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Rectal prolapse (RP) is the descent of the rectum, in its whole thickness, or all its coats, through the anus. RP occurs when the supporting structures of the rectum are absent, weakened, or destroyed and when a force appears that is capable of dislodging the rectum from its normal position. RP tends to occur at the extremes of age, in children and in elderly females. The development of RP is associated with certain predisposing influences. Anatomic factors include immature development of contiguous pelvic structures in children and changes associated with aging in adults. Among mechanical stressors are increased intra-abdominal pressure, intraluminal lesions, and trauma. Diseases related to RP include cystic fibrosis, pertussis, colorectal inflammation, brain or spinal cord abnormalities, mental illness, malnutrition, and infection. Intussusception and sliding hernia are two mechanisms used to explain the development of RP. Intussusception has been demonstrated as a precursor to RP by defecating proctogram. A sliding hernia occurs when the peritoneum covered anterior rectal wall invaginates into the rectum and then through the anal canal.

The assessment of patients with RP begins with the history and physical examination. A provocative maneuver such as sitting on a commode may be required to visualize the prolapse. Predisposing causes of RP are identified. Associated incontinence, constipation, bleeding, medical comorbid conditions, and fitness for operation are assessed. Anorectal physiological testing may provide useful information concerning anal sphincter function. Colon evaluation may reveal large intestinal pathology.

The role of surgery for adults and children differs. In children, RP often responds to conservative therapy. For these patients, initial treatment is directed at eliminating causes of prolapse; and surgery is reserved for persistent cases. In adults, operative management usually is the best form of treatment. Objectives of operations and procedures described for the treatment of RP include: prolapse reduction, anal encirclement, rectal shortening, pelvic floor reconstruction, rectal/sigmoid colon resection, rectal suspension, cul-de-sac obliteration, reverse intussusception, colostomy, and acupuncture. Surgical approaches are divided broadly into transabdominal and perineal types. Selection of the best surgical procedure for RP is made difficult because there are many operations for which excellent results are reported. To date, no single procedure or approach has shown clear superiority over all others. Sclerosis has maintained a prominent position in the treatment of RP in children because of both good immediate results in the majority and minimal invasiveness. For adults, abdominal procedures are associated with a lower recurrence rate but at a significantly higher cost in terms of complications. Perineal operations avoid the complications of laparotomy but are more apt to result in recurrence. The introduction of laparoscopy has demonstrated advantages that include reduced surgical trauma, earlier return of diet and activity, and shorter hospital stay. General factors that are considered in the selection of a specific procedure include: fitness of the patient for operation and prior surgical history. Among abdominal operations, rectopexy enjoys popularity. However, both the extent of rectal mobilization and the mechanism by which rectal suspension is achieved are quite variable. The potential benefit of additional maneuvers such as sigmoid resection, to avoid postoperative constipation, must be weighed against the risk of complications such as anastomotic leak. Among perineal operations, mucosal resection, perineal proctosigmoidectomy, and anal encirclement remain in common practice.

Rectal intussusception (RI) or internal RP is present when the prolapse begins high up in the rectum or sigmoid flexure and extends down into the ampulla of the rectum but does not protrude through the anal orifice. The risk of full-thickness RP developing in patients treated medically for RI has been reported as being small; and therefore, the presence of RI alone may not be an indication for operation. Treatment of RI may include bulk laxatives, psychotherapy, pelvic floor rehabilitation, or surgery. Operative management of RI is considered for symptoms of fecal incontinence, severe pain, a strong sensation of obstruction, and progression to complete RP. Operations described for the treatment of incomplete prolapse have included rectal suspension and transanal mucosectomy. Not all patients with RI who undergo operation will experience benefit, especially, if the principal symptom is constipation.

RP, either overt or occult, may occur in conjunction with disorders of other pelvic organs including the bladder, uterus, vagina, pelvic floor muscles, small bowel, and colon. In addition to physical examination, tests to assess these organ systems are available. Among these are multiple organ contrast radiography, dynamic magnetic resonance imaging, endosonography, and 3-dimensional computed tomography. Repair of RP and coexisting genitourinary abnormalities may be accomplished simultaneously.

RI also is associated with solitary rectal ulcer syndrome (SRUS) and rectosigmoid polypoid change. Similarities between SRUS and mucosal prolapse have led to the term “mucosal prolapse syndrome” to describe disorders in which mucosal prolapse is the common underlying pathologic mechanism. Successful surgical treatment of RP associated with SRUS and rectosigmoid polyposis by rectopexy and resection rectopexy have been reported.

Reoperation for recurrent RP may involve either abdominal or perineal approaches. The same surgical options are available for repeat operations as for primary ones. Caution is advised when considering a repeat resectional operation because of the risk of a devascularized segment unless the surgeon resects a previous anastomosis.

In summary, the management of RP continues to evolve. The number of operative procedures designed to treat RP has steadily increased over time. However, large rigorous trials are needed to improve the evidence with which to define optimum surgical treatment for RP. The selection of the best procedure for RP still is left to the judgment and experience of the surgeon.