Management of Rectal Prolapse
For patients experiencing symptoms of rectal prolapse, initial management should focus on gentle manual reduction under mild sedation or anesthesia if the prolapse is incarcerated without signs of ischemia or perforation. 1
Initial Assessment and Management
Clinical Evaluation
- Complete blood count, serum creatinine, and inflammatory markers (C-reactive protein, procalcitonin, lactates) should be requested to assess the patient's status 1
- In hemodynamically stable patients with irreducible or strangulated rectal prolapse, an urgent contrast-enhanced abdomino-pelvic CT scan should be performed to detect complications and assess for colorectal cancer 1
- Imaging should not delay appropriate treatment in hemodynamically unstable patients 1
Conservative Management
- For incarcerated rectal prolapse without signs of ischemia or perforation, attempt gentle manual reduction under mild sedation or anesthesia 1
- Conservative management should not delay surgical intervention in hemodynamically unstable patients 1
Surgical Management
Indications for Immediate Surgical Treatment
- Presence of shock or gangrene/perforation of prolapsed bowel requires immediate surgical intervention 1
- Bleeding, acute bowel obstruction, or failure of non-operative management necessitates urgent surgical treatment 1
Surgical Approach Selection
- In patients without peritonitis or hemodynamic instability, the choice between abdominal and perineal procedures should be based on patient characteristics and surgeon expertise 1
- For hemodynamically stable patients requiring abdominal approach, the decision between open or laparoscopic surgery depends on patient characteristics and surgeon expertise 1
- An abdominal approach is recommended for patients with signs of peritonitis 1
- Patients with hemodynamic instability should undergo an abdominal open approach 1
Resection Considerations
- When performing resectional surgery, the decision between primary anastomosis (with or without diverting ostomy) and terminal colostomy should be based on the patient's clinical condition and individual risk of anastomotic leakage 1
Pharmacological Management
- Empiric antimicrobial therapy should be administered in patients with strangulated rectal prolapse due to the risk of intestinal bacterial translocation 1
- The antibiotic regimen should be tailored based on the patient's clinical condition, individual risk for multidrug-resistant organisms, and local resistance patterns 1
Long-term Considerations
- Rectal prolapse should be viewed as a symptom of an underlying condition rather than a discrete disease entity 2
- Potential causes include increased intraabdominal pressure, diarrheal diseases, malnutrition, and conditions predisposing to pelvic floor weakness 2
- Rectal prolapse is associated with decreased anal sphincter tone, levator muscle diastasis, and a deep anterior cul-de-sac 3
- Internal rectal prolapse may present with fecal incontinence (56%) and/or evacuation disorders (85%) 4
Common Pitfalls and Caveats
- Do not delay surgical management in hemodynamically unstable patients to attempt conservative management 1
- Avoid performing digital rectal examination before obtaining abdominal X-rays in cases where foreign bodies might be present, as this could cause injury to the examining physician 1
- Be aware that rectal prolapse in children has a strong association with cystic fibrosis, making sweat tests mandatory for infants and children with recurrent rectal prolapse 2
- Division of lateral ligaments during rectopexy may be associated with less recurrent prolapse but more post-operative constipation 5