What are the treatment options for rectal prolapse?

Treatment of Rectal Prolapse

For uncomplicated rectal prolapse, attempt conservative manual reduction first, but proceed directly to surgery for symptomatic grade 3-4 prolapse, complicated cases with ischemia/perforation, or when conservative management fails. 1

Initial Management Approach

Conservative Management

• Manual reduction should be attempted first for partial or incarcerated rectal prolapse without signs of ischemia or perforation, performed with the patient in Trendelenburg position under intravenous sedation and analgesia 1
• Techniques to reduce edema and facilitate reduction include topical granulated sugar, hypertonic solutions, submucosal hyaluronidase infiltration, and elastic compression wraps 1
• Do not delay surgical treatment if conservative measures fail, as the failure rate is high 1
• Asymptomatic grade 1-2 prolapse can be managed with pelvic floor biofeedback therapy to correct underlying dysfunction 2, 1

Surgical Indications (Algorithmic Approach)

Immediate Surgery (Within Hours)

• Proceed immediately if signs of shock, gangrene, or perforation of prolapsed bowel are present 3
• Proceed immediately if hemodynamic instability exists 3

Urgent Surgery (Within 24-48 Hours)

• Active bleeding from prolapsed tissue 3
• Acute bowel obstruction 3
• Failure of manual reduction attempts 3

Elective Surgery

• All symptomatic grade 3-4 rectal prolapse requires surgical correction 1
• Persistent symptoms despite conservative management 2

Surgical Approach Selection

Patient-Based Algorithm

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

• Choose abdominal approach (open or laparoscopic rectopexy ± sigmoid resection) as it provides lower recurrence rates 1
• Laparoscopic vs. open decision based on surgeon expertise and patient anatomy 3
• Options include suture rectopexy, mesh rectopexy, or ventral rectopexy 2, 4

For elderly patients with significant comorbidities:

• Choose perineal approach (Altemeier's or Delorme's procedure) despite higher recurrence rates, as perioperative morbidity is lower 1, 5
• Perineal rectosigmoidectomy in elderly high-risk patients has minimal morbidity with median 4-day hospital stay 5
• Add levatoroplasty if fecal incontinence is present, as 10 of 11 patients improved or regained continence with this addition 5

For complicated prolapse with peritonitis:

• Use abdominal approach 3

For complicated prolapse with hemodynamic instability:

• Use open abdominal approach (not laparoscopic) 3

Specific Technical Considerations

Regarding sigmoid resection:

• Include sigmoid resection during rectopexy to reduce postoperative constipation 1
• Avoid bowel resection in patients with preexisting diarrhea or incontinence, as symptoms may worsen 1

Regarding lateral ligament division:

• Division of lateral ligaments reduces recurrent prolapse but increases postoperative constipation 6
• Preservation maintains bowel function but may increase recurrence risk 6

Regarding mesh rectopexy:

• Posterior mesh rectopexy can cause severe constipation in up to 50% of patients 1
• Ventral rectopexy is preferred for high rectoceles or associated pelvic floor disorders 2

Pharmacological Management

• Administer empiric antimicrobial therapy for strangulated rectal prolapse due to risk of bacterial translocation 3, 1
• Base antibiotic regimen on clinical condition, individual risk for multidrug-resistant organisms, and local resistance patterns 3, 1

Critical Pitfalls to Avoid

• Do not perform posterior rectopexy alone in patients with preexisting constipation, as it worsens constipation in up to 50% 1
• Do not delay surgery in hemodynamically unstable patients attempting conservative measures 1
• Do not expect perfect correlation between anatomical correction and symptom improvement, as underlying functional disorders may persist despite surgical repair 2
• Be aware that STARR (Stapled Transanal Rectal Resection) has disappointing long-term outcomes despite initial improvement, with rare but serious complications including fistula, peritonitis, and bowel perforation 2
• Do not confuse pouch of Douglas protrusion with rectal intussusception or full-thickness prolapse 1

Anastomotic Decision-Making in Emergency Settings

• For resectional surgery in complicated prolapse, base the decision between primary anastomosis (with or without diverting ostomy) versus terminal colostomy on clinical condition and individual anastomotic leak risk 3