What are the treatment options for rectal prolapse?

From the Guidelines

Rectal prolapse treatment should be individualized based on the severity of the prolapse and the patient's overall health status, with surgery being the definitive treatment for symptomatic grade 3-4 prolapse, using either an abdominal or perineal approach. The choice of surgical approach depends on the patient's characteristics, surgeon's skills, and expertise 1. For patients with complicated rectal prolapse, the decision between abdominal and perineal procedures should be based on the specific patient's characteristics and surgeon's skills and expertise 1.

Key Considerations

• Asymptomatic Grade 1-2 rectal prolapse can be managed with conservative measures, such as stool softeners, high-fiber diet, and pelvic floor exercises to reduce straining 1.
• Patients with symptomatic grade 3-4 prolapse require surgery, with options including abdominal approaches (rectopexy, sometimes with sigmoid resection) or perineal procedures (Delorme procedure or Altemeier procedure) 1.
• Abdominal approaches have lower recurrence rates but higher surgical risks, making them better for younger, healthier patients, while perineal procedures are less invasive and preferred for elderly or medically compromised patients 1.
• Non-operative management (NOM) can be attempted for incarcerated rectal prolapse without signs of ischemia or perforation, but surgery should not be delayed if NOM fails 1.

Surgical Approaches

• Abdominal approaches: rectopexy, sometimes with sigmoid resection, have lower recurrence rates but higher surgical risks 1.
• Perineal procedures: Delorme procedure or Altemeier procedure, are less invasive and preferred for elderly or medically compromised patients 1.
• Laparoscopic rectopexy is associated with fewer post-operative complications and shorter hospital stay than open rectopexy 1.

Recovery and Follow-up

• Recovery typically requires 4-6 weeks of activity restrictions, stool softeners, and dietary modifications to prevent constipation 1.
• Surgery addresses the anatomical defect by fixing the rectum to surrounding structures or removing redundant tissue, preventing recurrence of the prolapse and improving bowel control 1.

From the Research

Treatment Options for Rectal Prolapse

• Surgical options are available to treat rectal prolapse, and the choice of surgery depends on the patient's symptoms, bowel habits, anatomy, and pre-operative expectations 2
• Preoperative workup includes physical exam, colonoscopy, anoscopy, and, in some patients, anal manometry and defecography to determine the best surgical approach 2
• Abdominal versus perineal, minimally invasive versus open, and posterior versus ventral rectopexy +/- sigmoidectomy are some of the surgical techniques used to treat rectal prolapse 2

Conservative Management

• Conservative management of obstructed defecation syndrome (ODS), which may be associated with rectal prolapse, includes fiber diet, bulking laxatives, rectal irrigation or hydrocolontherapy, biofeedback, transanal electrostimulation, yoga, and psychotherapy 3
• Biofeedback therapy can be used to treat patients with fecal incontinence, constipation, and rectal pain, with mean success rates ranging from 41.2% to 72.3% 4

Surgical Procedures

• Rectal prolapse excision or obliterative suture, rectocele and/or enterocele repair, retrograde Malone's enema, and partial myotomy of the puborectalis muscle are effective in selected cases 3
• Laparoscopic ventral sacral colporectopexy may be an effective surgical option for rectal prolapse 3
• Stapled transanal rectal resection may lead to severe complications, while the Transtar procedure seems to be safer for recto-rectal intussusception 3

Diagnosis and Evaluation

• The diagnosis of rectal prolapse is made based on physical examination, although several other modalities are used to provide additional information about the patients' condition 5
• A comprehensive update concerning the diagnostic and therapeutic pathway for rectal prolapse is required to draw recommendations for clinical practice 6
• The Dutch guidelines for the management of patients with rectal prolapse provide recommendations for diagnostic approach, conservative and surgical management, and treatment options 6