What is the difference between high and low take-off rectal prolapse?

From the Guidelines

The main difference between high and low take-off rectal prolapse is the anatomical origin and extent of the prolapse, with high take-off being a full-thickness prolapse requiring more extensive surgical interventions like rectopexy or resection rectopexy, as opposed to low take-off which can be managed with less invasive procedures. The distinction between high and low take-off rectal prolapse is crucial for determining the appropriate treatment approach, with high take-off prolapses originating higher in the rectum and involving all layers of the rectal wall, including the mucosa, submucosa, and muscular layers 1. Some key points to consider in the management of rectal prolapse include:

• Asymptomatic Grade 1–2 rectal prolapse does not require surgery and can be managed with conservative and/or biofeedback therapy to correct underlying dyssynergia 1
• Patients with symptomatic grade 3–4 prolapse require surgery, using either an abdominal approach or perineal resection 1
• The choice of surgical approach depends on various factors, including the patient's overall health, presence of medical comorbidities, and the specific characteristics of the prolapse 1
• Laparoscopic rectopexy has been associated with fewer post-operative complications and shorter hospital stay compared to open rectopexy 1
• Bowel resection during rectopexy can be beneficial in reducing constipation, but should be avoided in patients with preexisting diarrhea and/or incontinence 1. In clinical practice, the perineal approach is often preferred due to its lower perioperative morbidity, although it is associated with a higher recurrence rate 1. Ultimately, the goal of treatment is to alleviate symptoms, improve quality of life, and minimize morbidity and mortality, with the choice of surgical approach depending on a careful consideration of the individual patient's needs and circumstances.

From the Research

Difference between High and Low Take-Off Rectal Prolapse

• High take-off rectal prolapse is characterized by a higher level of origin on proctography, with a greater rectosigmoid junction caudal mobility and a trend towards a lower resting rectosigmoid position 2.
• Low take-off rectal prolapse, on the other hand, has a lower level of origin on proctography, with less rectosigmoid junction caudal mobility and a higher resting rectosigmoid position 2.
• The difference between high and low take-off rectal prolapse may be related to different pathological phenotypes of prolapse, with high take-off potentially being associated with connective tissue failure and low take-off being associated with levator ani factors 2.
• Anal sphincter function has been found to be reduced in both high and low take-off external rectal prolapse, but with some differences between the two phenotypes, suggesting that high take-off may have similar sphincter function to grade IV rectal intussusception 3.

Clinical Implications

• Understanding the difference between high and low take-off rectal prolapse may be important for determining the best surgical approach for each patient 2.
• Defaecation proctography can be used to characterize high and low take-off prolapse preoperatively, allowing for a more tailored surgical approach 2.
• The choice of surgical procedure may depend on the specific characteristics of the prolapse, including the level of origin and the presence of other pelvic floor disorders 4, 5.

Diagnostic Evaluation

• Defaecation proctography is a useful diagnostic tool for characterizing high and low take-off rectal prolapse 2.
• Anal manometry and acoustic reflectometry may also be used to evaluate anal sphincter function in patients with rectal prolapse 3.
• A comprehensive diagnostic evaluation, including physical exam, colonoscopy, anoscopy, and defaecation proctography, is necessary to determine the best course of treatment for each patient 4.