What are the treatment options for rectal prolapse?

Treatment Options for Rectal Prolapse

All patients with external rectal prolapse should be offered surgical repair, with the specific approach determined by whether the prolapse is complicated (requiring immediate/urgent surgery) versus uncomplicated (allowing for elective repair), and by patient fitness for abdominal versus perineal surgery. 1, 2

Initial Management Strategy

Conservative Management

• Attempt manual reduction first for uncomplicated rectal prolapse without signs of ischemia or perforation, using gentle reduction under mild sedation with the patient in Trendelenburg position 2
• Apply topical granulated sugar, hypertonic solutions, submucosal hyaluronidase infiltration, or elastic compression wraps to reduce edema and facilitate manual reduction 2
• Do not delay surgical treatment if conservative management fails, as the failure rate is high 2
• Asymptomatic Grade 1-2 prolapse can be managed with pelvic floor biofeedback therapy, but symptomatic Grade 3-4 prolapse requires surgical correction 3, 2

When to Operate Immediately

• Proceed directly to emergency surgery if the patient has signs of shock, gangrene, or perforation of the prolapsed bowel 1, 2
• Perform urgent surgery for bleeding, acute bowel obstruction, or when manual reduction fails 1, 2

Surgical Approach Selection

Abdominal vs. Perineal Decision Algorithm

For younger, fit patients: Choose abdominal approach (open or laparoscopic rectopexy ± sigmoidectomy) as it provides lower recurrence rates 2

For elderly patients with significant comorbidities: Choose perineal approach (Delorme's or Altemeier's procedure) despite higher recurrence rates, because perioperative morbidity is lower 2

Specific Abdominal Techniques

• Ventral rectopexy is recommended for high rectoceles or those associated with other pelvic floor disorders, and can be performed open or laparoscopically 3
• Include sigmoid resection during rectopexy to reduce post-operative constipation, but avoid bowel resection in patients with preexisting diarrhea or incontinence as symptoms may worsen 2, 4
• Avoid posterior rectopexy as it can cause severe constipation in up to 50% of patients 2

Laparoscopic vs. Open Access

• In hemodynamically stable patients, base the decision between open or laparoscopic surgery on patient characteristics and surgeon expertise 1
• Use open abdominal approach in hemodynamically unstable patients 1

Management of Complicated Prolapse

• Perform abdominal approach if signs of peritonitis are present 1
• For resectional surgery, decide between primary anastomosis (with or without diverting ostomy) versus terminal colostomy based on the patient's clinical condition and individual risk of anastomotic leakage 1

Pharmacological Management

• Administer empiric antimicrobial therapy for strangulated rectal prolapse due to risk of intestinal bacterial translocation 1, 2
• Base antibiotic regimen on the patient's clinical condition, individual risk for multidrug-resistant organisms, and local resistance epidemiology 1, 2

Critical Pitfalls to Avoid

• Do not confuse internal prolapse with external prolapse: Internal prolapse alone rarely requires surgery unless associated with enterocele, rectocele, or cystocele 5
• Counsel patients about realistic expectations: The correlation between symptom improvement and anatomical correction is often weak, as anatomical abnormalities may be caused by underlying functional disorders not corrected by surgery 3
• Monitor for serious complications after transanal procedures: Stapled Transanal Rectal Resection (STARR) carries risks of fistula, peritonitis, bowel perforation, infection, pain, incontinence, and bleeding 3
• Recognize that long-term outcomes may be disappointing: Despite initial improvement after STARR, long-term results show variable success rates 3