|Year : 2012 | Volume
| Issue : 2 | Page : 57-62
Management of rectal prolapse
Saleh M Al Daqal
Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
|Date of Web Publication||3-Apr-2013|
Saleh M Al Daqal
Department of Surgery, King Abdulaziz University, Jeddah
Source of Support: None, Conflict of Interest: None
Background: Rectal prolapse is a chronic disease that commonly affects elderly women in which the rectum partially or fully intussuscepts and comes out through anal canal. Management of this condition is challenging and there are different surgical approaches to this disease. The objective of this study was to evaluate and compare different surgical treatment modalities in the treatment of rectal prolapse.
Materials and Methods: Literature review of all articles concerned with management of rectal prolapse which were published in PubMed was done between the periods from January 1990 to July 2012. Different surgical options for rectal prolapse repair were reviewed and the outcome of these procedures in terms of the recurrence rate and the complications were evaluated.
Results: Surgical options in management of rectal prolapse are abdominal, perineal, laparoscopic, and robotic approaches.
Conclusion: The choice of treatment in rectal prolapse is determined by several factors including the patient age, sex, general condition of the patients, and institutional capabilities. Perineal procedures are less invasive and are the ideal choice for elderly debilitated women and young male patients' consideration, but it is associated with higher rate of recurrence. The open abdominal approach is beneficial to patients with long redundant sigmoid colon and has less recurrence rate, but it is associated with prolonged recovery period and higher morbidities. Laparoscopic and robotic approaches are less invasive and provide the low recurrence rate of the abdominal approach with a recovery period that is more like the perineal approach.
Keywords: Laparoscopic rectopexy, rectal prolapse, rectopexy, robotic rectopexy
|How to cite this article:|
Al Daqal SM. Management of rectal prolapse. Arch Int Surg 2012;2:57-62
| Introduction|| |
Prolapse of the rectum is a rare benign condition in which rectum either partially or fully intussuscepts and comes out through anal canal. Rectal prolapse was described as early as in 1500 B.C in Ebers Papyrus.  Partial prolapse involves only mucosa and are few centimeters long while complete prolapse involves all layers of rectal wall. Mucosal prolapse appears as radially oriented folds while full thickness rectal prolapse appears as concentric circular folds. Long standing constipation plays a role in weakening pelvic floor musculature and may initiate rectal prolapse. Incontinence is commonly associated with rectal prolapse which may be due to weak anal sphincter. Certain anatomic variations like deep sac of pouch of Douglas and redundant sigmoid colon, diastasis of levatorani, mobile mesorectum, and patulous anus are associated with rectal prolapse. Prolapsed hemorrhoids must be distinguished from rectal prolapse by proper examination. Management of prolapsed rectum is surgical either through a perineal or abdominal approach. Abdominal procedures are nowadays done laparoscopically with same results, and there is a trend to shift to laparoscopy and laparoscopic-assisted robotic surgery in the management of rectal prolapse. This is a literature review using the PubMed to review the best surgical treatment of this disease.
| Epidemiology|| |
True incidence of this disease is not known due to under reporting. It is common between fourth and seventh decade and more common in females. Women more than 50 years of age are six times more likely to present with rectal prolapse.  Complete prolapse is more common in elderly females. It is found with pelvic floor descent and prolapse of uterus or bladder. It is commonly associated with multiple pregnancies and only 35% of females are nulliparous. About 50% to 75% have fecal incontinence and 25% to 50% have constipation associated with rectal prolapse. In children it occurs in less than 3 years of age and more in infants. ,
| Etiology|| |
There are two theories in the etiology of rectal prolapse; the first states that rectal prolapse is a sliding hernia through a defect in the pelvic fascia. The other theory holds that rectal prolapse starts as a circumferential internal intussusception of rectum beginning 6-8 cm proximal to anal verge. It progresses to full thickness with straining and passage of time. About 50% of rectal prolapse patients have pudendal neuropathy and may cause atrophy of external anal sphincter due to denervation. ,
It was observed that deep pouch of Douglas has association with rectal prolapse as early as 1912 and sliding hernia of the anterior rectal wall through defect in pelvic fascia was proposed cause of rectal prolapse. Later on, rectal intussusception of mucosa becoming leading point was postulated as a cause of rectal prolapse. This intussusception is made worse by excessive straining due to long-standing constipation. This was demonstrated by cinedefecography as well as by radiographs after radio isotopes applied to rectal mucosa.  Perineal nerve injury theory was proposed by Parks et al. after biopsying of pelvic floor in patients undergoing posterior repair for rectal prolapse and fecal incontinence and histology confirmed the injury of perineal nerve. This nerve injury causes weakness of pelvic floor and fecal incontinence. Perineal nerve injury may be caused by excessive straining in chronic constipation, descent of pelvic floor, and by vaginal delivery. Other causes are relaxation of lateral ligaments and inertia of muscles of pelvic floor. 
The following are associated risk factors for rectal prolapse-pelvic floor dysfunction, previous surgery, psychiatric disease, neurological diseases like pelvic trauma, cauda equina syndrome, spinal tumors, and multiple sclerosis. Other risk factors are those associated with increased intraabdominal pressure like constipation, diarrhea, benign prostatic hypertrophy, pregnancy, chronic cough, and chronic obstructive pulmonary disease. Parasitic infections like amoebiasis and schistosomiasis are also risk factors for rectal prolapse. In children, Hirschsprung's disease, malnutrition, rectal polyps, cystic fibrosis, and Ehlers-Danlos syndrome More Details are associated risk factors.
| Clinical Presentation|| |
Rectal prolapse is more common in females. Common complaint is something coming out of anus in majority of patients. Initially they complain of prolapse during straining at defecation but with the passage of time rectum may remain prolapsed even without straining. Some patients complain of mucus discharge and fecal incontinence. Bleeding per rectum is the other associated complaint. Long-standing rectal prolapse is associated with bladder stone and urethral stricture. Prolapse of bladder or uterus may also occur with rectal prolapse. ,
It is important to differentiate full-thickness prolapse from mucosal prolapse or internal intussusception especially in children. Full-thickness prolapse is the circumferential full-thickness protrusion of the rectal wall through the anal orifice, which presents as circumferential folds by clinical examination. In mucosal prolapse, there is a breakdown or laxity of the connective tissue between the submucosa and muscular portion of the anal canal resulting in a protrusion of only the rectal mucosa which shows clinically as radial folds. Examination of perineum may show soilage with a patulous anus with poor tone. Sometimes prolapse is not obvious in the lateral decubitus position then a patient should be asked to strain on toilet to make it visible. Anorectal manometry is done to evaluate pelvic floor dysynergia and transit study for chronic colonic inertia. Pudendal nerve terminal motor latency (PNTML), manometry, and colonic transit study are adjuncts to the diagnosis of rectal prolapse. Cine defecography if patient present with obstructive defecation and associated defects like vaginal vault prolapse, cystocele, or enterocele. Electromyography and endo-anal ultrasound are done to evaluate incontinent patient. Decreased anal squeeze and decreased anal pressure may lead to the development of rectal prolapse. 
| Management|| |
Generally, treatment of rectal prolapse is surgical. Non-operative treatment produces only temporary or symptomatic relief. It includes high-fiber diet, biofeedback training to reduce the time spent straining at defection, Transin Dolor device with battery-operated unit to simulate the sphincter and then allow it to rest before the next surge, and injection of sclerosing agents into the retrorectal and perirectal space which shows some efficacy in children. There are no available studies comparing medical and surgical treatment of rectal prolapse. ,
More than hundred surgical methods for rectal prolapse are available but none is without complications. It is of paramount importance to address each patient separately and tailor treatment which will be best for the patient. Broadly, two surgical options are available: Abdominal procedures and perineal procedures. Perineal procedures aim to strengthen the anus with prosthetic material and reefing rectal mucosa (Delorme procedure), and resection of prolapsed rectum (Perineal rectosigmoidectomy or Altemeier procedure). There is also rectosigmoidectomy and levatorplasty, the addition of levatorplasty reduces the recurrence and incontinence rates. Anal cerclage procedures are nowadays abandoned due to high recurrence and complications. Laparoscopic procedures are now more frequently employed for management of rectal prolapse. Laparoscopic-assisted robotic surgery is a new tool in the hands of surgeons with promising results.
This approach is associated with less perioperative pain and morbidity and decreased hospital stay. The recurrence rates are higher than the abdominal approach and less satisfying functional results. The various procedures are as follows.
This procedure is mentioned just to condemn as it is anal encirclement by non-absorbable suture or silastic tubing or a silver wire. It acts by reducing anal orifice which prevents prolapse of rectum. It has complications like mechanical obstruction with fecal impaction and erosion of wire, and now it has been abandoned worldwide.
This procedure was described in 1900 which uses a trans-anal approach to resect prolapsed rectal mucosa and re-anastomoses after plication of muscularis propria. Patients who are frail and elderly can be offered this operation although it has mortality of 0% to 4% and high recurrence rate because rectum is not fixed to sacrum as high as 4% to 38%.  High range of recurrence is probably due to technique of mucosal resection, plication of muscular layer, and the variable length of mucosa resected. Other studies with comparable results are as follows.
Perineal resection of rectum was first described by Mikulicz in 1889 but was popularized by Altemeier in 1971. Through the trans-anal approach, full thickness excision of rectum and a portion of sigmoid is done and anastomosis is done by absorbable sutures or staplers. It is the procedure of choice for those who have gangrenous, incarcerated rectal prolapse. Following studies [Table 1] showed mortality from 0% to 5% and recurrence rate of 0% to 29%. ,
A comparison of the Altemeier and Delorme procedure was done by Yoon et al. which showed no difference in mortality but shorter hospital stay and lower morbidity and higher subjective satisfaction score in the Delorme procedure. A combination of Delorme and Theirsch, over Delorme procedure, has added advantage of decreased recurrence and better patient satisfaction score. ,
Various abdominal procedures are available for rectal prolapse repair which involve mobilization of rectum, fixation by suture or mesh, and resection of rectum by open surgery, laparoscopic, or robotic surgery. Abdominal procedures have better results and have become preferred option for younger patients despite slightly higher morbidity and mortality. ,
It is a key component in the abdominal approach and fixation of rectum to pelvis was first described by Cutait. After rectum is mobilized from the sacrum to anorectal junction, it is anchored to sacrum by sutures which induce fibrosis and fixation of rectum. Recurrence rate varies from 0% to 9%. More than half of patients experience constipation for the first time and 50% patients who had constipation prior to surgery complains of worsening constipation [Table 2]. It has been seen that dissection which involves division of lateral stalks has been associated with constipation probably due to denervation of neural efferent. ,
Rectopexy with mesh
It is of two types, posterior mesh rectopexy and anterior sling rectopexy. It employs mesh made up of prolene, nylon, Teflon, Ivalon or marlex which are non-absorbable and vicryl and Dexon which are absorbable.
Anterior sling rectopexy
It is also known as the Ripstein procedure which involves fixation of mesh to the anterior wall of rectum by sutures and rectum is pulled upward and posteriorly and fixation of the sling to presacral fascia below sacral promontory by sutures. Recurrence rates were 2-10% and mortality from 0% to 2.8%. Complication rates were up to 50% which were due to placement of foreign material on the anterior rectal wall. , Common complications were erosion of mesh, ureteral injury, recto-vaginal fistula, fecal impaction, and small or large bowel obstruction due to fibrosis.
Posterior mesh rectopexy
Mesh is placed between sacrum and rectum and is fixed to sacral fascia by sutures. Modified Well's technique using polyester or polypropylene mesh instead of Ivalon (polyvinyl alcohol) is a useful procedure especially for laparoscopic approaches. Recurrence rates are 0% to 6% and mortality 0% to 3% [Table 3]. Orr-Loygue rectopexy utilizes mesh strips that are attached to the anterolateral rectum and then secured to sacral promontory. Recurrence rates are low but have evacuation difficulties. , D'Hoore, et al. described ventral rectopexy which involves mobilization of rectum with fixation of mesh to the anterior wall and then fixation of mesh to sacrum. It has a recurrence rate of 3.4% that decreased rate of constipation to 23%.
Frykman and Goldberg introduced resection rectopexy in 1969, which involves resection of redundant sigmoid. It has been added to other procedure to have better fixation of rectum to sacrum as anastomosis induces strong fibrosis with sacrum and by removing excess of rectum volvulus of sigmoid can be prevented, thereby reducing recurrence. Recurrence rates from following studies are 0% to 9% [Table 4]. Constipation following resection seems to get reduced in some studies. ,
Anterior resection alone to treat rectal prolapse is associated with high recurrence rates and significant post-operative morbidity. The recurrence rate at 2, 5, 10 years is about 3%, 6%, and 12% respectively with operative morbidity of 29%. ,
With the advent of laparoscopic surgery, its application to management of rectal prolapse has improved the outcome with shorter hospital stay, less pain, and early recovery. First laparoscopic rectal repair was done in 1993. , In conventional laparoscopic repair, five trocar techniques are used. In D' Hoore procedure, incision to peritoneum was made at the right side of sacral promontory in inverted J form along rectum and denonvillier fascia is opened in males and rectovaginal septum in females. No lateral dissection is done in order to preserve rectal innervations. Dacron mesh is fixed to sacral promontory by stapler and then sutured to ventral aspect of rectum. In Well's procedure, a piece of polypropylene mesh is stapled to sacral promontory and wrapped at two sides around the lifted rectum where it is fixed on the anterolateral side. The posterior prosthetic rectopexy is emerging as a preferred choice for rectal prolapse repair. Various studies [Table 5] as shown below demonstrate comparable rates of recurrence. Recurrence rate for laparoscopic suture rectopexy ranges from 0% to 6%, while for laparoscopic posterior mesh repair it ranges from 0% to 4%. As for laparoscopic resection rectopexy, it is put at 0% to 2.5% while the mortality rate is less than 1%. Two randomized reports comparing open versus laparoscopic procedures using mesh rectopexy showed no difference in recurrence rates. , The indications for a laparoscopic approach are similar to an abdominal approach; patients without previous surgeries are better candidates for laparoscopic repair. They have less wound complications, early recovery, shorter hospital stay, and better pain control. Purkayastha, et al. did a meta-analysis comparing laparoscopic versus open surgery for rectal prolapse for full thickness prolapse which involved six studies found no significant difference in morbidity or recurrence but operative time was longer and shorter hospital stay in laparoscopic group. ,
Yoon, et al. compared laparoscopic rectopexy with Delorme-Theiersch repair and found no difference in hospital stay and mortality but longer operative time and higher recurrence rate in laparoscopic rectopexy [Table 6]. ,
Robotic rectal prolapse surgery
Robotic rectopexy is done using four armed Da Vinci surgical system. The patient is positioned in the French steep Trendelenburg position. Robotic cart is positioned between legs of patient and 12 mm port for robotic camera is placed in the infra-umbilical position and other three 7 mm ports according to surgeon's preference. Another 12 mm trocar is placed in the suprapubic region to allow assistant to retract bladder and use EMS stapler to fix the mesh to promontory. Robotic-assisted laparoscopic rectal prolapse repair may shorten operating time and decrease learning curve.  It is a safe and feasible option for rectal prolapse repair. , Operation in crowded space like pelvis is much easier by robotic assistance due to increased range of motion of instruments and better vision. Many recent studies showed that robotic rectopexy is feasible, safe, and associated with less operative time in comparison to laparoscopic rectopexy. We need more studies on robotics rectopexy to determine recurrence rate and complication of it in comparison with other forms of surgical treatment of rectal prolapse.
| Conclusion|| |
Rectal prolapse is a chronic disease that commonly affects elderly women. The choice of treatment is determine by several factors including the patient age, sex, general condition of the patients, and institutional capabilities. Perineal procedures are less invasive and are the ideal choice for elderly debilitated women and young male patients in whom sexual function is an important consideration, but it is associated with higher rate of recurrence. The open abdominal approach is beneficial to patients with long-standing constipation and long redundant sigmoid colon and has less recurrence rate, but it could be associated with prolonged recovery period and higher morbidities. Laparoscopic and robotic approaches are less invasive and provide the low recurrence rate of the abdominal approach with a recovery period that is more like the perineal approach.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]