A 72-year-old woman comes to the office due to intermittent lower abdominal discomfort for the past several months. The patient also reports frequent urges for bowel movements every day producing small-volume stools or just mucus and are often followed by a sensation of incomplete evacuation. Physical examination shows a nondistended and nontender abdomen. Digital rectal examination reveals normal rectal tone and an empty rectal vault. When the patient is instructed to bear down, an erythematous mass with concentric rings protrudes through the anus and spontaneously retracts. Which of the following is the strongest risk factor for this patient's current condition?

Question

A 72-year-old woman comes to the office due to intermittent lower abdominal discomfort for the past several months.  The patient also reports frequent urges for bowel movements every day producing small-volume stools or just mucus and are often followed by a sensation of incomplete evacuation.  Physical examination shows a nondistended and nontender abdomen.  Digital rectal examination reveals normal rectal tone and an empty rectal vault.  When the patient is instructed to bear down, an erythematous mass with concentric rings protrudes through the anus and spontaneously retracts.  Which of the following is the strongest risk factor for this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d865_7f2e_bc81_99240121cd46_MD0003_00 This older woman has intermittent rectal protrusion of an erythematous mass, suggesting rectal prolapse. In rectal prolapse, a mucosal or full-thickness layer of rectal tissue slides through the anal orifice. It is most common in women age >40. Risk factors include multiparity, vaginal delivery, pelvic surgery, pelvic floor dysfunction, chronic constipation or straining, dementia, and stroke. Rectal prolapse usually presents with stool incontinence or constipation; a palpable mass is often present during defecation and may require manual reduction. Rectal irritation can produce a mucous discharge that may be tinged with blood. Although abdominal discomfort can occur, significant pain is not typical and suggests another diagnosis. Physical examination often demonstrates a patulous anus, and maneuvers that increase intraabdominal pressure (eg, Valsalva) can induce prolapse, revealing a painless, erythematous mass with concentric rings extending through the anus. The diagnosis is made clinically, and management includes increased fiber intake, pelvic floor muscle exercises, and, possibly, surgical repair. (Choice A) Colonic polyps can rarely cause rectal prolapse; however, the examination would likely demonstrate a prolapsed polyp (pedunculated mass) in addition to the rectum. Colonic polyps are more commonly associated with increased risk of colonic malignancy. (Choice B) Crohn disease is associated with increased risk of perianal disease (eg, fissure, abscess, fistula), not rectal prolapse. (Choice C) Human papillomavirus can lead to anogenital warts (cauliflower-shaped, fungating, skin-colored lesions) and squamous cell carcinoma of the anus (ulcerating lesion often associated with bleeding), not rectal prolapse. (Choice E) Portal hypertension increases the risk of hemorrhoids. Although internal hemorrhoids can occasionally prolapse, examination demonstrates bulging, purplish veins, not a ringed mass. In addition, hemorrhoids typically result in bleeding during defecation, not abdominal discomfort or passage of mucus. Educational objective: Rectal prolapse is characterized by intermittent protrusion of the rectum (ie, erythematous mass with concentric rings) through the anal orifice. It is often associated with fecal incontinence, constipation, and/or mucous discharge. Rectal prolapse is most common in women age >40. Risk factors include multiparity, vaginal delivery, pelvic surgery, pelvic floor dysfunction, chronic constipation or straining, dementia, and stroke.

A 72-Year-Old Woman Comes to the Office Due to Intermittent