Rectal Prolapse Treatment & Management

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. ^{[10, 11]} All of the procedures have their proponents, and there is no single right answer. The following video shows a perineal rectosigmoidectomy.

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. ^{[12, 13, 14]}

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.

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. ^{[15, 16, 17]}

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.

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. ^{[18, 19, 20]}

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.

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 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.

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.

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. ^[9] 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. ^[21] 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. ^[21] 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%. ^[22]

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.

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.

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.