How should I manage a patient with a swollen rectal prolapse?

Management of Swollen/Rectal Prolapse

Immediately assess for signs of strangulation (gangrene, necrosis, perforation, or hemodynamic instability), as these require emergency surgical intervention without delay. 1

Initial Assessment and Risk Stratification

Clinical Examination Priorities

• Distinguish between complicated and uncomplicated prolapse by examining for signs of strangulation: gangrenous or necrotic tissue on the prolapsed segment, irreducibility despite manual attempts, ulceration, or perforation 1
• Check vital signs for hemodynamic instability (hypotension, tachycardia, shock), which signals advanced tissue necrosis requiring immediate surgery 1
• Assess for peritoneal signs (abdominal rigidity, rebound tenderness, guarding) indicating perforation of strangulated bowel 1
• Differentiate true rectal prolapse (concentric, full-thickness protrusion) from prolapsed hemorrhoids (radial bulging of discrete anal cushions) 2

Laboratory Investigations

• Order complete blood count, serum creatinine, and inflammatory markers (C-reactive protein, procalcitonin, lactate) to assess patient status 2
• Elevated lactate reflects poor tissue perfusion and bowel ischemia, serving as a key marker of severe sepsis 1
• Elevated procalcitonin correlates with extent of intestinal necrotic damage and increased mortality risk 1
• Leukocytosis commonly indicates transmural bowel necrosis (except in immunocompromised patients) 1

Management Algorithm

STEP 1: Emergency Surgical Indications (Immediate Operating Room)

If ANY of the following are present, proceed directly to emergency surgery—do not delay for imaging or conservative measures:

• Signs of shock, gangrene, or perforation of prolapsed bowel 2, 1
• Hemodynamic instability 2, 1
• Peritoneal signs indicating perforation 1
• Use abdominal open approach for unstable patients 2, 1

STEP 2: Attempted Manual Reduction (Stable Patients Without Strangulation)

For irreducible prolapse without signs of ischemia in hemodynamically stable patients:

• Position patient in Trendelenburg with intravenous sedation and analgesia 2
• Apply topical granulated sugar to create hyperosmolar environment that reduces edema—this is the most accessible technique 2
• Alternative methods include: hypertonic solutions (50% dextrose or 70% mannitol), elastic compression wrap, or submucosal hyaluronidase injection 2, 3
• Critical caveat: The failure rate of non-operative management is high 2—do not persist beyond one reasonable attempt, as delay risks progression to strangulation

STEP 3: Surgical Planning for Stable Patients After Failed Reduction

For hemodynamically stable patients with complicated prolapse requiring surgery:

• Base decision between abdominal versus perineal approach on:

  • Patient age, comorbidities, and fitness for major surgery 2
  • Presence of peritonitis favors abdominal approach 2
  • Surgeon expertise and available resources 2

• For abdominal approach, choose between open versus laparoscopic based on:

  • Patient characteristics and hemodynamic stability 2
  • Surgeon skill and experience 2
  • Laparoscopic approach is contraindicated if patient becomes unstable 2

• Perineal procedures (e.g., Altemeier's procedure) can be utilized in emergency circumstances and may be safer for high-risk patients 4

STEP 4: Resection Decisions

• Base decision between primary anastomosis (with or without diverting ostomy) versus terminal colostomy on:
  • Patient's clinical condition and hemodynamic stability 2
  • Degree of bowel compromise or contamination 4
  • Individual risk of anastomotic complications 2

Critical Pitfalls to Avoid

• Never delay surgery in unstable patients to attempt conservative management—this is explicitly contraindicated 2, 1
• Do not perform imaging in hemodynamically unstable patients; rapid operative management takes absolute precedence 1
• Non-operative management is contraindicated when strangulation with gangrene or perforation is evident 2, 1
• Do not persist with multiple reduction attempts if initial effort fails—high failure rates mean you risk allowing progression to irreversible ischemia 2
• Pain is uncommon in uncomplicated prolapse; its presence suggests incarceration or strangulation requiring urgent intervention 5