What are the management options for rectal prolapse?

Grading and Management of Rectal Prolapse

Grading System

Rectal prolapse is graded 1-4, with grades 1-2 representing asymptomatic or minimally symptomatic internal prolapse that requires only conservative management, while grades 3-4 represent full-thickness external prolapse requiring surgical intervention. 1

Emergency Assessment and Immediate Management

Hemodynamic Status Determines Urgency

• If the patient is hemodynamically unstable with signs of shock, gangrene, or perforation, proceed immediately to open abdominal surgery without delay—do not attempt conservative reduction or imaging. 2, 3
• Check complete blood count, serum creatinine, inflammatory markers (CRP, procalcitonin), and lactate as a critical marker of bowel ischemia and poor tissue perfusion. 2
• Peritonitis, acute bowel obstruction, or bleeding from prolapsed tissue all mandate immediate surgical intervention. 2

For Stable Patients with Incarcerated Prolapse

• Attempt gentle manual reduction under intravenous sedation in Trendelenburg position only if there are no signs of ischemia, perforation, or gangrene. 1, 2, 3
• Apply topical granulated sugar directly to the prolapsed mucosa to create hyperosmolar environment and reduce edema, though overall efficacy is low. 1, 2
• Alternative edema-reduction techniques include hypertonic solutions (50% dextrose or 70% mannitol) applied with gauzes, or submucosal hyaluronidase infiltration to depolymerize hyaluronic acid. 1, 2
• Elastic compression wrapping can force edema fluid out of the prolapse. 2
• If manual reduction fails or any signs of gangrene/perforation develop, proceed immediately to surgery. 2, 3

Imaging Decisions

• Obtain contrast-enhanced abdomino-pelvic CT scan in hemodynamically stable patients to detect complications, assess for colorectal malignancy, and guide surgical approach selection. 1, 2
• Never delay treatment for imaging in unstable patients—timely management of strangulated prolapse is paramount. 1, 2, 3

Antimicrobial Therapy

• Administer empiric broad-spectrum antimicrobials in strangulated rectal prolapse due to risk of intestinal bacterial translocation; base regimen on clinical condition, multidrug-resistant organism risk factors, and local resistance patterns. 2

Elective Surgical Management

Patient Selection for Surgical Approach

Choose laparoscopic abdominal rectopexy for younger, fit patients as it offers significantly lower recurrence rates (0-8%) compared to perineal approaches (5-21%), with the added benefits of fewer complications and shorter hospital stay compared to open surgery. 1, 2, 4, 5

• Reserve perineal procedures (Altemeier proctosigmoidectomy) for elderly patients with significant medical comorbidities or contraindications to abdominal surgery, accepting the higher recurrence rate (5-21%) in exchange for lower perioperative morbidity. 1, 5
• Perineal proctosigmoidectomy may be combined with transperineal levatoroplasty to reduce recurrence risk. 1

Critical Decision: Adding Sigmoid Resection

• Add sigmoid resection during rectopexy if the patient has significant pre-existing constipation, as this reduces post-operative constipation rates. 1, 2
• Absolutely avoid bowel resection if the patient has pre-existing diarrhea or incontinence—these symptoms will worsen with resection. 1, 2, 3
• Division of lateral ligaments reduces recurrence but increases post-operative constipation risk—weigh this trade-off carefully. 1, 3
• Be aware that posterior rectopexy causes severe constipation in 50% of patients. 1, 3

Anastomosis vs. Ostomy in Emergency Cases

• In stable patients without significant contamination, primary anastomosis is reasonable. 2
• In unstable patients or with significant contamination, perform terminal colostomy rather than risking anastomotic leak. 2

Conservative Management (Non-Surgical)

Asymptomatic grade 1-2 rectal prolapse does not require surgery—manage with pelvic floor biofeedback therapy to correct underlying dyssynergia and stool softeners to eliminate straining. 1, 3

Mandatory Cancer Screening

All patients with rectal prolapse must undergo colonoscopy or flexible sigmoidoscopy, as they have a 4.2-fold increased risk of rectosigmoid cancer compared to age-matched controls (5.7% prevalence vs. 1.4%). 1, 2, 3

Critical Pitfalls to Avoid

• Never persist with conservative management in hemodynamically unstable patients—this delays life-saving surgery. 1, 2, 3
• Do not assume anatomic correction correlates with symptom improvement—functional disorders like incontinence and constipation may persist despite successful anatomic repair. 3
• Do not add bowel resection to patients with diarrhea or incontinence—you will make them worse. 1, 2, 3
• Do not perform CT scan if it delays treatment in strangulated prolapse. 1, 2

Post-Operative Management

• Prescribe stool softeners during recovery to prevent straining. 2
• Encourage early mobilization to prevent complications. 2
• Most patients return to full activities by 6 weeks. 2