapse are as follows:

    Chinese medicine believes that children are prone to prolapse of the anus if the blood is not vigorous in children, and the blood in the elderly has declined. Rectal prolapse is very common in children under 5 years of age. Due to the delicate physique of children, the development is not fully mature, the vitality is not strong, the sacrum is not fully curved, the submucosa of the rectum is relatively loose, the rectum lacks the support of the sacrum, and the rectum and pelvis Almost straight, that is, a vertical state, relatively active, not conducive to fixation, and increase the load of the anal sphincter, and it is prone to malnutrition, pertussis, enteritis, diarrhea and other diseases in childhood. Long-term intra-abdominal pressure increases and loses the traction and fixation effect on the rectum, and rectal prolapse is prone to occur. This is the main reason why children are susceptible to rectal prolapse. Clinically, it is also common in children to defecate, urinate and sit for too long to induce this disease. With the development of the pelvis and the curvature of the sacrum in children, most patients with rectal prolapse can often heal on their own, so non-surgical treatment is generally used.

    Rectal prolapse in the elderly is mostly caused by old age and weakness, insufficient qi and blood, subsidence of qi, and lack of qi. "Deficiency" is the main cause of the elderly. Due to the deterioration of the body's tissues and muscle relaxation in the elderly, plus some chronic diseases, such as constipation, bronchitis, cough, enlarged prostate, and difficulty urinating. Frequent increases in abdominal pressure, while the diaphragm muscles drop, press the abdominal organs to push the sigmoid colon and rectum downward, and because the elderly are weak and weak, the sphincter muscles relax, the pelvic rectal fossa, ischiorectal fossa loses fat mass, which is also easy for the elderly One of the reasons for incomplete rectal prolapse. Therefore, in the treatment of the elderly suffering from rectal prolapse, attention should be paid not only to local pathogenic factors, but also to the overall condition of the whole body.

    For people who are susceptible to rectal prolapse, rectal prolapse should be prevented early to prevent constipation and diarrhea. The elderly can exercise properly to strengthen their physical fitness and stay away from rectal prolapse.

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