What are the management options for rectal prolapse?

Management of Rectal Prolapse

For symptomatic full-thickness rectal prolapse, surgical intervention is the definitive treatment, with the choice between abdominal and perineal approaches determined primarily by patient age, fitness, and comorbidities—younger, fit patients should undergo abdominal rectopexy (preferably laparoscopic ventral rectopexy), while elderly patients with significant comorbidities are better suited for perineal procedures. 1

Initial Assessment and Conservative Management

Severity Grading and Initial Approach

• Asymptomatic Grade 1-2 rectal prolapse can be managed conservatively with pelvic floor biofeedback therapy to address underlying pelvic floor dysfunction 1
• Symptomatic Grade 3-4 rectal prolapse requires surgical correction as conservative measures are unlikely to provide adequate relief 1

Emergency Presentations Requiring Immediate Action

• Immediate surgical treatment is mandatory for complicated prolapse with signs of shock, gangrene, perforation, or hemodynamic instability 1
• Urgent surgery is indicated for bleeding, acute bowel obstruction, or failure of manual reduction 1
• For incarcerated prolapse without ischemia or perforation, attempt manual reduction in Trendelenburg position under IV sedation using techniques like topical granulated sugar, hypertonic solutions, or elastic compression to reduce edema 1
• Empiric antimicrobial therapy should be initiated for strangulated prolapse due to risk of bacterial translocation, tailored to local resistance patterns 1

Surgical Approach Selection Algorithm

For Younger, Fit Patients (Abdominal Approach Preferred)

• Abdominal procedures offer lower recurrence rates compared to perineal approaches and should be the first choice in this population 1
• Laparoscopic ventral rectopexy is the recommended technique for most patients, as it can be performed with modern anesthesia even in octogenarians with multiple comorbidities 1, 2
• Ventral rectopexy is particularly appropriate for high rectoceles or those with associated pelvic floor disorders 3
• Avoid posterior rectopexy as it results in severe constipation in up to 50% of patients 1

For Elderly or High-Risk Patients (Perineal Approach Preferred)

• Perineal procedures (Delorme's operation or Altemeier's operation) have lower perioperative morbidity despite higher recurrence rates 1
• These approaches are safer in patients who cannot tolerate laparotomy due to significant comorbidities 1, 4
• Perineal proctectomy with levatorplasty can be safely repeated if recurrence occurs after initial perineal repair 5

Critical Surgical Considerations and Pitfalls

Bowel Resection Decisions

• Avoid bowel resection in patients with preexisting diarrhea or incontinence, as these symptoms will worsen postoperatively 1
• If resectional procedures are planned, consider sigmoid resection with colorectal anastomosis combined with rectopexy 4
• In recurrent prolapse after initial resection, strongly consider non-resectional procedures (like Delorme's) to avoid creating an ischemic segment between two anastomoses 5

Managing Concurrent Symptoms

• Fecal incontinence often persists or fails to improve after surgical correction of the prolapse itself, and patients must be counseled accordingly 3, 5
• The correlation between anatomical correction and symptom improvement is often weak, particularly for defecation difficulties 3
• Surgical management should be individualized based on understanding each patient's specific symptoms (incontinence vs. constipation), bowel habits, and quality of life impact 2, 6

Preoperative Workup Requirements

• Physical examination to confirm full-thickness circumferential protrusion 6
• Colonoscopy and anoscopy to exclude other pathology 6
• Anal manometry and defecography in select patients to assess sphincter function and identify occult intussusception 6
• Distinguish pouch of Douglas protrusion from true rectal intussusception and full-thickness prolapse 1

Recurrence Management

• Overall recurrence rates exceed 15% across all surgical approaches 5
• Perineal approaches have higher recurrence rates but can be safely repeated 1, 5
• Average time to recurrence is 14 months (range 6-60 months), requiring long-term follow-up 5
• For recurrent prolapse after perineal repair, either repeat perineal procedure or consider abdominal approach if patient fitness allows 5