From the Guidelines
Management of rectal prolapse should be tailored to the patient's age, comorbidities, and prolapse severity, with surgical intervention being the definitive treatment, and the choice of surgical technique depending on the patient's characteristics and the surgeon's skills and expertise 1. The management options for rectal prolapse include:
- Initial conservative management with high-fiber diet, adequate hydration, and stool softeners
- Manual reduction for mild cases by applying gentle pressure with a lubricated, gloved hand to return the prolapsed tissue to its normal position
- Surgical intervention, which is the definitive treatment for rectal prolapse Some key points to consider in the management of rectal prolapse include:
- For frail or elderly patients, perineal approaches like Delorme's procedure or Altemeier's rectosigmoidectomy are preferred due to lower anesthetic risk 1
- Healthier patients typically benefit from abdominal procedures such as rectopexy (with or without sigmoid resection), which can be performed laparoscopically or robotically with lower recurrence rates 1
- Ventral mesh rectopexy has gained popularity for its lower risk of postoperative constipation
- Postoperatively, patients should continue bowel management to prevent straining, including osmotic laxatives like polyethylene glycol (17g daily) if needed
- Physical therapy focusing on pelvic floor exercises can help strengthen supporting structures It's also important to note that the choice of surgical technique depends on the patient's characteristics and the surgeon's skills and expertise, and that there is no high-quality evidence regarding the best surgical approach in an emergency setting 1. In patients with complicated rectal prolapse, the decision between abdominal and perineal procedures should be based on the specific patient’s characteristics and on surgeon’s skills and expertise 1. In hemodynamically stable patients with complicated rectal prolapse, the decision between open or laparoscopic surgery should be based on patient’s characteristics and on surgeon’s skills and expertise 1. Immediate surgical intervention is reserved for those patients who present with incarcerated rectal prolapse complicated by gangrene, perforation, or signs of shock 1.
From the Research
Management Options for Rectal Prolapse
The management options for rectal prolapse can be categorized into surgical and non-surgical approaches.
- Surgical options include:
- Abdominal repairs: fixing the rectum to the sacrum using mesh or sutures, which tend to have the lowest recurrence rates 2, 3
- Perineal surgical repairs: well tolerated but generally associated with higher recurrence rates 3
- Laparoscopic surgical repair: similar morbidity and recurrence rates to open surgery, with benefits of reduced length of hospital stay, postoperative pain, and wound complications 2, 3
- Posterior mesh rectopexy with artificial material 2
- Resection of the sigmoid colon with colorectal anastomosis, with or without rectopexy 2
- Suture rectopexy 2, 4
- Stapled rectopexy 2
- Mucosal resection (Delorme) or perineal proctectomy (Altemeier) for full-thickness prolapse (procidentia) 4
- Non-surgical options include:
Considerations for Management
When choosing a management option, it is essential to consider each patient's symptoms, bowel habits, anatomy, and pre-operative expectations 5, 6. The surgical approach and technique should be tailored to the individual patient, taking into account factors such as incontinence, constipation, and the effect of rectal prolapse on the patient's overall quality of life 5, 6.