Rectal prolapse

Rectal prolapse
Diagnosis in short
Fibromuscular hyperplasia as seen in rectal prolapse. H&E stain.
LM	fibromuscular hyperplasia: lamina propria fibrosis and lamina propria muscle, thick muscularis propria, submucosal fibrosis, +/-ischemic mucosal changes
Site	rectum
Clinical history	women - multiparous & postmenopausal
Signs	"rectal mass"
Prevalence	not common
Prognosis	benign
Clin. DDx	rectal carcinoma (rarely)
Treatment	surgery

Rectal prolapse is a benign pathology of the rectum, typically seen in women that are multiparous and postmenopausal.

General

• Usually close to the anal verge.
• Rare forms can occasionally be confused with cancer.

Epidemiology:

• ~90% women, postmenopausal and multiparous.

Treatment:

• Surgical:
  • Delorme procedure = mucosa stripped.

Microscopic

Features:

• "Fibromuscular hyperplasia" - key feature:
  • Fibrosis (submucosa, lamina propria).
  • Muscularis mucosae is "too superficial" (muscle in the lamina propria).
• Surface ulceration + inflammation (neutrophils).
  • May show frank ischemic changes - see ischemic colitis.
• +/-Serration of epithelium at the surface.

Notes:

• Important negative: no nuclear atypia.
  • May be seen if ischemic changes are present.

Images

• 

  Rectal prolapse - low mag. (WC/Nephon)

• 

  Rectal prolapse - intermed. mag. (WC/Nephron)

Sign out

Rectum, Excision:
     - Colorectal wall with mild chronic mucosal inflammation,  
       and prominent submucosal fibrous tissue with dilated-appearing vessels.
     - NEGATIVE for dysplasia and NEGATIVE for malignancy.

Block letters

RECTAL MUCOSA, DELORME PROCEDURE:
- SUPERFICIAL RECTAL WALL WITH FIBROMUSCULAR HYPERPLASIA AND EDEMA.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY. 

RECTAL MUCOSA, DELORME PROCEDURE:
- SUPERFICIAL RECTAL WALL WITH FIBROMUSCULAR HYPERPLASIA, EDEMA, MILD INFLAMMATORY
  CHANGES, AND FOCAL REACTIVE CHANGES;
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.

Micro

The sections show rectal mucosa, submucosa and a small amount of muscularis propria. The mucosa shows fibromuscular hyperplasia with thickening of the muscularis mucosae and mild lamina propria fibrosis. The submucosa is edematous. The small amount of muscularis propria is unremarkable. The epithelium matures normally to the surface. No significant nuclear atypia is identified.

Ischemic changes present

RECTAL MUCOSA, DELORME PROCEDURE:
- SUPERFICIAL RECTAL WALL WITH REACTIVE CHANGES, ISCHEMIC CHANGES AND FIBROMUSCULAR
  HYPERPLASIA, SEE COMMENT.
- NEGATIVE FOR MALIGNANCY.

COMMENT:
The changes are compatible with prolapse (fibromuscular hyperplasia) and suggestive of
concurrent ischemia (see microscopic).

The mucosal reactive changes are marked. No definite dysplasia is identified; however, it
is difficult to completely exclude. Follow-up is recommended.

Micro

The sections show superficial rectal wall with ischemic changes (focal cryptitis, marked reactive epithelial changes, erosions, capillary congestion, goblet cell paucitity, epithelium with attenuated cytoplasm) and changes compatible with prolapse (fibromuscular hyperplasia).

See also

• Rectum.
• Solitary rectal ulcer.
• Prolapse.