What are the treatment options for rectal prolapse?

Treatment for Rectal Prolapse

Surgical repair is the definitive treatment for symptomatic rectal prolapse, with the choice between abdominal and perineal approaches determined primarily by patient hemodynamic stability, presence of complications, age, and surgical risk status.

Emergency vs. Elective Management

Complicated/Incarcerated Prolapse

• For hemodynamically unstable patients with strangulated or perforated rectal prolapse, proceed immediately to surgery without delay 1
• For incarcerated prolapse without ischemia or perforation in stable patients, attempt gentle manual reduction under sedation in Trendelenburg position before proceeding to elective surgery 1
• Non-operative reduction techniques include topical granulated sugar (most common), hypertonic solutions (50% dextrose or 70% mannitol), submucosal hyaluronidase injection, or elastic compression wrapping to reduce edema 1
• Do not delay surgical management if manual reduction fails or if signs of gangrene/perforation develop 1

Pre-operative Workup

• Obtain colonoscopy or flexible sigmoidoscopy in all patients with rectal prolapse to rule out colorectal malignancy, as these patients have a 4.2-fold increased risk of rectosigmoid cancer compared to age-matched controls 1
• Perform contrast-enhanced CT scan in complicated cases to assess for bowel obstruction, perforation, peritonitis, or prolapse of other pelvic organs, but do not delay surgery in unstable patients 1

Surgical Approach Selection

Abdominal Procedures (Preferred for Most Patients)

• Abdominal rectopexy (with or without sigmoid resection) is associated with significantly lower recurrence rates (0-8%) compared to perineal approaches 1, 2
• Laparoscopic rectopexy offers fewer postoperative complications and shorter hospital stays compared to open surgery 1, 3
• Laparoscopic resection rectopexy and ventral mesh rectopexy provide advantages in preventing new-onset constipation 3
• Avoid bowel resection in patients with preexisting diarrhea or incontinence, as these symptoms may worsen 1
• Division of lateral ligaments reduces recurrence but increases postoperative constipation risk 1

Perineal Procedures (For High-Risk Patients)

• Reserve perineal proctosigmoidectomy (Altemeier procedure) for elderly patients, those with significant medical comorbidities, or contraindications to abdominal surgery 1, 2
• Perineal approaches have higher recurrence rates (5-21%) but lower perioperative morbidity and shorter hospital stays (5 vs. 8 days) 1, 2
• Consider combining with transperineal levatoroplasty to reduce recurrence risk 1
• Despite higher recurrence, perineal procedures show comparable patient satisfaction to abdominal approaches 2

Conservative Management (Limited Role)

• Asymptomatic grade 1-2 rectal prolapse does not require surgery; manage with pelvic floor biofeedback therapy to correct underlying dyssynergia 1, 4
• Symptomatic grade 3-4 prolapse requires surgical intervention in addition to conservative measures 1, 4

Key Clinical Pitfalls

• Do not assume anatomic correction correlates with symptom improvement—symptoms may persist despite successful anatomic repair, as underlying functional disorders (impaired pelvic floor relaxation, excessive straining) are not corrected by surgery alone 1, 4
• Posterior rectopexy causes severe constipation in 50% of patients 1
• STARR procedure complications include fistula, peritonitis, bowel perforation, infection, pain, and incontinence in 15% of cases 1, 4
• The trend has shifted toward increased use of perineal procedures (from 22% to 79% over time) despite higher recurrence, reflecting recognition of lower morbidity in appropriate patient populations 2