What are the treatment options for rectal prolapse?

Treatment Options for Rectal Prolapse

The treatment of rectal prolapse should follow a stepwise approach, with initial conservative management for uncomplicated cases and surgical intervention for complicated cases or when conservative measures fail. 1

Initial Assessment and Management

Uncomplicated Rectal Prolapse

• First-line treatment: Gentle manual reduction under mild sedation or anesthesia for incarcerated rectal prolapse without signs of ischemia or perforation 1
• Conservative measures may include:
  • Stool softeners
  • Dietary modifications
  • Pelvic floor exercises
  • Avoidance of straining

Complicated Rectal Prolapse

• Immediate surgical treatment is mandatory in cases with:
  • Signs of shock
  • Gangrene/perforation of prolapsed bowel 1
• Urgent surgical treatment is indicated for:
  • Bleeding
  • Acute bowel obstruction
  • Failure of non-operative management 1

Surgical Management Decision Algorithm

1. Patient Stability Assessment

• Hemodynamically unstable patients: Immediate abdominal open approach 1
• Hemodynamically stable patients: Consider patient characteristics and surgeon expertise

2. Surgical Approach Selection

• For patients without peritonitis or hemodynamic instability:

  • Choose between abdominal and perineal procedures based on:
    • Patient characteristics (age, comorbidities)
    • Surgeon's expertise 1

• For patients with signs of peritonitis:

  • Abdominal approach recommended 1

3. Technique Selection

• Abdominal approach options:

  • Open vs. laparoscopic (based on patient characteristics and surgeon expertise) 1
  • Resection rectopexy vs. rectopexy without resection (resection associated with lower rates of constipation) 2

• Perineal approach options:

  • Altemeier procedure (rectosigmoidectomy with coloanal anastomosis) - particularly useful for strangulated rectal prolapse 3
  • Delorme procedure

Special Considerations

Antimicrobial Therapy

• Empiric antimicrobial therapy is recommended for strangulated rectal prolapse due to risk of intestinal bacterial translocation 1
• Regimen should be based on:
  • Patient's clinical condition
  • Individual risk for multidrug-resistant organisms
  • Local resistance epidemiology 1

Anastomosis Decisions

• For patients undergoing resectional surgery, the decision between primary anastomosis (with/without diverting ostomy) and terminal colostomy should be based on:
  • Patient's clinical condition
  • Individual risk of anastomotic leakage 1

Common Pitfalls and Caveats

• Avoid delay in surgical management for hemodynamically unstable patients with complicated rectal prolapse 1
• Don't miss signs of strangulation which require immediate intervention
• Consider functional outcomes - division of lateral ligaments during surgery is associated with less recurrent prolapse but more postoperative constipation 2
• Laparoscopic approach advantages include fewer postoperative complications and shorter hospital stay compared to open procedures, when appropriate for the patient 2

Long-term Outcomes

• Recurrence rates vary by procedure
• Postoperative functional outcomes (continence, constipation) should be monitored
• Quality of life improvements should be assessed following intervention