What are the treatment options for rectal prolapse?

Treatment of Rectal Prolapse

For complicated rectal prolapse with shock, gangrene, or perforation, immediate surgical intervention via an abdominal open approach is mandatory; for uncomplicated prolapse, the treatment algorithm depends on patient age, fitness, and symptom severity, with abdominal approaches preferred for younger fit patients and perineal approaches for elderly patients with significant comorbidities. 1, 2

Emergency vs. Elective Management

Immediate Surgical Indications

• Patients presenting with hemodynamic instability, signs of shock, or gangrene/perforation of the prolapsed bowel require immediate surgical treatment via an abdominal open approach. 1
• Urgent surgical intervention is indicated for complicated prolapse with bleeding, acute bowel obstruction, or failure of conservative management. 1
• Empiric antimicrobial therapy should be administered in strangulated prolapse due to risk of bacterial translocation, with regimen selection based on clinical condition, multidrug-resistant organism risk, and local resistance patterns. 1, 2

Conservative Management Approach

• For uncomplicated prolapse without ischemia or perforation, attempt gentle manual reduction under mild sedation with the patient in Trendelenburg position first. 2
• Techniques to reduce edema include topical granulated sugar, hypertonic solutions, submucosal hyaluronidase infiltration, and elastic compression wrapping. 2
• Conservative management should not delay surgical treatment if unsuccessful, as failure rates are high. 2
• Asymptomatic Grade 1-2 prolapse can be managed with pelvic floor biofeedback therapy, while symptomatic Grade 3-4 prolapse requires surgical correction. 3, 2

Surgical Approach Selection Algorithm

Patient-Based Decision Making

For younger, fit patients (typically <65 years with minimal comorbidities):

• Choose abdominal approach, which offers lower recurrence rates compared to perineal procedures. 2, 4
• Laparoscopic techniques are preferred over open surgery due to less pain, earlier recovery, and lower morbidity with comparable complication rates. 4
• Options include laparoscopic ventral mesh rectopexy or laparoscopic resection rectopexy. 3, 4

For elderly patients with significant comorbidities:

• Select perineal approach (Delorme's or Altemeier's procedure), which has lower perioperative morbidity despite higher recurrence rates. 2, 5
• This avoids the physiologic stress of abdominal surgery in high-risk patients. 5

Specific Surgical Technique Selection

When performing abdominal rectopexy:

• Laparoscopic ventral mesh rectopexy is recommended for high rectoceles or those with associated pelvic floor disorders. 3
• Laparoscopic resection rectopexy (sigmoid resection with rectopexy) provides advantages in preventing new-onset constipation compared to rectopexy alone. 4
• Division of lateral ligaments during rectopexy reduces recurrent prolapse but increases post-operative constipation risk—avoid in patients with pre-existing constipation. 6, 2

For patients with hemodynamic stability but peritonitis:

• Use abdominal approach rather than perineal. 1
• Base decision between primary anastomosis (with or without diverting ostomy) versus terminal colostomy on clinical condition and anastomotic leak risk. 1

Critical Pitfalls to Avoid

• Never perform bowel resection in patients with preexisting diarrhea or incontinence, as these symptoms will worsen post-operatively. 2
• Posterior rectopexy can cause severe constipation in up to 50% of patients—consider ventral rectopexy or resection rectopexy instead for patients with baseline constipation. 2
• The correlation between anatomical correction and symptom improvement is often weak, particularly for defecation difficulties—careful patient selection and counseling about realistic expectations is essential. 3
• For rectocele-associated prolapse, STARR (Stapled Transanal Rectal Resection) can reduce rectocele size from 3.8 cm to 1.9 cm on average, but long-term outcomes are disappointing despite initial improvement. 3
• Monitor for serious STARR complications including fistula, peritonitis, bowel perforation, infection, pain, incontinence, and bleeding. 3

Functional Outcome Considerations

• Abdominal approaches appear to result in less residual fecal incontinence compared to perineal approaches, though data are limited. 6
• Including sigmoid resection during rectopexy is associated with lower rates of post-operative constipation. 6
• For patients with combined rectal and genital prolapse, an interdisciplinary surgical approach addressing both simultaneously is required. 7