What are the management options for rectal prolapse?

Management of Rectal Prolapse

For symptomatic rectal prolapse, surgical intervention is the primary treatment, with the choice between abdominal and perineal approaches determined by patient age, fitness, and comorbidities—abdominal procedures (preferably laparoscopic) for younger, fit patients and perineal procedures for elderly patients with significant comorbidities. 1

Initial Assessment and Conservative Management

Grading and Initial Approach

• Asymptomatic Grade 1-2 rectal prolapse can be managed conservatively with pelvic floor biofeedback therapy to correct underlying pelvic floor dysfunction 1
• Symptomatic Grade 3-4 rectal prolapse requires surgical correction 1
• For partial rectal prolapse without ischemia or perforation, attempt gentle manual reduction first with the patient in Trendelenburg position under intravenous sedation 1

Techniques to Facilitate Manual Reduction

• Apply topical granulated sugar, hypertonic solutions, submucosal hyaluronidase infiltration, or elastic compression wrap to reduce edema 1
• Do not delay surgical treatment if conservative management fails, as the failure rate is high 1

Emergency Surgical Indications

Immediate surgical intervention is mandatory for:

• Signs of shock, gangrene, or perforation of prolapsed bowel 1
• Hemodynamic instability 1
• Bleeding or acute bowel obstruction 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)

• Abdominal procedures offer lower recurrence rates and greater functional improvement compared to perineal approaches 2
• Laparoscopic repair is preferred as it provides similar morbidity and recurrence rates to open surgery with reduced hospital stay, postoperative pain, and wound complications 3
• Options include suture rectopexy, mesh rectopexy, or ventral rectopexy—all produce equivalent results 2
• Add sigmoid resection to rectopexy if significant preoperative constipation is present to reduce postoperative constipation 3, 2
• Avoid posterior rectopexy as it can cause severe constipation in up to 50% of patients 1

For Elderly Patients with Significant Comorbidities (Perineal Approach)

• Perineal procedures (Delorme's or Altemeier's operation) are better tolerated in high-risk patients despite higher recurrence rates and persistent incontinence 1, 4
• These procedures have lower perioperative morbidity 1
• Modern anesthesia techniques have made abdominal approaches safer even for octogenarians, so consider laparoscopic repair if patient can tolerate it 5

Critical Pitfalls to Avoid

• Never perform bowel resection in patients with preexisting diarrhea or incontinence, as these symptoms will worsen 1
• Polyvinyl alcohol (Ivalon) sponge rectopexy should be abandoned due to increased infectious complications 2
• The correlation between anatomical correction and symptom improvement is often weak—counsel patients that surgery may not fully resolve defecation difficulties 6
• Do not confuse Pouch of Douglas protrusion with rectal intussusception or full-thickness prolapse 1

Expected Outcomes

• Diarrhea and incontinence often improve after surgery in many patients 3
• Abdominal approaches have the lowest recurrence rates overall 3, 2
• Perineal procedures have higher recurrence rates but are appropriate for the right patient population 4, 2

Special Considerations for Pediatric Patients

• Rectal prolapse in children is usually self-limiting and responds to conservative management with watchful expectancy and laxatives 7
• Surgery is only indicated if age >4 years, >2 episodes requiring manual reduction under sedation, or symptoms of pain, bleeding, and perianal excoriation persist 7
• Children presenting younger than 4 years with an associated underlying condition have better prognosis with conservative management 7