What is the treatment for rectal prolapse?

Treatment of Rectal Prolapse

The treatment of rectal prolapse should be stratified based on symptom severity, with asymptomatic grade 1-2 prolapse managed conservatively while symptomatic grade 3-4 prolapse requires surgical intervention using either abdominal or perineal approaches. 1

Initial Assessment and Conservative Management

Grading and Initial Approach

• Grade 1-2 (asymptomatic): Conservative management with:
  • Biofeedback therapy to correct underlying dyssynergia
  • Increased fiber intake and dietary modifications
  • Adequate hydration
  • Stool softeners to prevent straining
  • Education on proper defecation habits 1, 2

Management of Incarcerated Prolapse Without Ischemia

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

Surgical Management

Indications for Surgery

• Symptomatic grade 3-4 prolapse
• Failed conservative management
• Incarcerated prolapse with signs of ischemia or perforation
• Hemodynamically unstable patients with complicated prolapse 1

Surgical Approach Selection

Abdominal Approach

• Best for: Younger, lower-risk patients
• Techniques:
  • Rectopexy (with or without resection)
  • Laparoscopic rectopexy (preferred when expertise available)
• Advantages:
  • Lower recurrence rates (0-8%)
  • Laparoscopic approach has fewer post-operative complications and shorter hospital stay
• Disadvantages:
  • Higher risk of postoperative constipation (especially posterior rectopexy - up to 50% of patients)
  • Bowel resection during rectopexy associated with lower rates of constipation but should be avoided in patients with preexisting diarrhea/incontinence 1, 3

Perineal Approach

• Best for:
  • Elderly patients
  • Those with significant medical comorbidities
  • Contraindications for abdominal surgery
• Techniques:
  • Perineal proctosigmoidectomy (Altemeier procedure)
  • Delorme's procedure (mucosal sleeve resection)
  • Thiersch procedure (anal encirclement) for high-risk patients
• Advantages:
  • Lower perioperative morbidity
  • More frequently used in clinical practice
• Disadvantages:
  • Higher recurrence rate (5-21%) 1, 2

Special Considerations

• Transperineal levatoroplasty may be combined with perineal procedures to reduce recurrence risk 1
• Division rather than preservation of lateral ligaments is associated with less recurrent prolapse but more postoperative constipation 3
• For irreducible prolapse with signs of ischemia/gangrene, urgent perineal approach (Altemeier's procedure) is indicated 2

Treatment Algorithm

1. Assess prolapse grade and symptoms
2. For grade 1-2 asymptomatic prolapse:
   • Conservative management with biofeedback and dietary modifications
3. For symptomatic grade 3-4 prolapse:
   • If reducible: Plan elective surgery
   • If irreducible without ischemia: Attempt manual reduction under sedation
   • If irreducible with ischemia/gangrene: Urgent surgical intervention
4. Surgical approach selection:
   • For younger, lower-risk patients: Abdominal approach (preferably laparoscopic rectopexy)
   • For elderly, higher-risk patients: Perineal approach (Altemeier or Delorme procedure)

Common Pitfalls and Caveats

• Many patients undergo surgical therapy without a rigorous trial of conservative therapy; surgery should be necessary in only a small fraction (<5%) of patients with defecatory disorders 1
• Failure to recognize and address underlying pelvic floor dysfunction can lead to recurrence
• Bowel resection during rectopexy can worsen preexisting diarrhea or incontinence 1
• Delaying surgical treatment when conservative management fails increases risk of ischemia and perforation 1
• Pouch of Douglas protrusion is often confused with rectal intussusception and full-thickness rectal prolapse; it requires different management (sacrocolpopexy) 1

The evidence suggests that while there are multiple surgical options available, the choice between abdominal and perineal approaches should be guided primarily by patient characteristics, with careful consideration of the risk of recurrence versus the risk of postoperative constipation.