Rectal Prolapse 

Updated: Jul 24, 2020
Author: Jan Rakinic, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF 

Overview

Background

Rectal prolapse was described as early as 1500 BCE. Rectal prolapse occurs when a mucosal or full-thickness layer of rectal tissue protrudes through the anal orifice.[1, 2] Problems with fecal incontinence, constipation, and rectal ulceration are common.

Three different clinical entities are often combined under the umbrella term rectal prolapse:

  • Full-thickness rectal prolapse
  • Mucosal prolapse
  • Internal prolapse (internal intussusception)

Treatment of these three entities differs.

Full-thickness rectal prolapse (see the image below) is defined as protrusion of the full thickness of the rectal wall through the anus; it is the most commonly recognized type. Mucosal prolapse, in contrast, is defined as protrusion of only the rectal mucosa (not the entire wall) from the anus. Internal intussusception may be a full-thickness or a partial rectal wall disorder, but the prolapsed tissue does not pass beyond the anal canal and does not pass out of the anus.

Full-thickness rectal prolapse. Full-thickness rectal prolapse.

Most of this article focuses on full-thickness rectal prolapse, which will be referred to as rectal prolapse.

Anatomy

The rectum is the distal 12-15 cm of the large intestine between the sigmoid colon and the anal canal. It primarily serves as a reservoir for fecal material. The mucosa is the inner lining of the intestinal tract. The dentate line is the junction of the ectoderm and endoderm in the anal canal.

The internal anal sphincter is a smooth muscle that is the most distal extension of the inner circular smooth muscle of the colon and the rectum. It is 2.5-4 cm long and normally 2-3 mm thick. The internal sphincter is not under voluntary control and is continuously contracted to prevent unplanned loss of stool.

The external anal sphincter is striated muscle that forms a circular tube around the anal canal. Moving proximally, it merges with the puborectalis and the levator ani to form a single complex. Control of the external anal sphincter is voluntary.

Pathophysiology

The pathophysiology of rectal prolapse is not completely understood or agreed upon. There are two main theories, which essentially are different ways of expressing the same idea.

The first theory postulates that rectal prolapse is a sliding hernia through a defect in the pelvic fascia. The second theory holds that rectal prolapse starts as a circumferential internal intussusception of the rectum beginning 6-8 cm proximal to the anal verge. With time and straining, this progresses to full-thickness rectal prolapse, though some patients never progress beyond this stage.

The pathophysiology and etiology of mucosal prolapse most likely differ from those of full-thickness rectal prolapse and internal intussusception.[3] Mucosal prolapse occurs when the connective tissue attachments of the rectal mucosa are loosened and stretched, thus allowing the tissue to prolapse through the anus. This often occurs as a continuation of long-standing hemorrhoidal disease and is treated as such.

Often, prolapse begins with an internal prolapse of the anterior rectal wall and progresses to full prolapse.

Etiology

The precise cause of rectal prolapse is not defined; however, a number of associated abnormalities have been found. As many as 50% of prolapse cases are caused by chronic straining with defecation and constipation.

Other predisposing conditions include the following:

  • Pregnancy
  • Previous surgery
  • Diarrhea
  • Benign prostatic hypertrophy
  • Chronic obstructive pulmonary disease (COPD)
  • Cystic fibrosis
  • Pertussis (ie, whooping cough)
  • Pelvic floor dysfunction
  • Parasitic infections – Amebiasis, schistosomiasis
  • Neurologic disorders - Previous lower back or pelvic trauma/lumbar disk disease, cauda equina syndrome, spinal tumors, multiple sclerosis
  • Disordered defecation (eg, stool withholding)

Certain anatomic features found during surgery for rectal prolapse are common to most patients. These features include a patulous or weak anal sphincter with levator diastasis, deep anterior Douglas cul-de-sac, poor posterior rectal fixation with a long rectal mesentery, and redundant rectosigmoid. Whether these anatomic features are the cause or result of the prolapsing rectum is not known.[4]

In children, rectal prolapse is probably related to the vertical orientation of the rectum, the mobility of the sigmoid colon, the relative weakness of the pelvic floor muscle, mucosa that is poorly fixed to submucosa, and redundant rectal mucosa.

Epidemiology

United States statistics

Rectal prolapse is uncommon; however, the true incidence is unknown because of underreporting, especially in the elderly population. Peaks in occurrence are noted in the fourth and seventh decades of life, and most patients (80-90%) are women.[5]

The condition is often concurrent with pelvic floor descent and prolapse of other pelvic floor organs, such as the uterus or the bladder. Although multiple pregnancies are often implicated in the etiology, 35% of patients are nulliparous. A small subset of children is affected, usually before the age of 3 years. Evaluation and treatment of children with rectal prolapse is addressed elsewhere.

International statistics

The annual incidence of rectal prolapse in Finland was found to be 2.5 per 100,000 population.[6]

Age-related demographics

Although all ages can be affected, peak incidences are observed in the fourth and seventh decades of life. Pediatric patients usually are affected when younger than 3 years, with the peak incidence in the first year of life. Mucosal prolapse is more common than complete prolapse (possibly because of poor fixation of the submucosa to the mucosa in pediatric patients). The incidence of prolapsed rectum in children with cystic fibrosis approaches 20%.

Sex-related demographics

In the adult population, the male-to-female ratio is 1:6. Although in the adult population, women account for 80-90% of cases, in the pediatric population, the incidence of rectal prolapse is evenly distributed between males and females.[7]

Prognosis

The prognosis generally is good with appropriate treatment. Spontaneous resolution usually occurs in children. Of patients with rectal prolapse who are aged 9 months to 3 years, 90% will need only conservative treatment. Continence usually is initially worse after surgical treatment, but in most patients it improves over time; however, the degree of improvement is unpredictable.

Untreated rectal prolapse can lead to incarceration and strangulation (rare). More commonly, increasing difficulties with rectal bleeding (usually minor), ulceration, and incontinence occur.

Postoperative mortality is low, but the recurrence rate can be as high as 15%, regardless of the operative procedure performed (see below). The most common postoperative complications involve bleeding and dehiscence at the anastomosis. Other complications include mucosal ulceration and necrosis of the rectal wall. Operative complications are higher for abdominal operations, with a lower recurrence rate; the opposite is true for perineal operations, which have a much lower complication rate but a higher recurrence rate.

Recurrence

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

The recurrence rate for Marlex rectopexy ranges from 2% to 10%, with a morbidity of 3-29%. Continence is improved in 50-70% of patients. Constipation, however, is not improved and may worsen after this operation. The results of suture rectopexy are comparable.

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

The recurrence rate for Delorme mucosal sleeve resection ranges from 5% to 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.

The recurrence rate for Altemeier perineal rectosigmoidectomy ranges from 0% to 50%, with an average of approximately 10%. Continence may be improved if a levator plication is added to the procedure. A study by Altomare et al indicated that restoration of continence with this procedure can be unpredictable.[8]

 

Presentation

History

Patients with rectal prolapse report a mass protruding through the anus (see the image below). Initially, the mass protrudes from the anus only after a bowel movement and usually retracts when the patient stands up. As the disease process progresses, the mass protrudes more often, especially with straining and Valsalva maneuvers such as sneezing or coughing. Finally, the rectum prolapses with daily activities such as walking and may progress to continual prolapse.

Rectal prolapse. Rectal prolapse.

As the disease progresses, the rectum no longer spontaneously retracts, and patients may have to replace it manually. This condition may then progress to a point where the rectum prolapses immediately after being replaced and is continuously prolapsed. Rarely, the rectum becomes incarcerated, and patients cannot replace the rectum.

Pain is variable. Some 10-25% of patients also have uterine or bladder prolapse, and 35% may have an associated cystocele. Constipation occurs in 15-65% of cases. There may also be rectal bleeding.

In addition to a protruding mass from the anus, patients often report fecal incontinence (28-88%). Incontinence occurs for two reasons. First, the anus is dilated and stretched by the protruding rectum, disrupting the function of the anal sphincter. Second, the mucosa of the rectum is in contact with the environment and constantly secretes mucus, thus making the patient appear to be chronically wet and incontinent.

A detailed history to evaluate incontinence, constipation, or both is important because it plays a role in determining the appropriate surgical procedure.

Patients with mucosal prolapse have similar problems but not to the same degree. Patients with internal intussusception often report difficulty with defecation and a sensation of incomplete evacuation.

Physical Examination

Physical signs of rectal prolapse include the following:

  • Protruding rectal mucosa
  • Thick concentric mucosal ring
  • Sulcus noted between anal canal and rectum
  • Solitary rectal ulcer (10-25%)
  • Decreased anal sphincter tone

Rectal prolapse is a clinical diagnosis that physicians should be able to confirm in the office. The patient is asked to sit on a toilet and strain, after which the rectum should prolapse. If it does not prolapse with just straining, the administration of a phosphate enema usually produces the prolapse. In a small child, a glycerin suppository can be used instead.

The protruding mass should show concentric rings of mucosa. In cases of small prolapse, it is sometimes difficult to distinguish between mucosal and full-thickness rectal prolapse. Mucosal prolapse typically exhibits radial folds instead of concentric rings. If these cannot be clinically distinguished, a defecogram (see Workup) may be of help in differentiating these two conditions. A defecogram is unnecessary in the presence of an obvious rectal prolapse.

 

DDx

Diagnostic Considerations

The following conditions should be included in the differential diagnosis:

Rectal polyps should also be considered.

 

Workup

Approach Considerations

Rectal prolapse is usually only a symptom, and evaluation should focus on discovery of an underlying disorder.

In children, rectal prolapse is usually a benign condition that calls for evaluation of the underlying condition. Evaluate pediatric patients for cystic fibrosis; a significant percentage are affected with this disorder.

Laboratory Studies

The only pertinent laboratory studies for a patient with rectal prolapse are those studies that are dictated by the patient’s age and comorbidities. There are no specific tests that aid in the evaluation of rectal prolapse itself.

Perform a sweat chloride test for pediatric patients; as many as 11% of children with rectal prolapse have cystic fibrosis. Consider a stool examination and culture for infectious agents, particularly in pediatric patients.

Barium Enema and Colonoscopy

Before initiating surgical treatment of rectal prolapse (see Treatment), it is important to evaluate the entire colon in order to exclude any other colonic lesions that should be simultaneously addressed. The presence of such lesions may affect the choice of the procedure to be performed.

Evaluation of the colon may be accomplished by means of colonoscopy or barium enema. Barium enema is a better indicator of the redundancy of the colon.

Video Defecography

Video defecography is used to help document internal prolapse or to distinguish rectal prolapse from mucosal prolapse if it is not clinically obvious. It is not necessary for clinically diagnosed full-thickness rectal prolapse. Defecography may reveal intussusception of proximal colon or pelvic outlet obstruction.

Radiopaque material (usually barium paste) is instilled into the rectum, and the patient is asked to defecate on a radiolucent toilet. Spot films and videotapes are made and can be used to determine if the rectum intussuscepts on defecation.

Rigid Proctosigmoidoscopy

Rigid proctosigmoidoscopy should be performed to assess the rectum for additional lesions, especially solitary rectal ulcers. These ulcers are present in about 10-25% of patients with either internal or full-thickness prolapse. If ulceration is present, the area appears as a single ulcer or as multiple ulcers on the anterior rectal wall. The edges are often heaped up, and the area may be bleeding.

Biopsy should be performed to confirm the diagnosis and to exclude other pathology. Solitary rectal ulcers can usually be identified by an experienced pathologist. The prolapsed rectum may have ulcerated mucosa but is otherwise histologically normal.

Other Tests

Anal-rectal manometry is sometimes used to evaluate the anal sphincter muscles. In almost all patients, the results show a decrease in resting pressure in the internal sphincter and an absence of the anorectal inhibitory reflex. The significance of these results is unclear, and most surgeons do not use this test.

The Sitz marker study is occasionally used to measure colonic transit in a patient with constipation and rectal prolapse to help determine the need for colonic resection.

Pudendal nerve terminal motor latency assesses for neurologic injury or dysfunction.

 

Treatment

Approach Considerations

In adult patients, treatment of rectal prolapse is essentially surgical; no specific medical treatment is available. (Children, however, can usually be treated nonsurgically and by managing the underlying condition.) Which repair constitutes the best treatment is the main controversy in surgery for rectal prolapse.[9] All of the procedures have their proponents, and there is no single right answer. The following video shows a perineal rectosigmoidectomy.

Perineal rectosigmoidectomy for rectal prolapse. Procedure performed by Tracy Arnell, MD, ColumbiaDoctors, New York, NY. Video courtesy of ColumbiaDoctors (https://www.columbiadoctors.org).

A laparoscopic approach to rectal prolapse repair has become increasingly popular. This approach 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 continue to be studied.[10, 11, 12]

Nonoperative Management

Generally, a prolapsed rectum can be reduced with gentle digital pressure; 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.

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

Contributing factors, such as constipation and diarrhea, should be addressed and eliminated if possible. Supportive care should be provided according to the clinical picture, particularly in the presence of an irreducible prolapse and with gangrene or rupture of the rectal mucosa. Obtain a prompt surgical evaluation if anal incontinence is present.

If the prolapse cannot be reduced and the viability of the bowel is in question, emergency resection is required. Rupture of the rectum also constitutes a surgical emergency. Obtain a prompt surgical consultation with a general surgeon or a colorectal surgeon.

In cases of uncomplicated rectal prolapse, arrange surgical follow-up care for further evaluation and definitive treatment.

Surgical Options

Contraindications for surgical correction of rectal prolapse are based on the patient’s comorbidities and his or her ability to tolerate surgery. Surgical treatments can be divided into two categories according to the approach used to repair the rectal prolapse: abdominal procedures and perineal procedures. The choice between an abdominal procedure and a perineal procedure is mainly dictated by the patient’s age and comorbidities.[13, 14, 15]

On the whole, the abdominal procedures have a lower recurrence rate but a higher morbidity. Accordingly, older, debilitated patients (whose life expectancy is shorter) are generally treated with perineal procedures, whereas younger, healthier patients are typically treated with abdominal procedures. It should be noted, however, that many surgeons with copious 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.

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

Regardless of the type of procedure being planned, full mechanical and antibiotic bowel preparation should be carried out before surgery. Intravenous (IV) antibiotics should always be administered preoperatively; if a foreign material is being implanted, postoperative administration of antibiotics may also be considered.

Abdominal Surgical Procedures

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

Laparoscopic surgical rectopexy procedures have been developed that have outcomes as good as those of open abdominal procedures but are associated with shorter hospital stays and greater patient comfort.[16, 17, 18]

Anterior resection

Patients with rectal prolapse and constipation often have a redundant colon, and some surgeons believe that resection of this alleviates constipation and decreases recurrence of 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 anastomosis is performed without laxity in the colon so that the rectum is held in place and can no longer prolapse. At present, 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 (see the image below). A nonabsorbable material (eg, Marlex mesh or an Ivalon sponge) is fixed to the presacral fascia. The rectum is placed on tension, and the material is partially wrapped around the rectum to keep it in position. To prevent a circumferential obstruction, the anterior rectal wall is not covered with the sponge or mesh. The Ivalon sponge is not used in the United States.

Marlex rectopexy for rectal prolapse. Marlex rectopexy for rectal prolapse.

The peritoneal reflections are then closed to cover the foreign body. The Marlex mesh or sponge causes an intense inflammatory reaction that scars and fixes the rectum into place. This procedure should not be performed 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 the risk of infection.

Although the rate of Marlex erosion into the rectum is low, management is extremely difficult, and for this reason, many surgeons prefer resection with suture rectopexy (see below) to Marlex fixation.

Suture rectopexy

A suture rectopexy is essentially the same as a Marlex rectopexy, except that the rectum is fixed to the presacral fascia with suture material rather than mesh or an Ivalon sponge.

Resection rectopexy

A resection with rectopexy (Frykman-Goldberg procedure) is a combination of an anterior resection and a Marlex rectopexy; it 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 Surgical Procedures

Perineal procedures have higher recurrence rates but lower morbidities and are often performed in elderly persons or in patients for whom general anesthesia is contraindicated.

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 the procedure was initially described as using a wire, it now employs other materials (eg, Silastic tubing and nonabsorbable suture material) instead. Anal encirclement is effective in mechanically preventing the rectum from prolapsing, but it does not treat the underlying disorder.

Complications from this procedure include obstruction with fecal impaction and erosion of the wire with infection. Anal encirclement is no longer commonly performed; it is usually reserved for only the most debilitated patients and for patients with the highest surgical risks, in whom palliation is the goal. Anal encirclement carries a very high risk of fecal impaction.

Delorme mucosal sleeve resection

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

Delorme mucosal sleeve resection for rectal prolap Delorme mucosal sleeve resection for rectal prolapse.

Altemeier perineal rectosigmoidectomy

In an Altemeier perineal rectosigmoidectomy, a full-thickness circumferential incision is made in the prolapsed rectum about 1-2 cm from the dentate line (see the image below). The hernia sac is 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 either hand-sewn to the distal anal canal or stapled with a circular stapler. Before anastomosis, some surgeons plicate the levator ani muscles anteriorly, which may help improve continence.

Altemeier perineal rectosigmoidectomy for rectal p Altemeier perineal rectosigmoidectomy for rectal prolapse.

In a study of the long-term outcome of Altemeier perineal rectosigmoidectomy, Altomare et al reviewed the medical records of 93 patients and concluded that this operation is relatively safe and effective in frail, older patients, with postoperative morbidity being low.[8] However, the recurrence rate after the procedure was not negligible, and the operation was found to be unpredictable in terms of restoring continence. Recurrences can be treated with a repeat Altemeier procedure.

Hemorrhoidectomy

Mucosal prolapse is treated with a hemorrhoidectomy.

Perineal stapled prolapse resection

In a study of 32 patients with external rectal prolapse, Hetzer et al concluded that perineal stapled prolapse resection is a fast and effective treatment for this condition.[19] The operation, 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 with a curved Contour Transtar stapler.

The investigators reported no intraoperative complications, though two patients experienced minor postoperative complications.[19] 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.

Tschuor et al studied nine patients who underwent perineal stapled prolapse resection from 2007-2011. They concluded that although the procedure is fast and safe, the long-term functional outcome was poor, and the recurrence rate was 44%.[20]

Postoperative Care

Abdominal procedures

After abdominal procedures for rectal prolapse, patients usually have ileus and incisional pain. IV 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 undergone perineal procedures do well postoperatively, with minimal pain and a short hospital stay. Initially, they 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.

Complications

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

Infection

The most common source of infection in abdominal procedures is skin organisms in the wound. If foreign material has been implanted, infection can ensue (most often from skin organisms), and the material must be removed, if possible. Intense fibrosis can make removal of prosthetic material too dangerous; in these settings, long-term antibiotic therapy has been used. Long-term results are unclear. Infection after perineal procedures occurs rarely; more commonly, there can be a separation at the perineal anastomosis (see below).

Bleeding

Bleeding most commonly occurs in two situations. The first situation involves tearing of the presacral veins during abdominal procedures, when mesh or the rectum is directly affixed to the presacral fascia. This can lead to a presacral hematoma or to torrential bleeding.

Such 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 may occur 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 above). Unrecognized bowel injuries may occur with a laparoscopic approach by several mechanisms and, if not diagnosed quickly when the patient fails to improve, can lead to sepsis and death.

Anastomotic leakage

All procedures involving an anastomosis carry a risk of anastomotic leakage. Abdominal procedures complicated by a leak may not require reexploration if the leak is small and contained and the patient stable. The collection can be drained percutaneously, and these leaks often resolve with supportive care. If the patient fails to improve, abdominal washout with proximal fecal diversion becomes necessary.

If the leak is large and not contained, or if the patient is not stable, urgent reexploration is indicated. Pelvic sepsis makes further dissection in the pelvis challenging as well as dangerous for the patient, and washout with proximal diversion is the procedure of choice. Rarely will the anastomosis be completely disrupted; in this setting, exteriorization of the distal portion as an end colostomy with stapling or oversewing of the rectal stump is needed.

Rarely, anastomotic leakage can also occur after perineal rectosigmoidectomy. If leakage occurs after this procedure, the infection is localized and pelvic sepsis is rare.

Altered bladder and sexual function

Alteration of bladder and sexual 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, or retrograde ejaculation. This is an important consideration in the selection of the repair procedure, especially in men, though 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. Historically, abdominal procedures that tacked the rectum to the sacrum caused a high rate of outlet obstruction when the rectum was wrapped circumferentially, often necessitating release of the fixation to treat the problem; for this reason, the wrap, when performed, is now only done posteriorly and partially around the sides of the rectum.

Long-Term Monitoring

Follow-up care after the immediate postoperative period depends on which type of surgical procedure the patient underwent, but it usually consists of one or two 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 readily notice if the prolapse returns and can schedule further outpatient visits as necessary.

 

Medication

Medication Summary

There is no specific medical treatment for rectal prolapse. Stool softeners can be used to help decrease bowel movement straining caused by constipation.

Stool softeners

Class Summary

In addition to dietary modification, stool softeners help to decrease bowel movement straining secondary to constipation.

Polyethylene glycol solution (Miralax, Dulcolax Balance)

Polyethylene glycol is an osmotic stool softener used for treatment of occasional constipation. In theory, there is less risk of dehydration or electrolyte imbalance with isotonic polyethylene glycol than with hypertonic sugar solutions. A laxative effect is generated because polyethylene glycol is not absorbed and continues to hold water by osmotic action through the small bowel and colon, resulting in mechanical cleansing.

Polyethylene glycol is supplied with a measuring cap marked to contain 17 g of laxative powder when filled to the indicated line. It may require 2-4 days (48-96 hours) to produce bowel movement.

Mineral oil (Kondremul, Fleet Mineral Oil Enema)

Mineral oil lubricates the intestine and facilitates the passage of stool by decreasing water absorption from the intestine.

Lactulose (Enulose, Generlac, Kristalose, Constulose)

Lactulose is an osmotic agent and ammonium detoxifying agent. It produces an osmotic effect in the colon that results in distention and promotes peristalsis.

 

Questions & Answers

Overview

What is rectal prolapse?

How is rectal prolapse defined?

What is the relevant anatomy of rectal prolapse?

What is the pathophysiology of rectal prolapse?

What causes rectal prolapse?

What are predisposing conditions of rectal prolapse?

What anatomic features are associated with rectal prolapse?

What is the prevalence of rectal prolapse in the US?

What is the global incidence of rectal prolapse?

How does the incidence of rectal prolapse vary by age?

How does the incidence of rectal prolapse vary by sex?

What is the prognosis of rectal prolapse?

What is the recurrence rate for rectal prolapse following anterior resection?

What is the recurrence rate for rectal prolapse following Marlex rectopexy?

What is the recurrence rate for rectal prolapse following resection and rectopexy?

What is the recurrence rate for rectal prolapse following Delorme mucosal sleeve resection?

What is the recurrence rate for rectal prolapse following Altemeier perineal rectosigmoidectomy?

Presentation

What is the progression of rectal prolapse?

What should be the focus of clinical history for rectal prolapse?

What are the physical signs characteristic of rectal prolapse?

How is rectal prolapse diagnosed?

DDX

What should be included in the differentials for rectal prolapse?

Workup

What are the approach considerations in the workup of rectal prolapse?

What is the role of lab studies in the workup of rectal prolapse?

How is the colon evaluated prior to surgical repair for rectal prolapse?

What is the role of video defecography in the workup of rectal prolapse?

What is the role of rigid proctosigmoidoscopy in the workup of rectal prolapse?

What is the role of anorectal manometry in the workup of rectal prolapse?

Treatment

What are the treatment options for rectal prolapse?

What is included in nonoperative management for rectal prolapse?

What are the surgical options for rectal prolapse?

When are abdominal surgical procedures used for repair of rectal prolapse?

How is anterior resection performed for the treatment of rectal prolapse?

How is Marlex rectopexy (Ripstein procedure) performed for the treatment of rectal prolapse?

What is a suture rectopexy for the treatment of rectal prolapse?

How is resection with rectopexy (Frykman-Goldberg procedure) performed for the treatment of rectal prolapse?

When are perineal surgical procedures performed for the treatment of rectal prolapse?

How is anal encirclement (Thiersch wire) performed for the treatment of rectal prolapse?

How is a Delorme mucosal sleeve resection performed for the treatment of rectal prolapse?

How is an Altemeier perineal rectosigmoidectomy performed for the treatment of rectal prolapse?

When is hemorrhoidectomy performed for the treatment of rectal prolapse?

What is the efficacy of perineal stapled prolapse resection for rectal prolapse?

What is included in postoperative care for rectal prolapse following abdominal procedures?

What is included in postoperative care for rectal prolapse following perineal procedures?

What causes postoperative bleeding in rectal prolapse and how is it managed?

What are complications of rectal prolapse?

How are postoperative infections managed in rectal prolapse?

What are the risks of bowel injury in rectal prolapse surgery?

How is anastomotic leakage managed in rectal prolapse?

What is the risk of altered bladder and sexual function following surgery for rectal prolapse?

How is postoperative constipation/outlet obstruction in rectal prolapse prevented?

What is included in long-term monitoring of rectal prolapse?

Medications

What is the medical treatment for rectal prolapse?

Which medications in the drug class Stool softeners are used in the treatment of Rectal Prolapse?