What are the treatment options for rectal prolapse?

Treatment Options for Rectal Prolapse

All patients with external rectal prolapse should be offered surgical repair, as the natural history frequently leads to complications of incontinence and constipation. 1

Initial Conservative Management

For uncomplicated rectal prolapse without signs of ischemia or perforation, attempt conservative measures with gentle manual reduction under mild sedation or anesthesia first. 2

• Position the patient in Trendelenburg with intravenous sedation and analgesia for manual reduction of incarcerated prolapse 2
• Use topical granulated sugar, hypertonic solutions, submucosal hyaluronidase infiltration, or elastic compression wrap to reduce edema and facilitate reduction 2
• Do not delay surgical treatment if conservative management fails, as the failure rate is high 2
• For asymptomatic Grade 1-2 rectal prolapse, manage conservatively with pelvic floor biofeedback therapy 3, 2

Indications for Immediate Surgical Intervention

Proceed directly to immediate surgery for complicated rectal prolapse with any of the following:

• Signs of shock, gangrene, or perforation of prolapsed bowel 4, 2
• Hemodynamic instability 4, 2

Proceed to urgent surgery (within hours) for:

• Bleeding, acute bowel obstruction, or failure of non-operative management 4, 2

Surgical Approach Selection Algorithm

Step 1: Assess Patient Stability and Peritonitis

For hemodynamically unstable patients or those with signs of peritonitis, perform an open abdominal approach. 4

Step 2: For Stable Patients, Choose Based on Patient Characteristics

Abdominal approach is preferred for:

• Younger, fit patients with acceptable operative risk 2
• Lower recurrence rates compared to perineal approach 2, 5
• Patients where improved continence outcomes are prioritized 5

Perineal approach is preferred for:

• Elderly patients with significant comorbidities 2
• Higher recurrence rates but lower perioperative morbidity 2
• Patients who cannot tolerate abdominal surgery 2

Step 3: Select Specific Abdominal Technique

For abdominal rectopexy, base the decision between open versus laparoscopic on patient characteristics and surgeon expertise. 4

• Laparoscopic repair has similar morbidity and recurrence rates to open surgery, with reduced hospital stay, postoperative pain, and wound complications 6
• Add sigmoid resection to rectopexy if significant preoperative constipation is present 6
• Bowel resection during rectopexy is associated with lower rates of postoperative constipation 5

Step 4: Consider Lateral Ligament Management

• Division of lateral ligaments results in less recurrent prolapse but more postoperative constipation 5
• Avoid bowel resection in patients with preexisting diarrhea and/or incontinence, as these symptoms may worsen 2

Step 5: Decide on Anastomosis Type if Resection Performed

Base the decision between primary anastomosis (with or without diverting ostomy) versus terminal colostomy on the patient's clinical condition and individual risk of anastomotic leakage. 4

Pharmacological Management

Administer empiric antimicrobial therapy for strangulated rectal prolapse due to risk of intestinal bacterial translocation. 4, 2

• Select antibiotic regimen based on patient's clinical condition, individual risk for multidrug-resistant organisms, and local resistance epidemiology 4, 2

Critical Pitfalls to Avoid

• Posterior rectopexy can result in severe constipation in up to 50% of patients 2
• Preserve lateral ligaments if constipation is a concern, but accept higher recurrence risk 5
• Do not perform surgery for isolated internal prolapse without associated pelvic floor disorders, as the correlation between symptom improvement and anatomical correction is often weak 3, 1
• Symptomatic grade 3-4 prolapse requires surgical correction 3, 2