From the Guidelines
Grading of rectal prolapse is crucial in determining the treatment approach, with asymptomatic Grade 1-2 prolapse managed conservatively and symptomatic Grade 3-4 prolapse requiring surgical intervention. The grading system helps clinicians determine the anatomical extent of the prolapse, which directly influences whether conservative management is appropriate or if surgical intervention is necessary 1.
Key Considerations
- Asymptomatic Grade 1-2 rectal prolapse does not require surgery and should be managed with conservative and/or biofeedback therapy to correct underlying dyssynergia 1.
- Symptomatic Grade 3-4 prolapse requires surgical intervention, with options including abdominal approaches (rectopexy with or without resection) or perineal procedures (Altemeier procedure or perineal rectosigmoidectomy) 1.
- Patient factors such as age, comorbidities, and functional status are considered alongside the grade when determining the optimal treatment approach 1.
- In patients with complicated rectal prolapse, non-operative management (NOM) may be attempted, but surgery should not be delayed if NOM fails or if there are signs of ischemia, perforation, or hemodynamic instability 1.
Treatment Approaches
- Conservative management: dietary modifications, stool softeners, pelvic floor exercises, and outpatient procedures like rubber band ligation or sclerotherapy may be sufficient for Grade 1 prolapse.
- Minimally invasive procedures: Delorme's procedure (mucosal stripping and plication) may be considered for Grade 2 prolapse.
- Surgical intervention: abdominal approaches (rectopexy with or without resection) or perineal procedures (Altemeier procedure or perineal rectosigmoidectomy) are typically necessary for Grade 3-4 prolapse.
Recent Guidelines
- The WSES-AAST guidelines suggest attempting conservative measures and gentle manual reduction under mild sedation or anesthesia for patients with incarcerated rectal prolapse without signs of ischemia or perforation 1.
- The guidelines also recommend against delaying surgical management to attempt conservative management in hemodynamically unstable patients with complicated rectal prolapse 1.
From the Research
Grading of Rectal Prolapse
The grading of rectal prolapse is significant in determining the treatment approach, as it helps in assessing the severity of the condition.
- The grading system can be used to classify rectal prolapse into different types, such as low-type (true rectal prolapse) or high-type (intussusception of the sigmoid with a fixed lower rectum) 2.
- A new endoscopic grading of rectal internal mucosal prolapse (RIMP) has been proposed, which classifies RIMP into three degrees based on the extent of the prolapse 3.
- The degree of the prolapse has been found to correlate with the occurrence and severity of symptoms, such as obstructed defecation, bleeding, and fecal soiling 3.
Treatment Approach
The treatment approach for rectal prolapse depends on the grade and type of the prolapse.
- For low-type prolapse, a perineal approach is appropriate, while for high-type prolapse, an abdominal rectopexy with or without high anterior resection is needed 2.
- The proposed classification can help in selecting the most suitable approach for repair, minimizing anaesthetic and surgical risks, and resulting in lower recurrence rates 2.
- Conservative treatment with high-fiber diet and/or rubber band ligation can be carried out in cases of first and second-degree RIMP, while surgery may be required for severely symptomatic third-degree RIMP 3.
Surgical Outcomes
The surgical outcomes for rectal prolapse have been found to be favorable, with low recurrence rates and improved continence.
- A study found that extended abdominal rectopexy resulted in a cure of complete prolapse in all cases, with no deaths and few major complications 4.
- Another study found that laparoscopic resection-rectopexy was safe and effective, with favorable functional results with respect to recurrence 5.
- However, the choice of surgical procedure depends on various factors, including the type and grade of the prolapse, and the patient's overall health and risk factors 6, 5.