What is the initial management of rectal prolapse in the Emergency Department (ED)?

Initial Management of Rectal Prolapse in the Emergency Department

For uncomplicated rectal prolapse without signs of ischemia or perforation, attempt gentle manual reduction under mild sedation using topical sugar application or elastic compression to reduce edema, but proceed immediately to surgery if the patient shows signs of strangulation, gangrene, perforation, or hemodynamic instability. 1

Immediate Assessment and Risk Stratification

Upon presentation, rapidly determine the patient's hemodynamic status and assess for complications:

• Check for signs requiring immediate surgery: shock, gangrene of prolapsed bowel, perforation, or hemodynamic instability—these mandate immediate surgical intervention without delay 1
• Examine the prolapsed tissue: look for ischemia (dark discoloration, lack of bleeding), ulceration, or signs of perforation 1
• Assess for acute bowel obstruction or active bleeding: these indicate urgent (not immediate) surgical treatment if conservative measures fail 1

Non-Operative Management Approach

For incarcerated prolapse without ischemia or perforation, attempt manual reduction before considering surgery 1:

Reduction Technique

• Position patient in Trendelenburg position with intravenous sedation and analgesia 1, 2
• Apply topical granulated sugar to the prolapsed tissue—this creates a hyperosmolar environment that draws out edema and facilitates reduction 1, 3
• Alternative methods include elastic compression wrap, hypertonic solutions, or submucosal hyaluronidase infiltration 2, 4
• Perform gentle manual reduction after edema reduction 1

Critical Caveat

Do not delay surgical management in hemodynamically unstable patients to attempt conservative reduction 1. The failure rate of conservative management is high, and time is critical in complicated cases 2.

Imaging Considerations

In stable patients with reducible prolapse, obtain contrast-enhanced CT of abdomen/pelvis to detect:

• Associated complications (bowel obstruction, perforation, peritonitis) 1
• Prolapse of other pelvic organs 1
• Underlying colorectal malignancy (5.7% prevalence in rectal prolapse patients, representing a 4.2-fold increased risk) 1

In hemodynamically unstable or strangulated prolapse, do not delay treatment for imaging 1.

Pharmacological Management

Administer empiric antibiotics for strangulated rectal prolapse due to risk of bacterial translocation 1, 2:

• Base regimen on patient's clinical condition, risk for multidrug-resistant organisms, and local resistance patterns 1, 2
• This applies even before frank perforation is evident 1

Indications for Surgical Intervention

Immediate Surgery (Strong Recommendation)

• Signs of shock 1
• Gangrene or perforation of prolapsed bowel 1
• Hemodynamic instability 1

Urgent Surgery

• Active bleeding 1
• Acute bowel obstruction 1
• Failure of manual reduction attempts 1, 5

Common Pitfalls to Avoid

• Never delay definitive treatment in unstable patients to attempt reduction or obtain imaging 1
• Do not perform digital rectal examination before imaging if foreign body is suspected, as sharp objects may injure the examiner 1
• Recognize that successful reduction is only temporizing—these patients need elective definitive surgical repair after stabilization 1
• Consider colorectal cancer screening after acute management, as rectal prolapse may be the first manifestation of malignancy 1