What is the initial management and treatment for rectal prolapse?

Initial Management and Treatment for Rectal Prolapse

For uncomplicated rectal prolapse in stable patients, attempt gentle manual reduction under sedation in Trendelenburg position, followed by colonoscopy to rule out malignancy and elective surgical repair; however, patients with signs of shock, gangrene, or perforation require immediate surgical intervention. 1, 2

Immediate Assessment and Stabilization

Hemodynamic Status Determines Urgency

• Hemodynamically unstable patients with strangulated or perforated prolapse require immediate open abdominal surgery without delay for imaging or conservative measures (strong recommendation, 1A evidence). 1
• Hemodynamically stable patients with incarcerated prolapse but no ischemia or perforation should undergo attempted manual reduction before proceeding to elective surgery. 1, 2

Manual Reduction Techniques for Stable Patients

• Position the patient in Trendelenburg and provide intravenous sedation and analgesia. 1
• Apply topical granulated sugar directly to the prolapsed mucosa to create a hyperosmolar environment that reduces edema by drawing out water molecules. 1, 2
• Alternative techniques include hypertonic solutions (50% dextrose or 70% mannitol), submucosal hyaluronidase injection, or elastic compression wrapping. 1, 2
• If manual reduction fails or signs of gangrene/perforation develop, proceed immediately to urgent surgical treatment. 1, 2

Pre-operative Workup (For Stable Patients)

Mandatory Cancer Screening

• Perform colonoscopy or flexible sigmoidoscopy in all patients with rectal prolapse, 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
• Rectal prolapse may be the first clinical manifestation of colorectal malignancy, particularly in the age group most commonly affected. 1

Imaging for Complicated Cases

• In stable patients with irreducible or strangulated prolapse, obtain urgent contrast-enhanced CT scan of abdomen and pelvis to detect complications, assess for colorectal cancer, and evaluate for prolapse of other pelvic organs. 1, 2
• Do not delay surgery in unstable patients to obtain imaging. 1

Surgical Indications and Timing

Immediate Surgery (Strong Recommendation)

• Signs of shock, gangrene, or perforation of prolapsed bowel mandate immediate surgical treatment. 1
• Use open abdominal approach in hemodynamically unstable patients. 1

Urgent Surgery

• Bleeding, acute bowel obstruction, or failure of non-operative management require urgent surgical intervention. 1

Elective Surgery

• All patients with external rectal prolapse should be offered surgical repair, as the natural history leads to complications of incontinence and constipation. 3
• Asymptomatic grade 1-2 internal prolapse without external component can be managed conservatively with pelvic floor biofeedback therapy. 2

Surgical Approach Selection

Abdominal vs Perineal Approach

• Abdominal rectopexy (with or without mesh) has significantly lower recurrence rates (0-8%) compared to perineal approaches. 2
• In stable patients without peritonitis, base the decision between abdominal and perineal procedures on patient characteristics (age, comorbidities, surgical fitness) and surgeon expertise. 1, 4, 5
• Laparoscopic ventral rectopexy offers low morbidity, low recurrence rates, and good functional improvement with benefits of reduced pain, early recovery, and shorter hospital stay. 4, 5, 6

Special Considerations

• Avoid bowel resection in patients with preexisting diarrhea or incontinence, as these symptoms may worsen postoperatively. 2
• Consider sigmoid resection at time of rectopexy if significant preoperative constipation is present. 6
• Division of lateral ligaments reduces recurrence but increases postoperative constipation risk. 2

Antibiotic Therapy

• In patients with strangulated rectal prolapse, administer empiric antimicrobial therapy due to risk of intestinal bacterial translocation. 1
• Base the antibiotic regimen on clinical condition, individual risk for multidrug-resistant organisms, and local resistance patterns. 1

Critical Pitfalls to Avoid

• Do not assume anatomic correction correlates with symptom improvement—functional symptoms (incontinence, constipation) may persist despite successful anatomic repair because underlying functional disorders are not corrected by surgery alone. 2, 4
• Posterior rectopexy causes severe constipation in 50% of patients. 2
• Do not perform surgery for isolated internal prolapse without associated pelvic floor defects, as the extent to which internal prolapse causes symptoms is unclear. 3