What is the treatment approach for rectal prolapse?

Rectal Prolapse: Workup and Treatment

Immediate Assessment and Risk Stratification

The treatment approach for rectal prolapse depends critically on whether the patient is hemodynamically stable and whether signs of bowel compromise exist—unstable patients with gangrene or perforation require immediate open abdominal surgery, while stable patients without ischemia can attempt conservative reduction before proceeding to elective repair. 1, 2

Emergency Indicators Requiring Immediate Surgery

• Signs of shock, gangrene, or perforation mandate immediate surgical intervention without delay for imaging or conservative measures 1, 2
• Hemodynamic instability requires an immediate abdominal open approach 1, 2
• Peritonitis necessitates proceeding directly to abdominal surgery 1, 2
• Bleeding from prolapsed tissue, acute bowel obstruction, or failure of manual reduction are urgent surgical indications 1, 2

Initial Workup for Complicated Prolapse

• Obtain complete blood count, serum creatinine, and inflammatory markers (C-reactive protein, procalcitonin, lactate) to assess severity and tissue perfusion 1, 2
• Lactate is particularly important as a marker of bowel ischemia 2
• In hemodynamically stable patients with irreducible or strangulated prolapse, perform contrast-enhanced abdomino-pelvic CT scan to detect complications and assess for colorectal malignancy—but never delay treatment for imaging in unstable patients 1, 2

Non-Operative Management (Stable Patients Only)

Attempt gentle manual reduction only in hemodynamically stable patients without signs of ischemia, perforation, or gangrene. 1, 2, 3

Reduction Technique

• Position patient in Trendelenburg position with intravenous sedation and analgesia 1, 2
• Apply gentle manual reduction under mild sedation or anesthesia 1, 2
• Topical granulated sugar can reduce edema through hyperosmolar effect, though overall efficacy is low 1, 2
• Alternative techniques include hypertonic solutions (50% dextrose or 70% mannitol) applied with gauzes, submucosal hyaluronidase infiltration to depolymerize hyaluronic acid, or elastic compression wrapping 1, 2

Critical Pitfall

Never delay surgery in hemodynamically unstable patients to attempt conservative management, and do not persist with non-operative management if initial attempts fail. 1, 2, 3

Surgical Approach Selection for Elective or Urgent Cases

Abdominal vs. Perineal Approach

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

• In stable patients without peritonitis or hemodynamic instability, base the decision between abdominal and perineal procedures on patient characteristics and surgeon expertise 1, 2
• Perineal approaches (Delorme's or Altemeier's operations) are reserved for elderly, high-risk patients despite higher recurrence and persistent incontinence rates 4, 5

Laparoscopic vs. Open Surgery

Laparoscopic rectopexy is preferred over open surgery for reduced complications and shorter hospital stay in stable patients. 2

• In hemodynamically stable patients choosing abdominal approach, base the decision between open or laparoscopic on patient characteristics and surgeon expertise 1, 2
• Laparoscopic repair has similar recurrence rates to open surgery with benefits of reduced hospital stay, postoperative pain, and wound complications 5

Adding Sigmoid Resection

Add sigmoid resection if the patient has significant pre-existing constipation to reduce post-operative constipation. 2

• Critical pitfall: Avoid bowel resection if patient has pre-existing diarrhea or incontinence—these symptoms will worsen. 2, 3
• Division of lateral ligaments reduces recurrence but increases postoperative constipation risk 3, 6

Intraoperative Decisions

Resection and Anastomosis

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, 2

• In stable patients without contamination, primary anastomosis is reasonable 2
• In unstable patients or with significant contamination, consider terminal colostomy 2

Pharmacological Management

• Administer empiric antimicrobial therapy in strangulated rectal prolapse due to risk of intestinal bacterial translocation; base regimen on clinical condition, multidrug-resistant organism (MDRO) risk, and local resistance patterns 1, 2
• Prescribe stool softeners during recovery to prevent straining 2
• Encourage early mobilization to prevent complications 2

Essential Pre-operative Screening

All patients with rectal prolapse should undergo colonoscopy or flexible sigmoidoscopy—they have a 4.2-fold increased risk of colorectal cancer compared to age-matched controls. 1, 2, 3

• This screening should not be overlooked given the association between chronic mucosal irritation, constipation, and increased rectosigmoid cancer prevalence (5.7% vs. 1.4% in controls) 1

Conservative Management for Mild Cases

• Asymptomatic grade 1-2 rectal prolapse does not require surgery; manage with pelvic floor biofeedback therapy to correct underlying dyssynergia 3

Key Clinical Pitfall

Do not assume anatomic correction correlates with symptom improvement—symptoms may persist despite successful anatomic repair, as underlying functional disorders are not corrected by surgery alone. 3