What are the treatment options for partial rectal prolapse?

Treatment of Partial Rectal Prolapse

For partial rectal prolapse without signs of ischemia or perforation, conservative measures with gentle manual reduction under mild sedation or anesthesia should be attempted first, followed by surgical intervention if conservative management fails. 1

Conservative Management Options

• For incarcerated rectal prolapse without signs of ischemia or perforation, attempt manual reduction with the patient in Trendelenburg position under intravenous sedation and analgesia 1
• Several techniques can be used to reduce edema and facilitate manual reduction:
  • Topical application of granulated sugar to create a hyperosmolar environment that reduces edema 1
  • Topical application of hypertonic solutions (50% dextrose or 70% mannitol) 1
  • Submucosal infiltration of hyaluronidase to decompose extracellular matrix and reduce edema 1
  • Elastic compression wrap to force edema fluid out of the prolapse 1
• Conservative management should not delay surgical treatment if unsuccessful, as the failure rate is high 1

Indications for Surgical Management

• Immediate surgical treatment is recommended for:
  • Complicated rectal prolapse with signs of shock 1
  • Gangrene or perforation of prolapsed bowel 1
  • Hemodynamic instability 1
• Urgent surgical treatment is suggested for:
  • Bleeding 1
  • Acute bowel obstruction 1
  • Failure of non-operative management 1
• Asymptomatic Grade 1-2 rectal prolapse can be managed conservatively with biofeedback therapy 1
• Symptomatic grade 3-4 prolapse requires surgery 1

Surgical Approach Selection

• For stable patients without peritonitis, the choice between abdominal and perineal procedures should be based on:
  • Patient characteristics (age, comorbidities) 1, 2
  • Surgeon's skills and expertise 1
• Abdominal approach considerations:
  • Recommended for younger, fit patients 2, 3
  • Lower recurrence rates (0-8%) compared to perineal procedures 1, 2
  • Can be performed open or laparoscopically based on patient characteristics 1, 2
  • Laparoscopic procedures offer advantages of less pain, early recovery, and lower morbidity 2
  • Options include rectopexy (with or without mesh) and resection rectopexy 2, 3
  • Caution: 50% of patients may complain of severe constipation after posterior rectopexy 1
• Perineal approach considerations:
  • Better suited for elderly patients with significant comorbidities 1, 2, 3
  • Higher recurrence rates (5-21%) 1
  • Lower perioperative morbidity 1
  • Options include perineal proctosigmoidectomy (Altemeier procedure) and Delorme's procedure 1, 4
  • Can be performed under spinal or epidural anesthesia 4

Pharmacological Management

• For strangulated rectal prolapse, empiric antimicrobial therapy is suggested due to the risk of intestinal bacterial translocation 1
• The antibiotic regimen should be based on:
  • Patient's clinical condition 1
  • Individual risk for multidrug-resistant organisms 1
  • Local resistance epidemiology 1

Pitfalls and Caveats

• Do not delay surgical management to attempt conservative measures in hemodynamically unstable patients 1
• Bowel resection should be avoided in patients with preexisting diarrhea and/or incontinence as these symptoms may worsen 1
• The correlation between anatomical correction and symptom improvement is often weak 5
• Pouch of Douglas protrusion can be confused with rectal intussusception and full-thickness rectal prolapse 1
• Many patients undergo surgical therapy without a rigorous trial of conservative therapy 1