What is the treatment approach for a 28-year-old female (YOF) with rectal prolapse?

Treatment of Rectal Prolapse in a 28-Year-Old Female

For a 28-year-old female with symptomatic rectal prolapse, surgical intervention using an abdominal approach (laparoscopic rectopexy with or without resection) is the definitive treatment, offering the lowest recurrence rates (0-8%) and best long-term outcomes for this young patient population. 1

Initial Conservative Management

Before proceeding to surgery, attempt conservative measures for mild cases (Grade 1-2 asymptomatic prolapse):

• Pelvic floor muscle training (PFMT) should be trialed for 6 months under supervision, as it can improve prolapse symptoms and severity in some patients 2
• Biofeedback therapy to correct underlying pelvic floor dysfunction, particularly if dyssynergia is present 1
• Conservative management is not appropriate for symptomatic Grade 3-4 prolapse, which requires surgical correction 1

Surgical Approach Selection

Abdominal Approach (Preferred for Young Patients)

For a 28-year-old patient, abdominal rectopexy is strongly recommended due to:

• Significantly lower recurrence rates of 0-8% compared to perineal approaches (5-21%) 1
• Better long-term durability, which is critical for a young patient with decades of life ahead 3
• Laparoscopic technique should be utilized, offering fewer post-operative complications, shorter hospital stay, and reduced wound complications compared to open surgery 1, 3

Specific Surgical Options

Laparoscopic rectopexy techniques include:

• Suture rectopexy 4
• Mesh rectopexy (posterior or ventral) 5, 4
• Resection rectopexy (sigmoid resection with rectopexy) 4

Decision regarding bowel resection:

• Add sigmoid resection if the patient has significant pre-existing constipation, as this reduces post-operative constipation rates 1, 6
• Avoid resection if the patient has pre-existing diarrhea or fecal incontinence, as these symptoms may worsen 1
• Division of lateral ligaments during rectopexy reduces recurrence but increases constipation risk 6

Perineal Approach (Not Recommended for This Patient)

Perineal procedures (Altemeier or Delorme operations) are reserved for elderly patients or those with significant medical comorbidities 1:

• Higher recurrence rates (5-21%) make this inappropriate for a young patient 1
• Lower perioperative morbidity is the only advantage, which is not relevant for a healthy 28-year-old 1

Critical Pitfalls to Avoid

Common errors in management:

• Performing perineal surgery in young patients due to perceived simplicity—this leads to unacceptably high recurrence requiring reoperation 1
• Adding bowel resection in patients with pre-existing diarrhea or incontinence, which worsens these symptoms 1
• Delaying surgery in symptomatic Grade 3-4 prolapse while attempting prolonged conservative management 1
• Choosing posterior rectopexy without considering constipation risk—50% of patients develop severe constipation after this approach 1

Expected Outcomes and Recovery

Post-operative expectations:

• Recovery typically takes 4-6 weeks, with abdominal approaches requiring slightly longer recovery than perineal procedures 7
• Early mobilization prevents complications such as deep vein thrombosis 7
• Bowel management with stool softeners prevents straining during recovery 8
• Most patients return to full activities by 6 weeks 7

Symptom improvement:

• Fecal incontinence often improves after prolapse correction 3
• Constipation management depends on surgical technique chosen (resection vs. non-resection) 1

Surgical Decision Algorithm

1. Confirm symptomatic Grade 3-4 prolapse requiring surgery 1
2. Assess bowel function: constipation vs. diarrhea/incontinence 1
3. Choose laparoscopic abdominal approach for this young patient 1, 3
4. If constipation present: perform resection rectopexy 1
5. If diarrhea/incontinence present: perform rectopexy without resection 1
6. Consider mesh vs. suture rectopexy based on surgeon expertise 1, 4