Rectal Prolapse Treatment & Management

No medical treatment is available for rectal prolapse. However, always first treat internal prolapse medically with bulking agents, stool softeners, and suppositories or enemas. Biofeedback may be helpful if paradoxical pelvic floor contraction also exists.

An incarcerated rectal prolapse is rare. Several maneuvers to help reduce the prolapse have been described and include sedation, field block with local anesthetic, and sprinkling the prolapse with either salt or sugar to decrease the edema and to reduce the prolapse. Emergency resection is required if the prolapse cannot be reduced and the viability of the bowel is in question.

Surgical treatment can be divided into 2 categories according to the approach used to repair the rectal prolapse: abdominal procedures and perineal procedures. The choice of abdominal versus perineal procedure is mainly dictated by the patient's age and comorbidities.^{[3, 4]}

In general, the abdominal procedures have a lower recurrence rate but a higher morbidity rate. The converse is true of perineal procedures. In general, treat older, debilitated patients (whose life expectancy is shorter) with a perineal procedure, and treat younger, healthier patients with abdominal procedures, although surgeons with large experience and low recurrence rates also advocate perineal procedures for their younger, healthier patients.

The choice of procedure is also dictated by the presence or absence of constipation. Children are treated with linear cauterization (not described in this article).

Surgical therapy for internal prolapse is usually avoided because results are poor, with relief of symptoms occurring in fewer than 50% of patients.

Ensure a full mechanical and antibiotic bowel preparation before surgery, regardless of the type of procedure being planned. Perioperative intravenous antibiotics are often used, especially if a foreign material is being implanted.

Procedures are abdominal or perineal.

Abdominal procedures

These procedures are typically performed in younger, healthier patients whose life expectancy is longer. For these patients, procedures with lower recurrence rates but higher morbidity rates are most appropriate. The choice of abdominal procedure is often dictated by the extent of the associated constipation and by the surgeon's preference.

• Anterior resection

  • Patients with rectal prolapse and constipation often have a redundant colon, and resection of it is thought to improve constipation and cure rectal prolapse. In an anterior resection for rectal prolapse, the rectum is mobilized to the level of the lateral ligaments, and the redundant colon (sigmoid) is resected. The left colon is then anastomosed to the top of the rectum. This is performed without laxity in the colon so that the rectum is held in place and can no longer prolapse. Few colorectal surgeons perform this procedure because it is not thought to address anatomic abnormalities such as poor rectal fixation.
• Marlex rectopexy

  • In a Marlex rectopexy (Ripstein procedure), the entire rectum is mobilized down to the coccyx posteriorly, the lateral ligaments laterally, and the anterior cul-de-sac anteriorly. The Marlex rectopexy is illustrated in the image below. A nonabsorbable material, such as Marlex mesh or an Ivalon sponge, is then fixed to the presacral fascia. The rectum is then placed on tension, and the material is partially wrapped around the rectum to keep it in position. The anterior wall of the rectum is not covered with the sponge or mesh in order to prevent a circumferential obstruction. Marlex rectopexy.
  • The peritoneal reflections are then closed to cover the foreign body. The Marlex mesh or sponge causes an inflammatory reaction that scars and fixes the rectum into place. Do not perform this procedure on patients who have a large component of constipation or a very redundant sigmoid colon because the symptoms are likely to worsen. If the rectum is inadvertently entered during mobilization, the foreign material should not be implanted because of risk of infection.
• Suture rectopexy

  • This operation is essentially the same as a Marlex rectopexy except that the rectum is fixed to the presacral fascia with suture as opposed to mesh or an Ivalon sponge.
• Resection rectopexy

  • Resection rectopexy (Frykman Goldberg procedure) is a combination of the anterior resection and the Marlex rectopexy and is a good option for patients with a significant component of constipation. The rectum is completely mobilized to the coccyx posteriorly, to the lateral ligaments laterally (some surgeons divide the lateral ligaments), and to the cul-de-sac anteriorly.
  • The redundant sigmoid colon is then resected, and the remaining colon is anastomosed to the top of the rectum. The lateral ligaments or the rectal fascia are then sutured to the presacral fascia with the rectum on tension, which keeps the rectum in place and prevents further rectal prolapse. The rectopexy is accomplished with suture instead of nonabsorbable mesh because the bowel is opened for the anastomosis and the mesh may become contaminated.

Perineal procedures

Perineal procedures have a higher recurrence rate but a lower morbidity rate and are often performed in the elderly population or in patients who have a contraindication to general anesthetic.

• Anal encirclement

  • With anal encirclement (Thiersch wire), a nonabsorbable band is placed subcutaneously around the anus. The purpose of this procedure is to keep the rectum from prolapsing by restricting the size of the anal lumen. Although initially described using a wire, other materials (eg, silastic tubing, nonabsorbable suture) have replaced it. The therapy is effective in mechanically preventing the rectum from prolapsing, but it does not treat the underlying disorder.
  • Complications from the procedure include obstruction with fecal impaction and erosion of the wire with infection. This procedure is no longer commonly performed and is usually reserved for only the most debilitated patients and for patients with the highest surgical risks in whom palliation is the goal.
• Delorme mucosal sleeve resection

  • A circumferential incision is made through the mucosa of the prolapsed rectum near the dentate line; using electrocautery, the mucosa is stripped from the rectum to the apex of the prolapse and excised. This resection is depicted in the image below. The denuded prolapsed muscle is then pleated with a suture and is reefed up like an accordion. The transected edges of the mucosa are then sutured together. This procedure is often used for small prolapses but may also be used for large ones. Delorme mucosal sleeve resection.
• Altemeier perineal rectosigmoidectomy

  • A full-thickness circumferential incision is made in the prolapsed rectum at about 1-2 cm from the dentate line, as shown in image below. The hernia sac is then entered, and the prolapse is delivered. The mesentery of the prolapsed bowel is serially ligated until no further redundant bowel can be pulled down. The bowel is transected and hand sewn to the distal anal canal or stapled using a circular stapler. Before anastomosis, some surgeons plicate the levator ani muscles anteriorly, which may help improve continence. Altemeier perineal rectosigmoidectomy.
  • In a study of the long-term outcome of Altemeier perineal rectosigmoidectomy, Altomare et al reviewed the medical records of 93 patients who underwent the procedure.^[5] The authors concluded that this operation is relatively safe and effective in frail, older patients, with postoperative morbidity being low. However, the recurrence rate of prolapse following the procedure was not considered to be negligible, and the surgery was found to be unpredictable in terms of restoring continence.
• Surgery for mucosal prolapse

  • Mucosal prolapse is treated with a hemorrhoidectomy.
• Perineal stapled prolapse

  • In a study of 32 patients with external rectal prolapse, Hetzer et al investigated the efficacy of perineal stapled prolapse resection for the treatment of this condition. The surgery as performed in the study involved pulling out the prolapse completely and — at 3 and 9 o’clock, in lithotomy position — axially cutting it open with a linear stapler. Resection was performed using a curved Contour Transtar stapler.
  • Hertzer et al reported no intraoperative complications in their study, although 2 patients suffered minor postoperative complications. Median surgical time and hospital stay were 30 minutes and 5 days, respectively. At follow-up (median 6 months), at which time data was available for 31 patients, 90% of cohort members no longer had the severe fecal incontinence that had existed preoperatively, with the cohort's median Wexner score dropping from 16 to 1. No new cases of constipation were reported to have developed. The authors concluded that perineal stapled prolapse resection is a fast and effective treatment for external rectal prolapse.^[6]

Abdominal procedures

Postoperatively, patients usually have an ileus and incisional pain. Intravenous fluids are maintained until liquids are started with the return of bowel function or earlier, depending on whether an anastomosis has been performed. As bowel function improves, diet can be advanced. Patients with an anastomosis are maintained on a low-fiber diet for 2-3 weeks and are then started on fiber supplementation to help prevent the return of constipation and straining. Patients without an anastomosis can be started on a high-fiber diet sooner. A Foley catheter is placed perioperatively and is left in place for several days because the rectal dissection can inhibit bladder function. The length of hospital stay averages 3-7 days and is usually dependent on the return of bowel function and the control of incisional pain.

Perineal procedures

Patients who have had perineal procedures do well postoperatively with minimal pain and a short hospital stay. Initially, patients receive nothing by mouth for approximately 12-24 hours. After this period, liquids are instituted, and patients are rapidly advanced to a regular diet. Bowel function returns quickly because there is no abdominal incision, and patients can often be discharged 24-72 hours after the procedure.

Follow-up care in the immediate postoperative period depends on the type of surgery the patient underwent, but it usually consists of 1-2 visits over the ensuing month to ensure that all incisions are well healed and that the patient is not having difficulties with bowel evacuation. Further follow-up care is usually unnecessary because the patient will notice if the prolapse returns and can schedule further outpatient visits.

Serious complications after rectal prolapse surgery include infection, bleeding, intestinal injury, anastomotic leak, bladder and sexual function alterations, and constipation or outlet obstruction. The frequency of these complications is related to the type of procedure. Other complications, such as myocardial infarction, pulmonary embolus, deep vein thrombosis, and hernia, can occur but are not discussed since they are not unique to these types of procedures.

Infection

The most common source of infection is from inadvertent injury to the rectum during mobilization in abdominal procedures. Unrecognized, this could lead to leak of intestinal contents with pelvic abscess and sepsis. If foreign material has been implanted, infection ensues, and the material must be removed. Infection after perineal procedures probably occurs as often but rarely causes symptoms and is easier to treat because it is superficial.

Bleeding

Bleeding most commonly occurs in 2 situations. First, the presacral veins can be torn during abdominal procedures, when mesh or the rectum is directly fixed to the presacral fascia. This can lead to a presacral hematoma or to torrential bleeding. This bleeding can be difficult to control because the veins exit directly from the bone. The initial maneuver should apply direct pressure to the area for 10-15 minutes. If this fails to control the bleeding, titanium thumbtacks can be placed into the bone to tamponade the vessels. Dissection in the presacral space often increases bleeding and should be avoided.

The second common situation for bleeding occurs during the mucosal stripping in a Delorme procedure or from wound separation postoperatively.

Bowel injury

Bowel injury most frequently occurs during mobilization of the rectum. If it is recognized, the injury can usually be repaired without need for intestinal diversion. Foreign material should not be implanted if the bowel is injured. Unrecognized injury can lead to abscess formation and pelvic sepsis (see Infection).

Anastomotic leak

All procedures involving a resection carry a risk of anastomotic leak. Abdominal procedures complicated by a leak require reexploration. If the leak is small and contamination in the pelvis is limited, the anastomosis can be revised and protected with a diverting loop ileostomy.

If the leak is large with significant dehiscence of the anastomosis, the patient is often best served with a Hartman procedure (colostomy with rectal stump). Often, pelvic sepsis makes further dissection in the pelvis challenging, and revising or performing a new anastomosis can be very difficult. Anastomotic leak can also occur after perineal rectosigmoidectomy. Despite the fact that this is a very low anastomosis, leak is rare. The infection is localized and pelvic sepsis is rare when leak occurs after this procedure.

Bladder and sexual function alterations

Alteration of function should be a rare complication in a properly performed abdominal procedure. The pelvic sympathetic and parasympathetic nerves run along the rectum; if dissection is not carried out in the proper plane, injury can occur, leading to bladder dysfunction, impotence, and/or retrograde ejaculation. This is an important consideration when trying to decide which procedure to perform, especially in men, although the risk of injury should be less than 1-2%.

Constipation/outlet obstruction

Perineal procedures and anterior resection have a low risk of outlet obstruction. Abdominal procedures that tack the rectum to the sacrum can cause outlet obstruction if the rectum is wrapped circumferentially, often requiring release of the fixation to treat the problem.

Anterior resection

The recurrence rate for anterior resection without sacral fixation is about 7-9%, with a morbidity rate of 15-29%. This recurrence rate is higher than for other abdominal procedures.

Marlex rectopexy

Recurrence rates range from 2-10% with morbidity rates of 3-29%. Continence is improved in 50-70% of patients. Constipation is not improved and may worsen after this operation.

Suture rectopexy

Results are similar to Marlex rectopexy.

Resection rectopexy

The recurrence rate for this procedure is 3-4%, with several studies reporting a 0% recurrence rate. Morbidity rates range from 4-23%. Because the redundant colon is also resected, constipation improves in 60-80% of patients, and continence improves in 35-60%.

Delorme mucosal sleeve resection

Recurrence rates range from 5-26%, with a variable morbidity that is usually related to the patient's underlying comorbidities. Fecal incontinence and constipation improve in about 50% of patients.

Altemeier perineal rectosigmoidectomy

Recurrence rates vary from 0-50%, with an average of approximately 10%. Continence is improved, especially if a levator plication is added to the procedure. (As previously mentioned, however, a study by Altomare et al indicated that restoration of continence with this procedure can be unpredictable.)^[5]

Which repair constitutes the best treatment is the main controversy in surgery for rectal prolapse.^[7] All of the procedures have their proponents, and there is no right answer.

A laparoscopic approach to rectal prolapse repair has become increasingly popular and has intensified the controversy because it has decreased the morbidity of the abdominal approach to rectal prolapse in appropriate candidates. Long-term results of the laparoscopic approach are still being studied.^{[8, 9, 10]}

The second controversy revolves around the cause(s) of rectal prolapse.