You are in: eMedicine Specialties > General Surgery > Colorectal Rectal ProlapseArticle Last Updated: Aug 3, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: Lisa S Poritz, MD, Assistant Professor, Department of Surgery, Section of Colon and Rectal Surgery, Milton S Hershey Medical Center, Pennsylvania State University Lisa S Poritz is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, Association for Academic Surgery, and Society for Surgery of the Alimentary Tract Editors: Brian James Daley, MD, MBA, FACS, Associate Program Director, Professor, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital Author and Editor Disclosure Synonyms and related keywords: procidentia, full-thickness rectal prolapse, mucosal prolapse, internal prolapse, internal intussusception, pelvic floor descent, constipation, rectal ulcers, hemorrhoids, hemorrhoidal disease, cystocele, fecal incontinence, defecogram, anal rectal manometry, proctosigmoidoscopy, Marlex rectopexy, Ripstein procedure, suture rectopexy, resection rectopexy, Frykman Goldberg procedure, anal encirclement, Thiersch wire, Delorme mucosal sleeve resection, Altemeier perineal rectosigmoidectomy, hemorrhoidectomy INTRODUCTIONSection 2 of 12
  Rectal prolapse was described as early as 1500 BC. ProblemThree different clinical entities are often combined and called rectal prolapse: full-thickness rectal prolapse, mucosal prolapse, and internal prolapse (internal intussusception). Treatment of these 3 entities differs. Full-thickness rectal prolapse is the most commonly recognized type and is defined as protrusion of the full thickness of the rectal wall through the anus (see Media file 1). In mucosal prolapse, only the rectal mucosa (not the entire wall) protrudes 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. Most of this article focuses on full-thickness rectal prolapse, which will be referred to as rectal prolapse. FrequencyRectal 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. 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 different from that for adults and is not addressed in this article. EtiologyThe etiology of rectal prolapse is unknown, but it is often associated with long-standing constipation. Other predisposing conditions include chronic straining during defecation, pregnancy, previous surgery, and neurologic disease. The pathophysiology of rectal prolapse is also not completely understood or agreed upon. The 2 main theories are essentially 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, although some patients never progress beyond this stage. 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. Mucosal prolapse most likely has a different etiology and pathophysiology than full-thickness rectal prolapse and internal intussusception. 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. ClinicalPatients with rectal prolapse report a mass protruding through the anus. 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. As the disease progresses, the rectum no longer spontaneously retracts, and patients may have to manually replace it. This condition may then progress to a point at which the rectum prolapses immediately after being replaced and is continuously prolapsed. Rarely, the rectum becomes incarcerated, and patients cannot re-place the rectum. Pain is variable. Ten to 25% of patients also have uterine or bladder prolapse, and 35% may have an associated cystocele. In addition to a protruding mass from the anus, patients often report fecal incontinence. Incontinence occurs for 2 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. 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. 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 glycerine suppository can be used instead. The protruding mass should show concentric rings of mucosa, which are classic signs of rectal prolapse. 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 may be of help in differentiating these two conditions. A defecogram is unnecessary in the presence of an obvious rectal prolapse. A detailed history to evaluate incontinence and/or constipation is important, as it plays a role in determining the appropriate surgical procedure. For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article Rectal Prolapse. INDICATIONSSection 3 of 12
The existence of rectal prolapse is an indication for surgery. RELEVANT ANATOMYSection 4 of 12
CONTRAINDICATIONSSection 5 of 12
Contraindications to surgical correction of rectal prolapse are based on the patient's comorbidities and his or her ability to tolerate surgery. WORKUPSection 6 of 12
Lab Studies
Imaging Studies
Other Tests
Diagnostic Procedures
Histologic FindingsSolitary rectal ulcers can usually be identified by an experienced pathologist. The prolapsed rectum may have ulcerated mucosa but is otherwise histologically normal. TREATMENTSection 7 of 12
Medical therapyNo medical treatment is available for rectal prolapse. However, always first treat internal prolapse medically with bulking agents, stool softeners, and suppositories or enemas. Biofeedback may be helpful if paradoxical pelvic floor contraction also exists. 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. Emergency resection is required if the prolapse cannot be reduced and the viability of the bowel is in question. Surgical therapySurgical treatment can be divided into 2 categories according to the approach used to repair the rectal prolapse: abdominal procedures and perineal procedures. The choice of abdominal versus perineal procedure is mainly dictated by the patient's age and comorbidities. In general, the abdominal procedures have a lower recurrence rate but a higher morbidity rate. The converse is true of perineal procedures. In general, treat older, debilitated patients (whose life expectancy is shorter) with a perineal procedure, and treat younger, healthier patients with abdominal procedures, although surgeons with large 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 (not described in this article). Surgical therapy for internal prolapse is usually avoided because results are poor, with relief of symptoms occurring in fewer than 50% of patients. Preoperative detailsEnsure a full mechanical and antibiotic bowel preparation before surgery, regardless of the type of procedure being planned. Perioperative intravenous antibiotics are often used, especially if a foreign material is being implanted. Intraoperative detailsAbdominal proceduresThese procedures are typically performed in younger, healthier patients whose life expectancy is longer. For these patients, procedures with lower recurrence rates but higher morbidity rates are most appropriate. The choice of abdominal procedure is often dictated by the extent of the associated constipation and by the surgeon's preference. Anterior resection Patients with rectal prolapse and constipation often have a redundant colon, and resection of it is thought to improve constipation and cure 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 is performed without laxity in the colon so that the rectum is held in place and can no longer prolapse. 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 Media file 2). A nonabsorbable material, such as Marlex mesh or an Ivalon sponge, is then fixed to the presacral fascia. The rectum is then placed on tension, and the material is partially wrapped around the rectum to keep it in position. The anterior wall of the rectum is not covered with the sponge or mesh in order to prevent a circumferential obstruction. The peritoneal reflections are then closed to cover the foreign body. The Marlex mesh or sponge causes an inflammatory reaction that scars and fixes the rectum into place. Do not perform this procedure 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 risk of infection. Suture rectopexy This operation is essentially the same as a Marlex rectopexy except that the rectum is fixed to the presacral fascia with suture as opposed to mesh or an Ivalon sponge. Resection rectopexy Resection rectopexy (Frykman Goldberg procedure) is a combination of the anterior resection and the Marlex rectopexy and 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 proceduresPerineal procedures have a higher recurrence rate but a lower morbidity rate and are often performed in the elderly population or in patients who have a contraindication to general anesthetic. 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 initially described using a wire, other materials (eg, silastic tubing, nonabsorbable suture) have replaced it. The therapy is effective in mechanically preventing the rectum from prolapsing, but it does not treat the underlying disorder. Complications from the procedure include obstruction with fecal impaction and erosion of the wire with infection. This procedure is no longer commonly performed and is usually reserved for only the most debilitated patients and for patients with the highest surgical risks in whom palliation is the goal. Delorme mucosal sleeve resection A circumferential incision is made through the mucosa of the prolapsed rectum near the dentate line; using electrocautery, the mucosa is stripped from the rectum to the apex of the prolapse and excised (see Media file 3). The denuded prolapsed muscle is then pleated with a suture and is reefed up like an accordion. The transected edges of the mucosa are then sutured together. This procedure is often used for small prolapses but may also be used for large ones. Altemeier perineal rectosigmoidectomy A full-thickness circumferential incision is made in the prolapsed rectum at about 1-2 cm from the dentate line (see Media file 4). The hernia sac is then 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 hand sewn to the distal anal canal or stapled using a circular stapler. Before anastomosis, some surgeons plicate the levator ani muscles anteriorly, which may help improve continence. Surgery for mucosal prolapse Mucosal prolapse is treated with a hemorrhoidectomy. Postoperative detailsAbdominal procedures Postoperatively, patients usually have an ileus and incisional pain. Intravenous 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 had perineal procedures do well postoperatively with minimal pain and a short hospital stay. Initially, patients 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. Follow-upFollow-up care in the immediate postoperative period depends on the type of surgery the patient underwent, but it usually consists of 1-2 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 notice if the prolapse returns and can schedule further outpatient visits. COMPLICATIONSSection 8 of 12
Serious complications after rectal prolapse surgery include infection, bleeding, intestinal injury, anastomotic leak, bladder and sexual function alterations, and constipation or outlet obstruction. The frequency of these complications is related to the type of procedure. Other complications, such as myocardial infarction, pulmonary embolus, deep vein thrombosis, and hernia, can occur but are not discussed since they are not unique to these types of procedures. The most common source of infection is from inadvertent injury to the rectum during mobilization in abdominal procedures. Unrecognized, this could lead to leak of intestinal contents with pelvic abscess and sepsis. If foreign material has been implanted, infection ensues, and the material must be removed. Infection after perineal procedures probably occurs as often but rarely causes symptoms and is easier to treat because it is superficial. Bleeding Bleeding most commonly occurs in 2 situations. First, the presacral veins can be torn during abdominal procedures, when mesh or the rectum is directly fixed to the presacral fascia. This can lead to a presacral hematoma or to torrential bleeding. This 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 most frequently occurs 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 Infection). Anastomotic leak All procedures involving a resection carry a risk of anastomotic leak. Abdominal procedures complicated by a leak require reexploration. If the leak is small and contamination in the pelvis is limited, the anastomosis can be revised and protected with a diverting loop ileostomy. If the leak is large with significant dehiscence of the anastomosis, the patient is often best served with a Hartman procedure (colostomy with rectal stump). Often, pelvic sepsis makes further dissection in the pelvis challenging, and revising or performing a new anastomosis can be very difficult. Anastomotic leak can also occur after perineal rectosigmoidectomy. Despite the fact that this is a very low anastomosis, leak is rare. The infection is localized and pelvic sepsis is rare when leak occurs after this procedure. Bladder and sexual function alterations Alteration of 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, and/or retrograde ejaculation. This is an important consideration when trying to decide which procedure to perform, especially in men, although 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. Abdominal procedures that tack the rectum to the sacrum can cause outlet obstruction if the rectum is wrapped circumferentially, often requiring release of the fixation to treat the problem. OUTCOME AND PROGNOSISSection 9 of 12
Anterior resection The recurrence rate for anterior resection without sacral fixation is about 7-9%, with a morbidity rate of 15-29%. This recurrence rate is higher than for other abdominal procedures. Marlex rectopexy Recurrence rates range from 2-10% with morbidity rates of 3-29%. Continence is improved in 50-70% of patients. Constipation is not improved and may worsen after this operation. Suture rectopexy Results are similar to Marlex rectopexy. Resection rectopexy The recurrence rate for this procedure is 3-4%, with several studies reporting a 0% recurrence rate. Morbidity rates range from 4-23%. Because the redundant colon is also resected, constipation improves in 60-80% of patients, and continence improves in 35-60%. Delorme mucosal sleeve resection Recurrence rates range from 5-26% with a variable morbidity that is usually related to the patient's underlying comorbidities. Both fecal incontinence and constipation improve in about 50% of patients. Altemeier perineal rectosigmoidectomy Recurrence rates vary from 0-50% with an average of approximately 10%. Continence is improved, especially if a levator plication is added to the procedure. FUTURE AND CONTROVERSIESSection 10 of 12
Which repair constitutes the best treatment is the main controversy in surgery for rectal prolapse. All of the procedures have their proponents, and there is no right answer. A laparoscopic approach to rectal prolapse repair has become increasingly popular and 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 are still being studied. The second controversy revolves around the cause(s) of rectal prolapse. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
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