Pediatric Rectal Prolapse Treatment & Management

Patients who present with a prolapsed rectum should undergo manual reduction. Conservative management is appropriate in selected patients. The more difficult cases of reduction and the recurrent cases of prolapse are less likely to respond to conservative management. If possible, the underlying cause of the prolapse must be treated. Treating the underlying cause allows conservative management to be successful.

In patients with cystic fibrosis, initiation of adequate pancreatic enzyme replacement usually results in cessation of rectal prolapse.

Some pediatric surgeons are reluctant to inject sclerosing agents into a child’s anorectum, out of concern for possible induction of fibrosis and the potential long-term risk for carcinogenicity. The benefit of using biofeedback in patients with chronic straining or paradoxical contractions of the anal sphincters is yet to be elucidated. For many years, case series and expert opinions proposed biofeedback as a first-choice treatment option for fecal incontinence. Most case series reported positive patient outcomes, often in more than 70% of patients.^[35]

Inpatient management of rectal prolapse is usually reserved for patients in whom surgical therapy is necessary. Surgical management is usually reserved for failed conservative management in children younger than 4 years who have tried nonsurgical management for longer than 1 year; it is also used in cases of complicated rectal prolapse (eg, recurrent rectal prolapse that requires manual reduction, painful prolapse, ulceration, and rectal bleeding). The procedures work better in children younger than 4 years but include the possible complications of surgery.^[36]

If prolapse is present at the time of examination, reduction should be promptly performed before the onset of edema. Parents should be provided with gloves and lubricant and taught how to reduce the prolapse. However, prolapses often spontaneously reduce without reduction techniques.

The prolapsed bowel may be grasped with lubricated gloved fingers and pushed back in with gentle steady pressure. If the bowel has become edematous, firm steady pressure for several minutes may be necessary to reduce the swelling and allow for reduction. Digital rectal examination should always follow this procedure to verify complete reduction. If the prolapse immediately recurs, it may be reduced again and the buttocks taped together for several hours.

Prompt reduction is critical. The prolapsed mucosa becomes edematous as a result of lymphatic obstruction. If the process is not reversed at this stage, venous obstruction ensues, accelerating and aggravating the edema (see the image below) and leading to arterial vessel obstruction with subsequent necrosis. Once the bowel becomes necrotic, emergency surgical reduction or resection is required. An acutely strangulated rectal prolapse should be covered with moist towels, and the patient should be brought to the emergency department (ED) immediately.

When the reduction has become difficult because of profuse edema, topical table sugar may be used as an osmotic aid to help decrease the edema and facilitate reduction, thereby obviating emergency surgical intervention.^{[37, 38]} This allows the patient to be treated electively under relatively stable conditions.^[38] The sugar exerts a mild osmotic power over the prolapsed mucosa, helping the edema to slowly resolve, which permits a nontraumatic reduction and prevents complications.

Sugar does not irritate the mucosa like other substances (eg, salt). The author has used sugar to reduce edematous prolapsed bowel in 12 patients. The edema resolves by as much as 50% in 30-90 minutes. The entire prolapsed mucosa must be covered with sugar, and the process can be repeated as many as 3 times. This also improves the microcirculation in the affected segment, making it more favorable for any surgical procedure.

Conservative management is started in children younger than 4 years and in children older than 4 years who have uncomplicated, nonrecurrent rectal prolapse. Such management is aimed at treating the cause and reducing straining. It often works well in children younger than 4 years and prevents recurrence. In children older than 4 years, conservative management should be attempted for 1 year before surgical management is chosen.

In patients with diarrhea and constipation, rectal prolapse usually resolves when the stool pattern returns to normal. Therefore, constipation should be aggressively managed. Constipation is treated with dietary modification (total dose per day is 5 g of fiber plus an additional 1 g for each year of age; dose for adults is 20 g once or twice daily) and stool softeners (eg, polyethylene glycol) to reduce straining. Adequate fluid intake should be ensured.

Infectious diarrhea or parasitic infestation should be appropriately treated.

Further management should focus on parental reassurance and education. Instruction on how to reduce a prolapse may prevent repeated presentations to the ED.

The type of toilet that the child uses is also important; use of an adult toilet contributes to rectal prolapse because the buttocks are in a dependent position and the feet are unsupported. Using a special child’s toilet or using a step to support the feet can be a useful adjunct to treatment. In some patients, switching from a “potty” chair to an adult commode may help prevent recurrence. Time spent on the toilet should also be limited to minimize straining and pushing.

Surgery is infrequently required for rectal prolapse. However, if the prolapse persists after an adequate trial of medical therapy (usually a period of months), surgical intervention may be required. Age, duration of conservative management and frequency of recurrence ought to be taken into consideration. Pain, excoriations, and rectal bleeding are considered surgical indications.

If a patient has a prolapse when presenting to the ED and it cannot be reduced, or if necrosis is already present, emergency surgical resection is indicated. If a recurrent prolapsed rectum is successfully reduced in the ED, surgery is scheduled within the next 2 weeks to allow the edema to subside before the procedure.

The main purpose of surgical treatment for rectal prolapse is correction of the prolapsed rectum and recovery and prevention of the associated defecation dysfunction postoperatively. Therefore, when selecting surgical methods, the surgeon should understand the exact causative factors and anatomical variations.^[27]

The only absolute contraindication for surgery is poor general medical health that precludes a major operation. No absolute contraindications specific to surgical management of rectal prolapse in childhood are reported. However, an adequate trial of conservative measures should precede surgical therapy because this suffices in most patients, especially those with cystic fibrosis and rectal prolapse, in whom appropriate dietary manipulation and pancreatic enzyme therapy are usually effective.

A great deal of debate surrounds the optimal surgical management of rectal prolapse. Currently, more than 130 operative procedures for the treatment of rectal prolapse and the prevention of its recurrence are recognized. In 2008, a Cochrane Database Review of the small studies available in the adult literature found that all reparative procedures have similar clinical outcomes with various degrees of risk.^[39]

No single surgical procedure is appropriate for all patients with rectal prolapse^[40] : each has disadvantages and carries some risk of recurrence. No clear-cut indications for any procedure are known, and no consensus has been reached on the operation of choice. The personal experience of the surgeon is the major determinant. In general, however, elaborate operations are reserved for adults; they are difficult to justify, in view of the safety and efficacy of relatively noninvasive procedures.

Altemeier et al described their perineal approach in 1971. They used anterior closure of the pelvic diaphragm and transanal resection of the prolapsed segment, with primary end-to-end anastomosis.^[3] Ripstein and Lauter addressed the problem by suspending the rectum via an abdominal approach.^[41]

Ashcraft and Holder reported their experience with posterior repair in 46 children over a period of 17 years, with resolution in 42 patients.^[33] Three of the failures were attributed to sigmoid intussusception. Such outcomes highlight the importance of distinguishing this condition from rectal prolapse preoperatively.

Some authors have reported excellent results with injection sclerotherapy.^{[42, 43]}

Surgical treatment can be accomplished either transanally (perineal approach) or transabdominally. Transanal approaches have a lower morbidity, and abdominal approaches have a lower recurrence rate. Laparoscopic repair provides rectal fixation equal to that achieved through open procedures, with less morbidity.

Abdominal repairs involve mobilization of the rectum and fixation to the anterior sacral wall, which can be done with sutures or with prosthetic material. Fixation with prosthesis may increase the incidence or stenosis and obstruction. A sling prosthesis should be tailored to the individual patient, taking growth into consideration. In general, resection rectopexy has an acceptable recurrence rate (2-8%), but it is associated with the added morbidity of a colorectal anastomosis.

Injection sclerotherapy is a good initial procedure. Success rates range from 90% to 100%. Sclerotherapy is cheap and less invasive than surgical alternatives. It might be a good alternative in the management of rectal prolapse in patients with HIV infection or AIDS before surgical interventions are initiated.^[44]

Injection procedures use either phenol in oil, isotonic sodium chloride, D50, or ethyl alcohol as a sclerosant to promote adhesion formation, which stabilizes the rectum; each of these materials has its advantages and complications. This technique initiates an inflammatory reaction in the submucosal and perirectal tissues, resulting in fibrosis with subsequent cessation of the prolapse. It can be performed on an outpatient basis, with no need for bowel preparation.

The patient is placed in the lithotomy or left lateral position under general anesthesia. A 20-gauge spinal needle is introduced through the anal mucosa via a proctoscope or is externally introduced 2-3 cm from the anal margin, with a guiding finger in the anal canal, to a point several centimeters above the dentate line. The sclerosant is circumferentially injected into the submucosal and perirectal space as the needle is withdrawn. To prevent, necrosis, bleeding, or stenosis, care should be taken to avoid injecting the sclerosing agent into the mucosa.

Patients undergoing sclerosant injection are discharged the same day with simple analgesics and stool softeners.

The success rates and complications of the treatment reported in the literature differ for each sclerosing agent. Possible complications include injury to nerves, injury to surrounding tissue, and possible injury from sclerosing agents that may be carcinogenic.

In Spain, Ibanez et al used fibrin adhesive in patients aged 1 month to 8 years^[45] ; they reported no postinjection complications and found that adequate sclerosis was achieved in less than 24 hours.

In Egypt, Fahmy and Ezzelarab treated 130 children with rectal prolapse aged 6 months to 12 years who underwent injection with 98% ethyl alcohol (group 1), phenol in almond oil 5% (group 2), or dextranomer and hyaluronic acid injectable gel (Deflux; group 3); they found that submucosal injection resulted in no mortality and varying morbidity.^[46] Deflux had the lowest complication rate. Phenol in almond oil 5% had a high complication rate and should not be used. Alcohol is inexpensive and should be considered an alternative to Deflux.

Follow-up in this study was 2 months to 3 years.^[46] In group 1, the recurrence rate was 11%; 2 patients had mucosal sloughing, and 1 girl developed a rectovaginal fistula. In group 2, 18% had abscesses and mucosal sloughing, and 2 developed perianal fistula. In group 3, 2 patients had immediate postoperative prolapse that spontaneously resolved. No patients had mucosal ulceration or abscess formation, and none had recurrence on long-term follow-up.

In Turkey, Abes and Sarihan used 15% saline solution as an injected sclerosing agent in 16 children with rectal prolapse^[42] ; they found that prolapse ceased in 93.7% of the children after the first injection, only 1 patient required a second injection, and no complications occurred. The investigators concluded that 15% saline is preferable to other sclerosing agents because of the high cure rate, the safety of the procedure, the ease of injection, and the lack of complications.

Zganger et al published their 30-year experience in Croatia, using cow milk as a sclerosing agent. Their study included 86 children with rectal prolapse treated with cow milk injection sclerotherapy. Treatment was successful in 95.3% (82 children) of patients. They reported recurrent rectal prolapse in 4 (4.7%) patients, which subsequently underwent surgical treatment. Seventy-two percent of patients were younger than 4 years (62 children), whereas the remaining 24 patients were older (28%). Up to 3 applications may be needed. For children who needed operative treatment, the Thiersch procedure was performed without complications. They conclude that injection sclerotherapy with cow milk is a simple and effective treatment method for rectal prolapse in children, with minimal complications.^[47]

In procedures that include an abdominal approach, bowel resection, or both, prophylactic antibiotics should be used, and the patient is discharged once bowel function has returned.

Thiersch operation

The Thiersch procedure, sometimes referred to as a sling procedure, uses synthetic materials to create a perianal sling to support the rectum. It has a success rate of about 90%. This procedure is a good choice for children because it can be done with self-absorbing sutures to provide temporary relief of symptoms until the base pathology is managed. It is only a palliative procedure because it does not cure the prolapse itself. In adults, it is associated with a high recurrence rate.

Perianal sutures are subcutaneously placed as a cerclage (see the image below). The principle is to create a mechanical barrier for the prolapse and to provoke an inflammatory reaction on the perirectal tissues that generates a fibrous ring rather than a toneless sphincter.

Modifications involving the use of knitted polypropylene mesh (Marlex mesh) or other nonabsorbing materials have been described (see the image below).^[48] This finding highlights the importance of following the patients until the wire is removed. Anal encirclement according to the Thiersch- Ombredanne procedure or its modification has its advantages and recurrence rate. Advantages include simplicity, effectiveness, and safety. Disadvantages are poor tolerance, rigidity, breakage, and infection. Infection has always been described as local and superficial, although infection spreading to the scrotum has been described by Saleem and Al-Momani.^[49]

Lockhart-Mummery operation

Mesh gauze packing is placed temporarily (for 8-10 days) in the retrorectal space to promote adhesions that stabilize the rectum. The success rate is approximately 100%.

Cauterization

In this procedure, the prolapsed rectum is cauterized in a linear fashion extending to the submucosa in 4 quadrants. This produces perirectal inflammation and scarring that prevents prolapse. The success rate is approximately 80%.^[50]

Abdominal rectopexy (75% success rate)

Abdominal rectopexy may be done via either an endoscopic or an open approach. In this procedure, the perirectal tissues are attached to the presacral area to assure correct anatomic positioning and tissue adherence. This is done either with direct sutures or with a prosthetic material, such as polypropylene mesh (Ripstein procedure; see the first and second images below) or an Ivalon sponge (see the third image below).

This procedure has a high success rate for prolapse control (approximately 75%), and incontinence is improved in 60% of patients, although as many as 60% of patients have constipation after this procedure.

Ekehorn rectopexy (100% success rate)

Ekehorn rectopexy involves placing a mattress suture in the rectal ampulla from inside the rectum, through the lowest part of the sacrum and out through the skin, where it is tied externally.^[51] The suture is left in place for 10 days. This leads to local inflammation, which causes adhesions between the rectal wall and perirectal tissues, binding them together (sacrorectopexy). The procedure takes only a few minutes and is reportedly 100% effective.^[52]

Delorme procedure

In a Delorme repair, the mucosa and part of the underlying rectal muscle are excised, and the rectum is then plicated with polydioxanone sutures towards the anal canal.

Long-term results are not satisfactory, with a recurrence rate of 17%.^[53] This repair has been used in children with recurrent prolapse and has the advantage of not entering the abdomen. The observation that recurrence and complication rates may be lower in younger and medically fit patients suggests that the Delorme repair does not necessarily have to be restricted specifically to older, medically unfit patients.^[54]

Perineal resection

Mikulicz first described perineal resection in 1889.^[3] Perineal rectosigmoidectomy with rectopexy, correction of the pelvic floor (plication of the puborectalis muscles), and coloanal anastomosis is promising and could be a good approach for pediatric patients with intractable prolapse and redundant sigmoid. It has been successfully performed using stapling devices for the resection and reconstruction of colonic continuity.^[55] This technique avoids the abdominal approach, with its obvious complications.

Mucosal plication with anal encircling

In mucosal plication with anal encircling, Teflon tape is routed relatively deeply outside the external anal sphincter (EAS).^[56] Clinical results show a recurrence rate of 0-31%, with no mortality and almost no serious complications (eg, clinically significant bleeding or severe sepsis, which is occasionally encountered in other perineal procedures).

Levator repair and posterior suspension

Levator repair with posterior suspension is performed via a posterior sagittal approach. Nwako reported a 100% success rate with the Lockhart-Mummery procedure, which involves packing the presacral space with gauze through a posterior approach and excision of the prolapsed mucosa.^[25] Hight et al recommend linear rectal cauterization of the anorectal mucosa; they had 98% success in 72 patients.^[26]

Closed rectosacropexy

In Egypt, Lasheen described a technique of closed rectosacropexy for management of rectal prolapse in children.^[57] The technique simply involves passing several U-shaped sutures through stab incisions made in the skin posterior to the anus, into the sacral fascia, then into the wall of rectum, down to the anal canal, and out through the stab incisions. The strands of the suture are tied subcutaneously through the stab incisions.

This operation was successfully performed in 42 children (mean age, 3.5 years) who had recurrent rectal prolapse for 3-5 months. None of the children had any further recurrence or specific complications during follow-up of 1-3 years.

Several authors have tried the laparoscopic approach to correct rectal prolapse. Virtually every type of open transabdominal surgical approach to rectal prolapse now has its laparoscopic equivalent. Current laparoscopic surgical techniques include suture rectopexy, stapled rectopexy, posterior mesh rectopexy with artificial material, and resection of the sigmoid colon with colorectal anastomosis with or without rectopexy.

Laparoscopic repair of rectal prolapse is technically feasible and can be performed with mortalities and morbidities comparable to those of the conventional techniques. It has a normal learning curve and initially has a slightly longer operative time than corresponding open procedures. The growing body of literature suggests that laparoscopic surgical techniques can safely provide the benefits of low recurrence rates and improved functional outcome for patients with rectal prolapse. Lesser rates of adhesions formation can also be expected.

According to Kairaluoma et al (2003), the main advantages of the laparoscopic approach appear to be a shortened hospital stay and reduced intraoperative blood loss.^[58] The recurrence rate is not increased in the short term. Lesser postoperative pain, better cosmesis, and a faster recovery of the bowel function and introduction of diet have also been reported.^{[59, 60, 61]}

Koivusalo performed 8 laparoscopic sacrorectopexies with good results.^[60] He reported 2 patients with postoperative constipation. It appears that patients have less constipation and incontinence if the lateral rectal ligaments can be preserved, however, this requires further analysis.

D’Hoore and Penninckx described a laparoscopic ventral rectal colpopexy technique for the repair of rectal prolapse and enterocele.^[62]

Delaney reported 109 laparoscopic repairs in adults.^[59] Hospital stay was 3 days (compared with 6 days for open surgery), and recurrence rates were 8% for laparoscopic surgery compared 5% for open surgery. The procedure is described as follows:

• The presacral space is entered, and the rectum is mobilized
• A precut mesh is passed down a port and tacked to the sacral promontory in the midline
• The edges are then sutured to the lateral mesorectal tissue for support
• In patients having a resection (those with slow intestinal transit and severe constipation), the upper rectum is transected with an endoscopic stapler and pulled out through a small left lower quadrant muscle-splitting incision
• The resection is completed, and the anvil of a circular stapler is inserted in the proximal bowel before it is returned to the abdominal cavity
• The anastomosis to the rectal stump is performed before the lateral mesorectal tissue is sutured to the promontory

Saxena et al successfully treated a 22-month-old girl by using laparoscopic simple suture rectopexy with 5-mm instruments and the placement of a pair of 3-0 nonabsorbable sutures on either side of the rectum to secure it to the presacral fascia.^[63] No blood loss occurred, and the procedure was completed without complications. The child was followed up for 24 months, with good results.

In comparison with open surgery, laparoscopic surgery has the advantages of less pain, shortened hospital stay, early recovery, and early return to normal activities, such as school for the children and work for the parents.

All procedures applied to open abdominal surgery have been attempted by laparoscopy; nonetheless, among them, laparoscopic rectopexy is favored because it is considered a simple procedure, and bowel anastomosis can be avoided. The rate of surgical complications is 0-3%, and the recurrence rate ranges from 0-10%. Regarding complications, recurrence rate, and correction of the associated rectal dysfunction, its effectiveness is comparable to that of an open approach.^{[27, 64]}

Radiofrequency ablation and plication

Gupta reported promising results with radiofrequency ablation and plication in the treatment of rectal prolapse, on the basis of a short operation time, a shorter hospitalization period, less postoperative pain, faster wound healing, and a relatively low complication rate (9%, compared with a 23% complication rate for ligature and excision).^[65] This procedure seems to be safe and effective.

Diathermy

Diathermy has also been used to treat mucosal prolapse; however, it is reported to be painful.^[66] Further studies are needed.

Acupuncture

Reports describe successful management of rectal prolapse with acupuncture.^[67]

Complications of surgical treatment of rectal prolapse include the following:

• Postoperative pain
• Bleeding from the injection site
• Perirectal abscess formation
• Potential for damage to bladder neck or presacral nerve plexus

All of these are rare. Some children may have 1 or 2 further episodes of prolapse in the days immediately after injection but before resolution. As many as 12% of patients require a second injection, and as many as 8% need 3 injections. Failure rates approach 15%.

Saleem and Al-Momany reported a child who developed an acute scrotum one year after undergoing a Thiersch procedure, resulting from the spread of a perineal infection due to erosion of the wire used in the cerclage.^[49] This finding highlights the importance of following the patients until the wire is removed.

For pediatric rectal prolapse refractory to conservative medical therapy, the modified Thiersch procedure appears reasonable. Initial recurrences are not uncommon, and the incidence increases with the age of the child. Recurrences should be initially managed by a repeated Thiersch procedure. However, subsequent recurrences should be treated with a modified Altemeier. Procedure.^[68]

The following may also occur after surgical treatment:

• Mucosal prolapse - This can occur in 5-10% of cases postoperatively and is treated with elastic banding or excision under anesthesia.
• Incontinence - Postoperative perineal approach incontinence should be treated aggressively
• Postoperative recurrence - If the surgeon chooses to treat a recurrence with re-resection, any prior anastomosis must be resected to avoid leaving an ischemic segment

Surgical consultation is recommended in patients who meet any of the following criteria:

• Recurrent prolapse with mucosal ulceration
• Failure to reduce the prolapse despite adequate sedation
• Recurrent rectal prolapse associated with severe pain and discomfort despite intensive medical treatment
• Failure of conservative management
• Full-thickness rectal prolapse in patients with meningomyelocele, exstrophy of the bladder, and postoperative changes after pull-through operations for imperforate anus and Hirschsprung disease

All pediatric rectal prolapses should be approached as possible symptoms of another underlying disease process or disorder.

Evaluate the child for cystic fibrosis. Evaluate whether or not the child has exhibited signs of constipation or diarrhea. If sweat chloride test results are negative and the bowel regimen has been normal, consider proctosigmoidoscopy to rule out rectal polyps or lesions.

Instruct parents how to manually reduce a prolapse and to seek immediate help from a health care provider if reduction fails.

Usually, after surgical treatment, only 1 follow-up visit is required to ascertain that the prolapse has ceased and the child has tolerated the procedure.