How to manually reduce an uncomplicated rectal prolapse?

Manual Reduction of Uncomplicated Rectal Prolapse

For uncomplicated rectal prolapse, manual reduction should be attempted with the patient in Trendelenburg position under mild sedation or analgesia, using gentle manipulation to reduce the prolapse and avoid complications such as strangulation, ulceration, bleeding, and perforation. 1

Step-by-Step Reduction Technique

1. Patient Positioning

   • Place patient in Trendelenburg position (head down, pelvis elevated) 1, 2
   • This positioning uses gravity to assist with reduction

2. Pain Management

   • Administer appropriate analgesia or mild sedation before attempting reduction 1
   • Consider intravenous sedation for patient comfort during the procedure

3. Reduction Methods

   • Primary Method: Gentle Manual Manipulation

     • Apply steady, gentle pressure to the prolapsed tissue using gloved hands 1
     • Use lubricant to facilitate reduction
     • Direct pressure toward the anal canal in a progressive manner

   • For Edematous Prolapse: Consider These Additional Techniques

     • Elastic compression wrap - Apply wide elastic bandage around prolapsed rectum to provide progressive compression, reducing edema before manual reduction 1, 3
     • Topical application of granulated sugar or hypertonic solutions - Creates hyperosmolar environment that draws water out from edematous tissue 1
     • Submucosal adrenaline injections - Can reduce edema through vasoconstriction 1
     • Submucosal hyaluronidase infiltration - Depolymerizes hyaluronic acid to reduce edema 1

Important Considerations

• Time Sensitivity: Do not delay surgical management if reduction is difficult or unsuccessful 1

• Warning Signs: Manual reduction is contraindicated in cases of:

  • Strangulated rectal prolapse with signs of gangrene
  • Perforation
  • Hemodynamic instability 1

• Failure Rate: Be aware that non-operative management has a high failure rate for incarcerated rectal prolapse 1

• Post-Reduction Care:

  • Monitor for recurrence
  • Consider referral for definitive surgical management, as rectal prolapse often requires surgical correction 2
  • Implement conservative measures to prevent recurrence:
    • Increased fiber intake
    • Adequate hydration
    • Proper defecation habits to avoid straining 2

When to Escalate to Surgical Management

• Immediate surgical intervention is required if:

  • Manual reduction fails
  • Signs of ischemia, gangrene, or perforation are present
  • Patient is hemodynamically unstable 1, 2

• For uncomplicated but irreducible prolapse, surgical options include:

  • Perineal approaches (e.g., Altemeier's procedure) for elderly or high-risk patients
  • Abdominal approaches for younger, fit patients 2

Manual reduction should always be attempted for uncomplicated rectal prolapse before considering surgical intervention, as it can successfully resolve the immediate issue while allowing for planned elective surgery if needed.