What are the treatment options for rectal prolapse?

Treatment Options for Rectal Prolapse

For rectal prolapse treatment, a stepwise approach based on the severity and patient characteristics is recommended, with conservative measures attempted first for uncomplicated cases and surgical intervention for complicated or refractory cases. 1

Initial Assessment and Classification

• Complete blood count, serum creatinine, and inflammatory markers (CRP, procalcitonin, lactates) should be checked to assess patient status 1
• In stable patients with irreducible or strangulated prolapse, contrast-enhanced abdomino-pelvic CT scan is recommended to detect complications and assess for colorectal cancer 1
• Colonoscopy is important as rectal prolapse carries a 4.2-fold increased risk of colorectal cancer 1

Non-Operative Management (For Uncomplicated Cases)

For incarcerated rectal prolapse without signs of ischemia or perforation:

• Conservative measures with gentle manual reduction under mild sedation or anesthesia should be attempted first 1

• Techniques to reduce edema before manual reduction:

  • Topical application of granulated sugar or hypertonic sugar solutions (creates hyperosmolar environment to draw out fluid)
  • Submucosal adrenaline injections
  • Submucosal hyaluronidase infiltration
  • Elastic compression wrap

• Patient should be placed in Trendelenburg position with appropriate analgesia/sedation 1

Surgical Management

Indications for Immediate Surgery:

• Signs of shock or gangrene/perforation of prolapsed bowel 1
• Hemodynamic instability 1
• Failed conservative management 1
• Bleeding or acute bowel obstruction 1

Surgical Approach Selection:

1. For hemodynamically unstable patients or those with peritonitis:

   • Abdominal open approach is strongly recommended 1

2. For stable patients without peritonitis:

   • Choice between abdominal and perineal procedures should be based on patient characteristics and surgeon expertise 1

3. Specific approach considerations:

   • Abdominal procedures (lower recurrence rates, 0-8%):

     • Recommended for younger, healthier patients 1, 2
     • Options include resection rectopexy, suture rectopexy, or mesh rectopexy
     • Can be performed open or laparoscopically in stable patients
     • Adding bowel resection reduces post-operative constipation but should be avoided in patients with pre-existing diarrhea/incontinence 1

   • Perineal procedures (higher recurrence rates, 5-21%):

     • Better suited for elderly patients with significant comorbidities 1, 2
     • Options include perineal proctosigmoidectomy (Altemeier procedure) and Delorme procedure (mucosal resection)
     • Lower perioperative morbidity but higher recurrence rate 1
     • May be combined with levatoroplasty to reduce recurrence risk 1

Special Considerations

• Asymptomatic Grade 1-2 rectal prolapse does not require surgery and should be managed conservatively 1
• Symptomatic grade 3-4 prolapse requires surgical intervention 1
• For patients with constipation and rectal prolapse, resection rectopexy may provide better functional outcomes 1, 2
• For patients with incontinence, avoid bowel resection as it may worsen symptoms 1
• In patients requiring resectional surgery, the decision between primary anastomosis (with/without diverting ostomy) and terminal colostomy should be based on patient condition and risk of anastomotic leakage 1
• Empiric antimicrobial therapy is recommended for strangulated rectal prolapse due to risk of bacterial translocation 1

Pitfalls to Avoid

• Delaying surgical management in hemodynamically unstable patients to attempt conservative measures 1
• Performing bowel resection in patients with pre-existing diarrhea or incontinence 1
• Overlooking colorectal cancer screening in patients with rectal prolapse 1
• Performing STARR procedure without careful patient selection (can lead to complications including infection, pain, incontinence, bleeding, fistula, peritonitis, and bowel perforation) 1
• Treating only the anatomical abnormality without addressing underlying functional disorders 1

By following this structured approach to rectal prolapse management, clinicians can optimize outcomes while minimizing morbidity and mortality.