Date:
Patient:
Reason for Visit:
Follow-up for rectal prolapse
Assessment of symptoms and degree of prolapse
Evaluation of response to treatment and potential complications
History:
Presenting Illness:
Duration and severity of symptoms (e.g., rectal bulging, straining with bowel movements, fecal incontinence, mucus discharge)
Onset and characteristics of prolapse (complete or incomplete, internal or external)
Factors that worsen symptoms (straining, heavy lifting)
Prior attempts at treatment (conservative or surgical)
Past Medical History (PMH):
Underlying medical conditions that may contribute to prolapse (e.g., chronic constipation, chronic diarrhea, connective tissue disorders)
Prior pelvic surgeries (childbirth, hysterectomy)
History of straining with bowel movements
Social History:
Occupational demands that involve heavy lifting or straining
Physical Exam:
General: Assess for signs of malnutrition or dehydration (possible with chronic fecal incontinence).
Perianal: Look for external prolapse, skin breakdown, or hemorrhoids.
Digital rectal exam (DRE): Evaluate for degree of prolapse (internal or external), rectal wall integrity, and sphincter tone.
Diagnostic Tests (may be ordered depending on clinical presentation):
Proctoscopy or sigmoidoscopy: Visualize the rectum and sigmoid colon for mucosal prolapse and rule out other causes of bleeding or rectal symptoms.
Pelvic floor manometry: Evaluate anal sphincter strength and coordination (may be considered for complex cases).
Assessment:
Degree of rectal prolapse: Based on clinical presentation and imaging studies (internal vs external, complete vs incomplete).
Severity of symptoms: Impact on daily life and quality of life.
Presence of complications: Fecal incontinence, rectal bleeding, ulceration of prolapsed tissue.
Suitability for treatment options: Considering severity, patient preferences, and overall health.
Plan:
Conservative measures (may be recommended for mild prolapse or as initial approach):
Lifestyle modifications (increased fiber intake, weight management)
Stool softeners or laxatives to address constipation
Pelvic floor muscle exercises (Kegel exercises) to improve sphincter tone
Biofeedback therapy (may be helpful for some patients)
Surgical intervention (may be considered for moderate to severe prolapse or failed conservative management):
Various surgical techniques available depending on severity and anatomy (e.g., perineal repair, ventral mesh rectopexy).
Referral to a colorectal surgeon: For complex cases, surgical evaluation, and discussion of treatment options.
Referral to a pelvic floor therapist: For instruction and guidance on pelvic floor muscle exercises and biofeedback therapy.
Patient education: Provide information about rectal prolapse, risk factors, treatment options, and self-care strategies.
Discuss the importance of maintaining a healthy diet, managing constipation, and performing pelvic floor muscle exercises regularly.
Follow-up:
Schedule for follow-up appointments based on severity:
More frequent visits for patients with ongoing symptoms or post-surgical follow-up.
Less frequent visits for patients with well-managed symptoms and no complications.
Monitor response to treatment, adjust management plan as needed, and assess for potential complications.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of rectal prolapse.