What are the treatment options for rectal prolapse?

Treatment of Rectal Prolapse

Emergency vs. Non-Emergency Management

For complicated rectal prolapse with signs of shock, gangrene, or perforation, immediate surgical treatment is mandatory; for incarcerated prolapse without ischemia, attempt gentle manual reduction under sedation before proceeding to surgery. 1

Immediate Surgical Indications (Do Not Delay)

• Hemodynamic instability - requires immediate abdominal open approach 1
• Signs of gangrene or perforation of prolapsed bowel - immediate surgery required 1
• Peritonitis - proceed directly to abdominal approach 1

Urgent Surgical Indications

• Bleeding from prolapsed tissue 1
• Acute bowel obstruction 1
• Failure of non-operative management 1

Non-Operative Management (For Incarcerated Prolapse Without Ischemia)

Attempt conservative reduction only in hemodynamically stable patients without signs of ischemia, perforation, or gangrene. 1

Reduction Technique

• Position patient in Trendelenburg position 1
• Administer intravenous sedation and analgesia 1
• Apply gentle manual reduction under mild sedation or anesthesia 1

Edema Reduction Methods (in order of common use)

• Topical granulated sugar - most commonly used but has low overall efficacy; creates hyperosmolar environment to reduce edema 1
• Hypertonic solutions (50% dextrose or 70% mannitol) applied directly to rectal mucosa with gauzes 1
• Submucosal hyaluronidase infiltration - depolymerizes hyaluronic acid to allow fluid drainage 1
• Elastic compression wrap - uses continuous pressure to force edema fluid out 1

Critical Caveat

Do not delay surgical treatment if non-operative management fails - the failure rate is high and delay risks ischemia and perforation. 1

Surgical Approach Selection

For Hemodynamically Stable Patients Without Peritonitis

Choose abdominal rectopexy for younger, fit patients due to significantly lower recurrence rates (0-8%) compared to perineal approaches (5-21%). 2, 3

Abdominal Approach Decision Tree:

• Laparoscopic rectopexy is preferred over open for reduced complications and shorter hospital stay 1, 2
• Add sigmoid resection if patient has significant pre-existing constipation to reduce post-operative constipation 2
• Avoid bowel resection if patient has pre-existing diarrhea or incontinence - these symptoms will worsen 2, 3
• Base decision between open vs. laparoscopic on surgeon expertise and patient characteristics 1

Perineal Approach Indications:

• Elderly patients with significant comorbidities 3
• High-risk surgical candidates who cannot tolerate abdominal surgery 3
• Accept higher recurrence rates (5-21%) in exchange for lower operative risk 3

For Patients With Peritonitis

Use abdominal approach - perineal procedures are inadequate 1

For Hemodynamically Unstable Patients

Perform abdominal open approach immediately - do not attempt laparoscopy 1

Resection Decisions During Surgery

Base the decision between primary anastomosis (with or without diverting ostomy) versus terminal colostomy on the patient's clinical condition and individual risk of anastomotic leakage. 1

• In stable patients without contamination: primary anastomosis is reasonable 1
• In unstable patients or with significant contamination: consider terminal colostomy 1

Pharmacological Management

Antibiotics

Administer empiric antimicrobial therapy in strangulated rectal prolapse due to risk of intestinal bacterial translocation; base regimen on clinical condition, MDRO risk, and local resistance patterns. 1

Post-Operative Care

• Stool softeners during recovery to prevent straining 3
• Early mobilization to prevent complications 2
• Most patients return to full activities by 6 weeks 2

Diagnostic Workup (When Time Permits)

Laboratory Tests

• Complete blood count, serum creatinine, inflammatory markers (CRP, procalcitonin, lactate) to assess severity 1
• Lactate is particularly important as marker of poor tissue perfusion and bowel ischemia 1

Imaging

• Contrast-enhanced abdomino-pelvic CT scan in hemodynamically stable patients to detect complications and assess for colorectal malignancy 1
• Do not delay treatment for imaging in unstable patients 1

Cancer Screening

All patients with rectal prolapse should undergo endoscopic examination - they have 4.2-fold increased risk of colorectal cancer compared to age-matched controls. 1

Critical Pitfalls to Avoid

• Never delay surgery in hemodynamically unstable patients to attempt conservative management 1
• Do not persist with non-operative management if initial attempts fail - high failure rate mandates prompt surgical intervention 1
• Do not perform CT scan if it delays treatment in strangulated prolapse 1
• Do not add bowel resection in patients with diarrhea or incontinence - symptoms will worsen 2, 3