From the Guidelines
Treatment for rectal prolapse should be individualized based on the severity of the condition, with asymptomatic Grade 1–2 rectal prolapse managed conservatively and symptomatic grade 3–4 prolapse requiring surgery, as recommended by the most recent guidelines 1.
Overview of Treatment Options
Treatment options for rectal prolapse include both non-surgical and surgical approaches. For mild cases, conservative management involves:
- Treating constipation with increased fiber intake (25-30g daily)
- Adequate hydration
- Stool softeners like docusate sodium (100mg twice daily)
- Avoiding straining during bowel movements
- Pelvic floor exercises to strengthen supporting muscles
- Manual reduction for temporary relief by gently pushing the prolapsed tissue back into place using a lubricated, gloved hand
Surgical Intervention
Surgical intervention becomes necessary for persistent or severe cases. Common procedures include:
- Perineal rectosigmoidectomy (Altemeier procedure) for high-risk patients, which removes the prolapsed segment
- Abdominal rectopexy, which fixes the rectum to the sacrum using mesh or sutures
- Laparoscopic rectopexy, which offers faster recovery The choice of surgery depends on the patient's age, overall health, and prolapse severity, with consideration of the surgeon's skills and expertise 1.
Decision Making for Surgical Approach
In patients with complicated rectal prolapse and no signs of peritonitis or hemodynamic instability, the decision between abdominal and perineal procedures should be based on the specific patient’s characteristics and on surgeon’s skills and expertise 1. For hemodynamically stable patients, the decision between open or laparoscopic surgery should consider patient’s characteristics and surgeon’s skills and expertise 1.
Importance of Prompt Treatment
Prompt treatment is crucial as prolonged prolapse can lead to tissue damage, incontinence, or strangulation of the prolapsed segment. Immediate surgical treatment is recommended for patients with signs of shock or gangrene/perforation of prolapsed bowel 1, while urgent surgical treatment is suggested for patients with bleeding, acute bowel obstruction, or failure of non-operative management 1.
From the Research
Treatment Options for Rectal Prolapse
The treatment options for rectal prolapse can be categorized into surgical and non-surgical approaches.
- Surgical Management: Surgical management is aimed at restoring physiology by correcting the prolapse and improving continence and constipation with acceptable mortality and recurrence rates 2. The choice of surgical procedure depends on the patient's age, fitness, and comorbidities.
- Abdominal Procedures: Abdominal procedures, such as laparoscopic rectopexy, are ideal for young, fit patients and offer lower recurrence rates and greater chance for functional improvements 2, 3.
- Perineal Procedures: Perineal procedures, such as perineal rectosigmoidectomy, are reserved for older, frail patients with significant comorbidity and offer lower morbidity and shorter length of stay, but higher recurrence rates 2, 4.
- Laparoscopic Rectopexy: Laparoscopic rectopexy is a safe and feasible procedure in elderly patients with full-thickness rectal prolapse, but results in increased operative time 5.
- Non-Surgical Management: Non-surgical management, such as dietary changes and biofeedback, may be considered for patients with associated conditions, such as colitis cystica profunda and solitary rectal ulcer syndrome 6.
Factors Influencing Treatment Choice
The choice of treatment for rectal prolapse depends on several factors, including:
- Patient Age and Fitness: Abdominal procedures are generally better for young, fit patients, while perineal procedures are preferable for elderly, frail patients 2, 4.
- Comorbidities: Patients with significant comorbidities may be better suited for perineal procedures 2, 4.
- Presence of Pelvic Floor Defects: The presence of pelvic floor defects and coexistence of vaginal prolapse should be taken into account when choosing a treatment approach 3.
- Severe Constipation: Severe constipation should be considered when choosing a treatment approach, as some procedures may be more effective in addressing this symptom 3.