What are the management options for prolapse?

Management Options for Rectal Prolapse

Immediate surgical treatment is recommended for rectal prolapse with signs of shock, gangrene, or perforation of prolapsed bowel, while conservative management is appropriate as first-line therapy for most other cases of prolapse. 1, 2

Initial Assessment

• Evaluate for:

  • Signs of ischemia, perforation, or hemodynamic instability
  • Severity and reducibility of the prolapse
  • Patient's comorbidities and overall health status 2

• Diagnostic approach:

  • Clinical examination is sufficient for diagnosis
  • Laboratory tests (CBC, creatinine, CRP, procalcitonin, lactates) only needed for suspected complicated prolapse 1
  • Differentiate from hemorrhoids: rectal prolapse shows concentric protrusion vs. radial bulging with hemorrhoids 1

Management Algorithm

1. Non-Surgical Management (First-Line for Uncomplicated Cases)

• For reducible prolapse:

  • Pelvic floor muscle training 3, 4
  • Pessary placement 3, 4, 5
    • Follow-up every 3-6 months once properly fitted 5
  • Management of modifiable risk factors (weight loss, reducing heavy lifting, treating constipation) 6

• For incarcerated prolapse without ischemia:

  • Manual reduction under mild sedation/anesthesia with patient in Trendelenburg position 1, 2
  • Methods to reduce edema before manual reduction:
    • Topical application of granulated sugar or hypertonic solutions
    • Submucosal infiltration of hyaluronidase
    • Elastic compression wrap 1, 2

2. Surgical Management

• Immediate surgical intervention (do not delay) for:

  • Signs of shock
  • Gangrene or perforation of prolapsed bowel 1, 2

• Urgent surgical intervention for:

  • Bleeding
  • Acute bowel obstruction
  • Failure of non-operative management 1, 2

• Elective surgery when:

  • Conservative options fail to meet patient expectations
  • Symptoms are disabling and related to prolapse
  • Prolapse is significant (stage 2 or more) 3

Surgical Approach Selection:

• Perineal approach (preferred for elderly/high-risk patients):

  • Anal encirclement (Thiersch procedure)
  • Mucosal sleeve resection (Delorme's procedure)
  • Perineal proctosigmoidectomy (Altemeier's procedure) 1, 2
  • Benefits: Lower perioperative morbidity, shorter anesthesia time, faster recovery 2

• Abdominal approach (for lower-risk patients):

  • Suture rectopexy
  • Mesh rectopexy (various techniques)
  • Resection rectopexy 1
  • Benefits: Lower recurrence rates 2
  • Can be performed open or laparoscopically based on patient characteristics and surgeon expertise 1

• For patients with peritonitis: Abdominal approach recommended 1

• For hemodynamically unstable patients: Open abdominal approach recommended 1

Special Considerations

• Consider empiric antimicrobial therapy in cases of strangulated rectal prolapse due to risk of bacterial translocation 1, 2

• For isolated rectocele, posterior vaginal repair with autologous tissue is preferred over transanal approach 3

• For apical and anterior prolapse, laparoscopic sacrocolpopexy is recommended 3

• Colpocleisis may be appropriate for elderly and fragile patients 3

• Decision for mesh placement should involve multidisciplinary consultation 3

Pitfalls and Caveats

• High failure rate of non-operative management for incarcerated rectal prolapse—do not delay surgical treatment when indicated 1

• Rectal prolapse may coexist with other pelvic floor disorders, particularly in elderly women 2

• Consider screening for colorectal cancer due to increased risk in these patients 2

• Post-surgical follow-up is essential even in asymptomatic patients 3