STATEMENT OF THE PROBLEM
Rectal prolapse is a disorder characterized by a full-thickness intussusception of the rectal wall, which protrudes externally through the anus. It is associated with a spectrum of coexisting anatomic abnormalities, such as diastasis of the levator ani, an abnormally deep cul-de-sac, a redundant sigmoid colon, a patulous anal sphincter, and loss or attenuation of the rectal sacral attachments. Some have hypothesized that the condition is associated with (and preceded by) internal rectal intussusception or a traumatic solitary rectal ulcer, although these associations have never been clearly proven.1–3
Rectal prolapse is rare and is estimated to occur in ≈0.5% of the general population overall, although the frequency is higher in females and the elderly, and women aged ≥50 years are 6 times more likely as men to prolapse.4–6 Although it is commonly thought that rectal prolapse is a consequence of multiparity, approximately one third of female patients with rectal prolapse are nulliparous. The peak age of incidence is the seventh decade in women. Interestingly, although fewer men have the condition, the age of incidence for these men is generally ≤40 years. A striking characteristic of younger patients, both male and female, is an increased tendency to have autism, syndromes associated with developmental delay, or psychiatric comorbidities requiring multiple medications.7
Although rectal prolapse is a benign condition, it can be debilitating because of the discomfort of prolapsing tissue both internally and externally, associated drainage of mucus or blood, and the common occurrence of concomitant symptoms of fecal incontinence, constipation, or both.8 Approximately 50% to 75% of patients with rectal prolapse report fecal incontinence, and 25% to 50% of patients report constipation.9–13 Incontinence in the setting of rectal prolapse may be explained by the presence of a direct conduit (ie, the prolapse), which disturbs the sphincter mechanism, the chronic traumatic stretch of the sphincter caused by the prolapse itself, and continuous stimulation of the rectoanal inhibitory reflex by the prolapsing tissue.14 Up to one half of patients with prolapse demonstrate pudendal neuropathy,15 which may be responsible for denervation-related atrophy of the external sphincter musculature.16 Constipation associated with prolapse may result from intussuscepting bowel in the rectum, creating a blockage that is exacerbated with straining, pelvic floor dyssynergia, and colonic dysmotility, although causality versus correlation remains highly debated.11,12
The goals of surgery to correct rectal prolapse are 3-fold: 1) to eliminate the prolapse through either resection or restoration of normal anatomy, 2) to correct associated functional abnormalities of constipation or incontinence, and 3) to avoid the creation of de novo bowel dysfunction. Multiple operations have been developed to achieve this complex 3-fold goal, each with various strengths and weaknesses underscoring the importance of careful patient selection and thorough patient counseling when choosing a surgical approach.
These guidelines were built based on the last set of The American Society of Colon and Rectal Surgeons (ASCRS) practice parameters for treatment of rectal prolapse published in 2011.17 An organized search of Medline, PubMed, Embase, and the Cochrane Database of Collected Reviews was performed from October 2011 through December 2016. Retrieved publications were limited to the English language and human participants. The search strategies were based on the concepts of rectal prolapse and internal intussusception as primary search terms. Searches were also performed based on various treatments for rectal prolapse, including rectopexy, suture rectopexy, resection rectopexy, ventral rectopexy, D’Hoore rectopexy, Delorme procedure, and Altemeier procedure. An initial search identified 781 unique citations. These were ultimately categorized into subsets (see Table, Supplemental Digital Content 1, https://links.lww.com/DCR/A390). Directed searches of the embedded references from the primary articles were also performed in certain circumstances. Prospective, randomized controlled trials and meta-analyses were given preference in developing these guidelines. Ultimately, 172 articles were carefully reviewed, and articles with poor control subjects or unclear study end points were excluded. The final guideline was created using 110 unique citations listed in the references below. The final grade of recommendation was performed using the Grades of Recommendation, Assessment, Development, and Evaluation system (Table 1).18 A panel of members of the ASCRS Clinical Practice Guidelines Committee worked in production of these guidelines from inception to final publication. After initial completion of the article, the entire committee reviewed and edited it. Final recommendations were approved by the ASCRS Chairman and Vice Chairman of the Clinical Practice Guidelines Committee and then ultimately the Executive Council.
Evaluation of Rectal Prolapse
- 1. The initial evaluation of a patient with rectal prolapse should include a complete history and physical examination with focus on the prolapse, on anal sphincter structure and function, and on concomitant symptoms and underlying conditions. Recommendation: strong recommendation based on low-quality evidence, 1C.
A careful history and physical examination should be performed before considering any operative intervention. If a patient’s history suggests the diagnosis but no prolapse is detected on physical examination, the patient can be asked to reproduce the prolapse by straining while on a toilet with or without the use of an enema or a rectal balloon. The perineum can then be inspected with the patient in the sitting or squatting position. One should be careful, however, to avoid confusing rectal prolapse with prolapsing internal hemorrhoids or rectal mucosal prolapse. Full-thickness rectal prolapse will always have concentric folds of prolapsed tissue, whereas prolapsed hemorrhoids or rectal mucosa will have radial invaginations. If the prolapse is elusive, patients can be asked to photograph the prolapse at home or undergo an echography.
Full inspection of the perineum and complete anorectal examination are equally important. Usually, these will reveal a patulous anus with diminished sphincter tone. In 10% to 15% of cases, proctoscopy will show an anterior solitary rectal ulcer.
Initial evaluation should also include a careful assessment of the possible coexisting symptoms of constipation and fecal incontinence. Furthermore, a careful review of symptoms pertaining to anterior compartment prolapse, such as urinary incontinence and vaginal/uterine prolapse, needs to be evaluated, because 20% to 35% of patients with rectal prolapse report urinary incontinence, and ≈15% to 30% have significant vaginal vault prolapse.6,19 Patients with multivisceral prolapse require a multidisciplinary approach.20
- 2. Additional testing, such as a fluoroscopy or MRI defecography, colonoscopy, barium enema, and urodynamics, may be used selectively to refine the diagnosis and identify other important coexisting pathology. Recommendation: strong recommendation based on moderate-quality evidence, 1B.
If prolapse is suggested but cannot be seen during physical examination, fluoroscopic defecography, MRI defecography, or balloon expulsion testing may reveal the problem. Defecography may also reveal associated anterior pelvic floor support defects, such as cystocele, vaginal vault prolapse, and enterocele. These coexisting conditions, depending on symptoms, may require treatment as well.21,22 Patients with anterior compartment disorders and patients with urinary incontinence may benefit from urodynamics and urogynecologic examination to complete the evaluation and allow for concomitant surgical intervention to both the anterior and posterior pelvic compartments.23–25 Rarely, a neoplasm may form the lead point for a rectal prolapse.26 For this reason and because prolapse often occurs in the older population, colonoscopy should typically be performed before surgery, because this may change the operative plan.
- 3. Anal physiologic testing may be considered to assess and treat coexisting functional disorders associated with rectal prolapse, such as constipation or fecal incontinence. Recommendation: weak recommendation based on low-quality evidence, 2C.
Constipation is commonly encountered in patients with rectal prolapse. Patients with severe constipation require special consideration in accordance with the ASCRS constipation clinical practice guideline.27,28 Patients with constipation and/or evidence of pelvic dyssynergia on testing may not be ideal candidates for certain surgical maneuvers known to exacerbate constipation after surgery, such as posterior rectal mobilization, transection of the lateral ligaments during suture rectopexy, or levatorplasty during a perineal proctectomy, as discussed further in these guidelines.
Fecal incontinence, another commonly associated finding in patients with rectal prolapse, is thought to be caused by the chronic dilation of the anal sphincter preceded by years of diminished internal anal sphincter pressures. In general, because many patients with fecal incontinence secondary to rectal prolapse experience improvement in their symptoms once the prolapse is treated, rectal prolapse should be corrected as a first step in patients reporting of rectal prolapse and fecal incontinence. Patients with pre-existing fecal incontinence or incontinence thought to be attributed to a process other than prolapse should be evaluated in accordance with the ASCRS clinical practice guideline for fecal incontinence.29 If testing reveals decreased pudendal nerve terminal motor latencies, this may have postoperative prognostic significance: patients with evidence of nerve damage appear to have a higher rate of incontinence after surgical correction of the prolapse, although more studies are necessary to confirm the finding.30–32 Other maneuvers, such as additional bowel resection, may also diminish continence.
In general, many patients with fecal incontinence secondary to rectal prolapse experience some improvement in their symptoms once the prolapse is treated. Thus, in general, rectal prolapse should be corrected as a first step in patients reporting rectal prolapse and fecal incontinence. Conversely, constipation-inducing maneuvers, such as transection of the lateral ligaments during suture rectopexy, may be beneficial in these situations.
- 1. Rectal prolapse cannot be corrected nonoperatively, although some of the symptoms associated with this condition, such as fecal incontinence, pain, and constipation, can be palliated medically. Recommendation: weak recommendation based on low-quality evidence, 2C.
There are no reports of rectal prolapse being resolved through medical therapy alone. Although surgical treatment is under consideration, prolapse-associated symptoms of constipation and fecal incontinence can be treated nonsurgically to improve quality of life. Fiber and stool softeners may be used to treat constipation.33 Table sugar can be used topically to reduce edema and assist in reduction maneuvers with incarcerated rectal prolapse.34 Attention to skin care to avoid skin maceration may also be beneficial.
Although none of these palliative interventions addresses the prolapse itself, they may improve patient condition and ultimate quality of life. In addition, one recent retrospective study of 139 women showed that pretreatment of incontinence symptoms before surgery led to a better improvement in postoperative continence.35
Any surgical treatment must, of course, be tailored to the patent’s overall medical condition, history of previous procedures, and patient willingness to undergo an operation. However, all of the patients who are candidates for surgical treatment of rectal prolapse–including the elderly–should be advised to act quickly, where possible, and avoid unnecessary delays and occasional bowel incarceration. Although consideration of surgical treatment should be tailored to a patent’s overall medical condition and history of previous procedures, patients who are reasonable candidates for surgical treatment of rectal prolapse, including the elderly, should be advised to avoid unnecessary delays, because avoiding surgery can lead to significant deterioration in function. In the long term, patients with rectal prolapse who do not undergo surgery and are only managed medically will develop irreversible fecal incontinence.36 In addition, allowing prolapse to continue untreated beyond 4 years may lead to higher rates of subsequent rectal prolapse recurrence, presumably secondary to a secondarily weakened pelvic floor.37
Operations for Rectal Prolapse
Surgery is the main form of treatment for rectal prolapse, and many operative procedures have been described in the historical literature, including anal encirclement, mucosal resection, perineal proctosigmoidectomy, anterior resection with or without rectopexy, suture rectopexy alone, and a host of procedures involving the use of synthetic or biologic meshes affixed to the presacral fascia, including D’Hoore ventral rectopexy with mesh. Only a few procedures are actually routinely advocated. In general, these procedures adopt 1 of 2 predominant general approaches, abdominal versus perineal, which is usually dictated by the comorbidities of the patient, the surgeon’s preference and experience, and the patient’s age and bowel function.8,38–40 Another important decision involves the choice of pelvic dissection, either posterior or ventral. Here we discuss the procedures that are in common practice and are most commonly reported in the literature.
Abdominal Procedures for Rectal Prolapse
- 1. In patients with acceptable risk, the procedure of choice for the treatment of rectal prolapse should typically incorporate transabdominal rectal fixation. Recommendation: weak recommendation based on moderate-quality evidence, 2B.
According to numerous retrospective reports, recurrence rates after abdominal surgery for rectal prolapse are approximately one fourth those after perineal surgery, and the abdominal approach is associated with better functional outcomes.9,33,41 Because of these superior overall results, the abdominal approach is advocated by many, including our previous guideline,17 as the preferred treatment for younger and healthier patients.33,42 However, the data to support these lower recurrence rates have recently been called into question. A 2000 systematic Cochrane database review comparing 274 patients in 8 randomized or quazirandomized trials reported no significant differences in recurrent prolapse between abdominal and perineal approaches.43 A 2008 update of the Cochrane review including 12 randomized controlled trials involving 380 participants reached a similar conclusion,33,44 while lamenting the lack of large-scale, randomized controlled trials powered to measure these outcomes adequately. A third 2015 review of 15 randomized controlled trials involving 1007 patients was also unable to demonstrate a difference in recurrence rates between the 2 approaches.33,44
Some have raised concerns that patient selection bias (ie, the fact that perineal surgery is offered disproportionately to older, less healthy patients who may have higher rates of recurrence due to poor tissues and longer prolapse duration) may influence reported recurrence rates after perineal repairs. One study, in which all patients were treated with perineal proctectomy, showed that after 21 months of follow-up, rates of recurrent rectal prolapse in patients <50 years of age were comparable with those of patients generally offered abdominal repairs (<8%).45 A 2013 randomized controlled trial of 293 patients, the Prolapse Surgery Perineal or Rectopexy trial, devised by the Association of Coloproctology of Great Britain and Ireland to answer these questions, also reported no statistically significant difference in the rate of rectal prolapse recurrences based on the surgical approach.46 However, this study has been criticized for methodologic flaws and being underpowered.
Some surgeons who prefer a perineal approach have pointed to data suggesting that the morbidity and mortality rates of the abdominal approach are slightly higher. However, these studies have also been called into question recently by National Surgical Quality Improvement Program data, which suggest that the morbidity and mortality of the perineal approach have been underestimated. A recent comparison of 1469 patients reported a 4-fold increase in the risk of mortality in the high ASA patients treated by perineal approaches.47
Although many experts continue to advocate transabdominal repairs when feasible, the choice between perineal and abdominal approaches continues to be debated. We recommend careful consideration of patient comorbidities and associated bowel dysfunction with the goal of performing the operation with the highest chance of immediate success while also potentially alleviating coexisting bowel dysfunction.8,33,40,42,44,48
- 2. There is insufficient evidence to argue that posterior rectal prolapse repairs, such as suture rectopexy or resection with suture rectopexy, are better or worse than anterior rectal prolapse repairs, such as ventral mesh rectopexy. Recommendation: strong recommendation based on low-quality evidence, 1C.
Retrospective reviews suggest equivalent rates of recurrent rectal prolapse after posterior prolapse repair or anterior prolapse repair (both <10% at 10-year follow-up). However, these numbers may be viewed with some skepticism, because there is less long-term data available regarding ventral rectopexy patients and there have been few studies directly comparing the techniques. One article compared 28 patients treated with either standard resection rectopexy or ventral rectopexy and suggested similar improvement in functional symptoms, such as constipation, with a statistically significant increase in postoperative complications in the patients who underwent resection.49 However, the conclusion is marred by significant methodologic concerns, because the study amounts to a retrospective comparison of 2 groups of patients treated preferentially by one or the other approach in 2 different countries. Two additional single-center retrospective comparisons of 70 and 40 patients compared ventral rectopexy versus suture rectopexy without resection and demonstrated similar recurrence rates regardless of technique.50,51 Given the paucity of high-quality data, the choice of technique needs to be driven by surgical expertise and patient surgical history, comorbidities, and preference.52
Posterior Rectal Dissection Techniques to Repair Rectal Prolapse
- 1. Posterior rectal mobilization without a rectopexy (with or without a concomitant anterior resection) is associated with higher recurrence rates and complications and is typically not recommended. Recommendation: strong recommendation based on moderate-quality evidence, 1B.
Posterior dissection is a method of treatment in which the rectum is mobilized in the plane between the mesorectal fascia and the presacral fascia. This dissection usually starts at the sacral promontory and is carried down to the levators. It may be performed in isolation or in combination with an anterior resection.
Several studies show that posterior dissection alone (without rectopexy) does not provide lasting rectal prolapse repair.53 Even when the procedure is combined with a low anterior resection (not a sigmoid resection), several shortcomings are evident. In 1 review of 113 patients, the recurrence rate continued to climb after 2, 5, and 10 years to 3%, 6%, and 12%, with an operative morbidity of 29%, including 3 anastomotic leaks.54 Another review confirmed that, with an average follow-up of 6 years, recurrence occurred in 7% of cases.55 Moreover, low pelvic anastomoses in those with borderline continence may lead to additional loss of function. Given the lack of functional advantages for this procedure, the high recurrence and complication rates, and the availability of options that can achieve better outcomes with lower risk, low anterior resection or posterior rectal mobilization without additional added steps is not typically recommended.
Posterior Suture Rectopexy With and Without Sigmoid Resection
- 1. Rectopexy is a key component in the abdominal approach to rectal prolapse. Recommendation: strong recommendation based on high-quality evidence, 1A.
Rectopexy refers to the fixation of the rectum in the pelvis with suture and was first described by Cutait56 in 1959. Suturing the rectum to the sacral promontory aims to prevent the telescoping of the redundant bowel. Successful outcomes appear to be attributed, in part, to the fixation of the rectum with permanent suture and the scarring and fibrosis from the posterior dissection. Recurrence rates for suture rectopexy are generally reported to be from 3% to 9% at 2 years,57–62 although data from the Rectal Prolapse Recurrence Study Group suggests that the 10-year recurrence rate may rise to 29%.62
Placement of the pexy sutures is critical. A recent randomized controlled trial comparing 116 no-rectopexy patients (mobilization of rectum only) with 136 rectopexy patients demonstrated an 8-fold increase in recurrence rates in the patients treated with mobilization alone.53
Suture rectopexy with posterior rectal mobilization can produce or worsen constipation. At least 50% of patients with preoperative constipation report that their condition worsened after rectopexy, and ≈15% of patients with no preoperative constipation experienced constipation after the procedure.63 The precise etiology of constipation is unclear, but it is thought to be attributed to posterior mobilization of the rectum. Patients presenting with severe constipation and rectal prolapse should probably undergo more than a suture rectopexy; current options include resection suture rectopexy, ventral rectopexy, or perineal repairs (discussed below).
- 2. Sigmoid resection may be added to posterior suture rectopexy in patients with prolapse and preoperative constipation. Recommendation: strong recommendation based on moderate-quality evidence, 1B.
Resection rectopexy refers to the addition of a sigmoid resection to the standard suture rectopexy discussed above. The technique was first described by Frykman in 195564 and was popularized in articles in 196965 and 1989,66 which showed low prolapse recurrence rates (<2%) with an acceptable 4% complication rate and low rates of anastomotic leak. Subsequent retrospective reports have confirmed low recurrence rates, ranging from 2% to 5%, and reasonable major complication rates, ranging from 0% to 20%. The addition of sigmoidectomy to the rectopexy lowers the recurrence rate and improves functional outcome with a minimal increase in morbidity.67,68 In general, resection should be avoided in patients with recurrent rectal prolapse after a failed previous perineal rectosigmoidectomy, because transabdominal resection in this situation can lead to ischemic bowel. In addition to its favorable outcomes, the appeal of the resection rectopexy procedure includes the lack of artificial mesh, ease of operation, and the resection of a redundant sigmoid colon. In addition, 2 randomized controlled trials of patients who reported preoperative constipation found lower rates of postoperative constipation after resection rectopexy compared with rectopexy alone.33,44,67,69 However, the operation may present concerns for rectal prolapse patients with fecal incontinence; the resolution of fecal incontinence appears to be lower when sigmoid resection is performed.33,44 Some experts argue that sigmoid resection should not be offered to patients with markedly reduced anal pressures on manometry or patients with severe baseline incontinence.8,70 Sigmoid resection is not usually advocated in combination with repairs involving mesh.
- 3. Division of the lateral stalks during posterior rectal dissection may worsen postoperative constipation but is associated with decreased recurrence rates. Recommendation: weak recommendation based on moderate-quality evidence, 2B.
The division of lateral stalks during rectal dissection leads to lower recurrence rates for rectal prolapse33,44,71,72 but is generally associated with worsening constipation.33,44,55,61,68,71–74 A recent Cochrane review of 15 randomized controlled trials involving 1007 patients with and without lateral stalk division found that the division of the lateral stalks was associated with less recurrent rectal prolapse but more postoperative constipation, making this maneuver especially attractive in the patients presenting with fecal incontinence without constipation.8,44
Posterior Mesh Rectopexy
- 1. Posterior mobilization of rectum with mesh fixation of the anterior rectal wall to the sacral promontory may be used for treatment of rectal prolapse but is associated with higher morbidity. Recommendation: strong recommendation based on low-quality evidence, 1C.
The Ripstein repair75 (and its many iterations) involves placement of a prosthetic mesh around (“around” or “to”?) the mobilized rectum and attaching the mesh to the presacral fascia below the sacral promontory.11 In the original procedure, after mobilization of the rectum, Ripstein and Lanter75 placed a band of rectangular mesh around the anterior aspect of the rectum at the level of the peritoneal reflection, and sutures were used to secure the mesh to the rectum anteriorly, pulling the rectum upward and posterior. Then, both sides of the mesh were sutured to the presacral fascia. Recurrence rates ranged from 4% to 10%, but complication rates were excessive, <50%, primarily because of the placement of a foreign material on the anterior rectal wall.75–77 Complications included large-bowel obstruction, erosion of the mesh through the bowel, ureteral injury or fibrosis, small-bowel obstruction, rectovaginal fistula, and fecal impaction. As a result, McMahan and Ripstein78 modified the technique to include posterior fixation of the mesh to the sacrum with attachment of the ends of the mesh to the rectum laterally. This modified procedure produced similar recurrence rates (2%–5%) with a 20% postoperative morbidity rate (most of these complications were minor). Mesh rectopexy results in significant improvement in fecal incontinence in 20% to 60% of patients.6
- 2. A modified Wells procedure using a variety of foreign materials for posterior fixation of the rectum may be used for treatment of rectal prolapse. Recommendation: weak recommendation based on moderate-quality evidence, 2B.
The Wells procedure, as originally described, involved fixation of the rectum using an Ivalon (polyvinyl alcohol) sponge and transection of the lateral ligaments. Wells reported excellent results with minimal complications.79 However, a randomized trial of Ivalon sponge versus suture rectopexy found increased complication rates and postoperative constipation in the Ivalon group, with no improvement in recurrence rates. As a result, the study recommended that this technique be abandoned.61
Although the Ivalon sponge is no longer commercially available, the modified Wells technique using other materials, such as polyester, polypropylene, and biological mesh,80,81 continues to be popular, especially for laparoscopic approaches. There are no data, however, to suggest the superiority of these materials over sutures alone.
Anterior Rectal Dissection Techniques to Repair Rectal Prolapse
- 1. Ventral mesh rectopexy offers an alternative approach to the repair of rectal prolapse with acceptable short- and long-term complication rates. Recommendation: strong recommendation based on low-quality evidence, 1C.
Ventral mesh rectopexy, developed by D’Hoore and Penninckx,82 is the only technique for rectal prolapse repair that uses only a limited anterior rectal mobilization. The technique involves careful separation of the rectum from the vagina (or prostate) down to the perineal body anteriorly with no posterior dissection of the rectum from the sacrum (other than to clear a small spot of sacrum for the rectopexy). After this limited rectal mobilization, a ventral rectopexy is performed using synthetic or biologic mesh. The mesh buttresses the anterior wall of the rectum at the point of its intussusception and resuspends the rectum to the sacral promontory. This is in contrast to the Orr-Loygue procedure,83 where the rectum is mobilized both anteriorly and posteriorly before fixation to the sacrum.
In addition to being reported as being effective in repairing the prolapse, D’Hoore et al84 reported an 84% improvement in postoperative constipation and no incidence of new de novo constipation. They postulated that avoiding posterior rectal dissection decreases injury to the parasympathetic and sympathetic innervation of the rectum. Others followed with similarly promising retrospective results showing recurrence rates comparable to traditional suture rectopexy with less postoperative constipation.85 A subsequent systematic review comparing 728 nonrandomized patients treated with either posterior rectal dissection/rectopexy or ventral mesh rectopexy suggested that patients undergoing ventral rectopexy reported a recurrence rate of 3.4% and a weighted decrease in the postoperative constipation rate estimated to be 23.0%.86 These observations, combined with reports purporting reassuring rates of postoperative complications, have led many in Europe to believe that this new approach is the preferred method of treatment for rectal prolapse. A recent international consensus panel pertaining to this procedure suggested using this technique in patients with pre-existing constipation and abnormalities in the anterior compartment, such as enterocele.85 However, this technique has yet to gain full acceptance in the United States given the limited data on long-term efficacy when compared with more traditional approaches and the possibility of mesh-related complications. These concerns appear to be ameliorated, to some degree, by a recent retrospective report of 919 consecutive ventral rectopexy patients showing a 10-year recurrence rate of 8.2% and a 4.6% rate of mesh-related complications,86 but additional data are needed.
Additional Abdominal Surgery Considerations
- 1. A minimally invasive approach to rectal prolapse by experienced surgeons is associated with improved morbidity and comparable recurrences compared with open surgery and should be considered when technically feasible. Recommendation: strong recommendation based on moderate-quality evidence, 1B.
Minimally invasive treatment of rectal prolapse, first described in 1992, with a laparoscopic rectopexy, has the same goals as open surgery, which are eradicating full-thickness rectal prolapse, improving bowel function and continence, and minimizing recurrence rates,13 and the results do not appear to differ materially.33,50,51,87,88 Numerous studies comparing laparoscopic with open repair have shown equivalent recurrence rates (4%–8%) and morbidity (10%–33%) but clear benefits to the laparoscopic approach in terms of pain control, length of stay, and return of bowel function.50
Robotic rectal prolapse surgery seems to produce outcomes comparable with laparoscopic approaches, although there are no well-powered randomized controlled trials clearly describing long-term recurrence rates.62,89,90 Advocates of robotic approaches emphasize the ease of suturing and tying and superior visualization of the deep pouch of Douglas.91,92 Perceived disadvantages of robotic surgery, as compared with laparoscopy, are longer operating times and increased costs, although longer operating times may be a result of learning curves. One recent randomized controlled trial comparing the 2 minimally invasive approaches for ventral rectopexy performed by expert surgeons failed to show differences in the length of procedure or in outcomes.93 A meta-analysis of ventral rectopexy comparing robotics and laparoscopy showed no strong benefit of one approach over the other.94
Perineal Operations for Rectal Prolapse
- 1. Patients with a short segment of full-thickness rectal prolapse can be treated with mucosal sleeve resection. Recommendation: strong recommendation based on low-quality evidence, 1C.
The Delorme procedure, appropriate for patients with a short (<5 cm) full-thickness rectal prolapse, involves a circumferential mucosal sleeve resection and imbrication of the muscularis layer. Retrospective studies suggest that recurrence rates after Delorme in the range of 10% to 15% may be higher than recurrence rates after abdominal approaches,95–98 but a recent randomized controlled trial showed that recurrence rates and functional outcomes after Delorme procedures were comparable to perineal rectosigmoidectomy or abdominal procedures.46 The Delorme procedure, historically used more in elderly patients, is generally considered very safe. Approximately 4% to 12% of patients experience early complications mostly involving infection, urinary retention, bleeding, and fecal impaction.95,98 The procedure can improve constipation and fecal incontinence, but urgency and tenesmus do occur. One study of postoperative manometric findings found that mean resting and squeeze pressures were significantly increased from baseline, with an associated increase in continence.97
- 2. Rectal prolapse may be treated with a perineal rectosigmoidectomy. Recommendation: strong recommendation based on low-quality evidence, 1C.
Perineal rectosigmoidectomy, the Altemeier procedure, involves a transanal full-thickness resection of the prolapsed rectum and a coloanal anastomosis.99 The operation can be performed without general anesthesia and involves a shorter hospital stay and lower complication rates compared with transabdominal surgery. However, recurrence rates of 16% to 30% at 2 years are high9,48,100–102 and may be affected by the length of resected intestine.9 Recurrence rates after perineal rectosigmoidectomy might be decreased using a levatorplasty, which was shown in 1 study to reduce recurrence rates from 21% to 7%,103,104 presumably by treating the concomitant levator diastasis.
Generally speaking, patients undergoing perineal rectosigmoidectomy are older, with significantly more comorbidities than those who are considered for transabdominal repair.9,48,100 There are relatively little data comparing perineal rectosigmoidectomy with an abdominal approach. Neither of the 2 randomized controlled trials comparing the approaches showed a statistically significant difference in recurrence rates, but both studies were underpowered.46
The ASCRS is dedicated to ensuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing clinical practice guidelines based on the best available evidence. These guidelines are inclusive and not prescriptive. Their purpose is to provide information on which decisions can be made rather than to dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.
1. Brodén B, Snellman B. Procidentia of the rectum studied with cineradiography: a contribution to the discussion of causative mechanism. Dis Colon Rectum. 1968;11:330347.
2. Collinson R, Cunningham C, D’Costa H, Lindsey I. Rectal intussusception and unexplained faecal incontinence: findings of a proctographic study. Colorectal Dis. 2009;11:7783.
3. Sun WM, Read NW, Donnelly TC, Bannister JJ, Shorthouse AJ. A common pathophysiology for full thickness rectal prolapse, anterior mucosal prolapse and solitary rectal ulcer. Br J Surg. 1989;76:290295.
4. Gourgiotis S, Baratsis S. Rectal prolapse. Int J Colorectal Dis. 2007;22:231243.
5. Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg. 2005;94:207210.
6. Madiba TE, Baig MK, Wexner SD. Surgical management of rectal prolapse. Arch Surg. 2005;140:6373.
7. Marceau C, Parc Y, Debroux E, Tiret E, Parc R. Complete rectal prolapse in young patients: psychiatric disease a risk factor of poor outcome. Colorectal Dis. 2005;7:360365.
8. Bordeianou L, Hicks CW, Kaiser AM, Alavi K, Sudan R, Wise PE. Rectal prolapse: an overview of clinical features, diagnosis, and patient-specific management strategies. J Gastrointest Surg. 2014;18:10591069.
9. Kim DS, Tsang CB, Wong WD, Lowry AC, Goldberg SM, Madoff RD. Complete rectal prolapse: evolution of management and results. Dis Colon Rectum. 1999;42:460466.
10. Madoff RD, Mellgren A. One hundred years of rectal prolapse surgery. Dis Colon Rectum. 1999;42:441450.
11. Schultz I, Mellgren A, Dolk A, Johansson C, Holmström B. Long-term results and functional outcome after Ripstein rectopexy. Dis Colon Rectum. 2000;43:3543.
12. Schultz I, Mellgren A, Oberg M, Dolk A, Holmström B. Whole gut transit is prolonged after Ripstein rectopexy. Eur J Surg. 1999;165:242247.
13. Senagore AJ. Management of rectal prolapse: the role of laparoscopic approaches. Semin Laparosc Surg. 2003;10:197202.
14. Hawkins AT, Olariu AG, Savitt LR, et al. Impact of rising grades of internal rectal intussusception on fecal continence and symptoms of constipation. Dis Colon Rectum. 2016;59:5461.
15. Glasgow SC, Birnbaum EH, Kodner IJ, Fleshman JW, Dietz DW. Preoperative anal manometry predicts continence after perineal proctectomy for rectal prolapse. Dis Colon Rectum. 2006;49:10521058.
16. Snooks SJ, Henry MM, Swash M. Anorectal incontinence and rectal prolapse: differential assessment of the innervation to puborectalis and external anal sphincter muscles. Gut. 1985;26:470476.
17. Varma M, Rafferty J, Buie WD; Standards Practice Task Force of American Society of Colon and Rectal Surgeons. Practice parameters for the management of rectal prolapse. Dis Colon Rectum. 2011;54:13391346.
18. Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an american college of chest physicians task force. Chest. 2006;129:174181.
19. González-Argenté FX, Jain A, Nogueras JJ, Davila GW, Weiss EG, Wexner SD. Prevalence and severity of urinary incontinence and pelvic genital prolapse in females with anal incontinence or rectal prolapse. Dis Colon Rectum. 2001;44:920926.
20. Bordeianou L, Hicks CW, Olariu A, et al. Effect of Coexisting pelvic floor disorders on fecal incontinence quality of life scores: a prospective, survey-based study. Dis Colon Rectum. 2015;58:10911097.
21. Pescatori M, Spyrou M, Pulvirenti d’Urso A. A prospective evaluation of occult disorders in obstructed defecation using the ‘iceberg diagram.’ Colorectal Dis. 2006;8:785789.
22. Renzi A, Izzo D, Di Sarno G, et al. Cinedefecographic findings in patients with obstructed defecation sindrome: a study in 420 cases. Minerva Chir. 2006;61:493499.
23. Lim M, Sagar PM, Gonsalves S, Thekkinkattil D, Landon C. Surgical management of pelvic organ prolapse in females: functional outcome of mesh sacrocolpopexy and rectopexy as a combined procedure. Dis Colon Rectum. 2007;50:14121421.
24. Mellgren A, Johansson C, Dolk A, et al. Enterocele demonstrated by defaecography is associated with other pelvic floor disorders. Int J Colorectal Dis. 1994;9:121124.
25. Sagar PM, Thekkinkattil DK, Heath RM, Woodfield J, Gonsalves S, Landon CR. Feasibility and functional outcome of laparoscopic sacrocolporectopexy for combined vaginal and rectal prolapse. Dis Colon Rectum. 2008;51:14141420.
26. Bounovas A, Polychronidis A, Laftsidis P, Simopoulos C. Sigmoid colon cancer presenting as complete rectal prolapse. Colorectal Dis. 2007;9:665666.
27. Paquette IM, Varma M, Ternent C, et al. The American Society of Colon and Rectal Surgeons’ Clinical Practice Guideline for the Evaluation and Management of Constipation. Dis Colon Rectum. 2016;59:479492.
28. Watts JD, Rothenberger DA, Buls JG, Goldberg SM, Nivatvongs S. The management of procidentia: 30 years’ experience. Dis Colon Rectum. 1985;28:96102.
29. Paquette IM, Varma MG, Kaiser AM, Steele SR, Rafferty JF. The American Society of Colon and Rectal Surgeons’ Clinical Practice Guideline for the Treatment of Fecal Incontinence. Dis Colon Rectum. 2015;58:623636.
30. Birnbaum EH, Stamm L, Rafferty JF, Fry RD, Kodner IJ, Fleshman JW. Pudendal nerve terminal motor latency influences surgical outcome in treatment of rectal prolapse. Dis Colon Rectum. 1996;39:12151221.
31. Johansen OB, Wexner SD, Daniel N, Nogueras JJ, Jagelman DG. Perineal rectosigmoidectomy in the elderly. Dis Colon Rectum. 1993;36:767772.
32. Schultz I MA, Nilsson BY, Dolk A, Holmstrom B. Preoperative electrophysiologic assessment cannot predict continence after rectopexy. Dis Colon Rectum. 1998:13921398
33. Tou S, Brown SR, Malik AI, Nelson RL. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev. 2008;(4):CD001758.
34. Myers JO, Rothenberger DA. Sugar in the reduction of incarcerated prolapsed bowel: report of two cases. Dis Colon Rectum. 1991;34:416418.
35. Wallenhorst T, Bouguen G, Brochard C, et al. Long-term impact of full-thickness rectal prolapse treatment on fecal incontinence. Surgery. 2015;158:104111.
36. Cunin D, Siproudhis L, Desfourneaux V, et al. No surgery for full-thickness rectal prolapse: what happens with continence? World J Surg. 2013;37:12971302.
37. Fu CW, Stevenson AR. Risk factors for recurrence after laparoscopic ventral rectopexy. Dis Colon Rectum. 2017;60:178186.
38. Brown AJ, Anderson JH, McKee RF, Finlay IG. Strategy for selection of type of operation for rectal prolapse based on clinical criteria. Dis Colon Rectum. 2004;47:103107.
39. Gunner CK, Senapati A, Northover JM, Brown SR. Life after PROSPER: what do people do for external rectal prolapse? Colorectal Dis. 2016;18:811814.
40. Hrabe J, Gurland B. Optimizing treatment for rectal prolapse. Clin Colon Rectal Surg. 2016;29:271276.
41. Deen KI, Grant E, Billingham C, Keighley MR. Abdominal resection rectopexy with pelvic floor repair versus perineal rectosigmoidectomy and pelvic floor repair for full-thickness rectal prolapse. Br J Surg. 1994;81:302304.
42. Felt-Bersma RJ, Tiersma ES, Stella MT, Cuesta MA. Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele. Gastroenterol Clin North Am. 2008;37:64568, ix.
43. Bachoo P, Brazzelli M, Grant A. Surgery for complete rectal prolapse in adults. Cochrane Database Syst Rev. 2000;(2):CD001758.
44. Tou S, Brown SR, Nelson RL. Surgery for complete (full-thickness) rectal prolapse in adults. Cochrane Database Syst Rev. 2015;(11):CD001758.
45. Glasgow SC, Birnbaum EH, Kodner IJ, Fleshman JW Jr, Dietz DW. Recurrence and quality of life following perineal proctectomy for rectal prolapse. J Gastrointest Surg. 2008;12:14461451.
46. Senapati A, Gray RG, Middleton LJ, et al.; PROSPER Collaborative Group. PROSPER: a randomised comparison of surgical treatments for rectal prolapse. Colorectal Dis. 2013;15:858868.
47. Fang SH, Cromwell JW, Wilkins KB, et al. Is the abdominal repair of rectal prolapse safer than perineal repair in the highest risk patients? An NSQIP analysis. Dis Colon Rectum. 2012;55:11671172.
48. Riansuwan W, Hull TL, Bast J, Hammel JP, Church JM. Comparison of perineal operations with abdominal operations for full-thickness rectal prolapse. World J Surg. 2010;34:11161122.
49. Formijne Jonkers HA, Maya A, Draaisma WA, et al. Laparoscopic resection rectopexy versus laparoscopic ventral rectopexy for complete rectal prolapse. Tech Coloproctol. 2014;18:641646.
50. Kariv Y, Delaney CP, Casillas S, et al. Long-term outcome after laparoscopic and open surgery for rectal prolapse: a case-control study. Surg Endosc. 2006;20:3542.
51. Purkayastha S, Tekkis P, Athanasiou T, et al. A comparison of open vs. laparoscopic abdominal rectopexy for full-thickness rectal prolapse: a meta-analysis. Dis Colon Rectum. 2005;48:19301940.
52. Riansuwan W, Hull TL, Bast J, Hammel JP. Combined surgery in pelvic organ prolapse is safe and effective. Colorectal Dis. 2010;12:188192.
53. Karas JR, Uranues S, Altomare DF, et al.; Rectal Prolapse Recurrence Study Group. No rectopexy versus rectopexy following rectal mobilization for full-thickness rectal prolapse: a randomized controlled trial. Dis Colon Rectum. 2011;54:2934.
54. Schlinkert RT, Beart RW Jr, Wolff BG, Pemberton JH. Anterior resection for complete rectal prolapse. Dis Colon Rectum. 1985;28:409412.
55. Cirocco WC, Brown AC. Anterior resection for the treatment of rectal prolapse: a 20-year experience. Am Surg. 1993;59:265269.
56. Cutait D. Sacro-promontory fixation of the rectum for complete rectal prolapse. Proc R Soc Med. 1959;52:105.
57. Briel JW, Schouten WR, Boerma MO. Long-term results of suture rectopexy in patients with fecal incontinence associated with incomplete rectal prolapse. Dis Colon Rectum. 1997;40:12281232.
58. Carter AE. Rectosacral suture fixation for complete rectal prolapse in the elderly, the frail and the demented. Br J Surg. 1983;70:522523.
59. Graf W, Karlbom U, Påhlman L, Nilsson S, Ejerblad S. Functional results after abdominal suture rectopexy for rectal prolapse or intussusception. Eur J Surg. 1996;162:905911.
60. Khanna AK, Misra MK, Kumar K. Simplified sutured sacral rectopexy for complete rectal prolapse in adults. Eur J Surg. 1996;162:143146.
61. Novell JR, Osborne MJ, Winslet MC, Lewis AA. Prospective randomized trial of Ivalon sponge versus sutured rectopexy for full-thickness rectal prolapse. Br J Surg. 1994;81:904906.
62. Raftopoulos Y, Senagore AJ, Di Giuro G, Bergamaschi R; Rectal Prolapse Recurrence Study Group. Recurrence rates after abdominal surgery for complete rectal prolapse: a multicenter pooled analysis of 643 individual patient data. Dis Colon Rectum. 2005;48:12001206.
63. Aitola PT, Hiltunen KM, Matikainen MJ. Functional results of operative treatment of rectal prolapse over an 11-year period: emphasis on transabdominal approach. Dis Colon Rectum. 1999;42:655660.
64. Frykman HM. Abdominal proctopexy and primary sigmoid resection for rectal procidentia. Am J Surg. 1955;90:780789.
65. Frykman HM, Goldberg SM. The surgical treatment of rectal procidentia. Surg Gynecol Obstet. 1969;129:12251230.
66. Solla JA, Rothenberger DA, Goldberg SM. Colonic resection in the treatment of complete rectal prolapse. Neth J Surg. 1989;41:132135.
67. Luukkonen P, Mikkonen U, Järvinen H. Abdominal rectopexy with sigmoidectomy vs. rectopexy alone for rectal prolapse: a prospective, randomized study. Int J Colorectal Dis. 1992;7:219222.
68. Sayfan J, Pinho M, Alexander-Williams J, Keighley MR. Sutured posterior abdominal rectopexy with sigmoidectomy compared with Marlex rectopexy for rectal prolapse. Br J Surg. 1990;77:143145.
69. McKee RF, Lauder JC, Poon FW, Aitchison MA, Finlay IG. A prospective randomized study of abdominal rectopexy with and without sigmoidectomy in rectal prolapse. Surg Gynecol Obstet. 1992;174:145148.
70. Hsu A, Brand MI, Saclarides TJ. Laparoscopic rectopexy without resection: a worthwhile treatment for rectal prolapse in patients without prior constipation. Am Surg. 2007;73:858861.
71. Mollen RM, Kuijpers JH, van Hoek F. Effects of rectal mobilization and lateral ligaments division on colonic and anorectal function. Dis Colon Rectum. 2000;43:12831287.
72. Speakman CT, Madden MV, Nicholls RJ, Kamm MA. Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study. Br J Surg. 1991;78:14311433.
73. Scaglia M, Fasth S, Hallgren T, Nordgren S, Oresland T, Hultén L. Abdominal rectopexy for rectal prolapse: influence of surgical technique on functional outcome. Dis Colon Rectum. 1994;37:805813.
74. Yakut M, Kaymakçioğlu N, Simşek A, Tan A, Sen D. Surgical treatment of rectal prolapse: a retrospective analysis of 94 cases. Int Surg. 1998;83:5355.
75. Ripstein CB, Lanter B. Etiology and surgical therapy of massive prolapse of the rectum. Ann Surg. 1963;157:259264.
76. Gordon PH, Hoexter B. Complications of the Ripstein procedure. Dis Colon Rectum. 1978;21:277280.
77. Küpfer CA, Goligher JC. One hundred consecutive cases of complete prolapse of the rectum treated by operation. Br J Surg. 1970;57:482487.
78. McMahan JD, Ripstein CB. Rectal prolapse: an update on the rectal sling procedure. Am Surg. 1987;53:3740.
79. Wells C. New operation for rectal prolapse. Proc R Soc Med. 1959;52:602603.
80. Dulucq JL, Wintringer P, Mahajna A. Clinical and functional outcome of laparoscopic posterior rectopexy (Wells) for full-thickness rectal prolapse: a prospective study. Surg Endosc. 2007;21:22262230.
81. Madbouly KM, Senagore AJ, Delaney CP, Duepree HJ, Brady KM, Fazio VW. Clinically based management of rectal prolapse. Surg Endosc. 2003;17:99103.
82. D’Hoore A, Penninckx F. Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc. 2006;20:19191923.
83. Loygue J, Nordlinger B, Cunci O, Malafosse M, Huguet C, Parc R. Rectopexy to the promontory for the treatment of rectal prolapse: report of 257 cases. Dis Colon Rectum. 1984;27:356359.
84. D’Hoore A, Cadoni R, Penninckx F. Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Br J Surg. 2004;91:15001505.
85. Boons P, Collinson R, Cunningham C, Lindsey I. Laparoscopic ventral rectopexy for external rectal prolapse improves constipation and avoids de novo constipation. Colorectal Dis. 2010;12:526532.
86. Samaranayake CB, Luo C, Plank AW, Merrie AE, Plank LD, Bissett IP. Systematic review on ventral rectopexy for rectal prolapse and intussusception. Colorectal Dis. 2010;12:504512.
87. Boccasanta P, Venturi M, Reitano MC, et al. Laparotomic vs. laparoscopic rectopexy in complete rectal prolapse. Dig Surg. 1999;16:415419.
88. Solomon MJ, Young CJ, Eyers AA, Roberts RA. Randomized clinical trial of laparoscopic versus open abdominal rectopexy for rectal prolapse. Br J Surg. 2002;89:3539.
89. Byrne CM, Smith SR, Solomon MJ, Young JM, Eyers AA, Young CJ. Long-term functional outcomes after laparoscopic and open rectopexy for the treatment of rectal prolapse. Dis Colon Rectum. 2008;51:15971604.
90. DiGiuro G, Ignjatovic D, Brogger J, Bergamaschi R; Rectal Prolapse Recurrence Study Group. How accurate are published recurrence rates after rectal prolapse surgery? A meta-analysis of individual patient data. Am J Surg. 2006;191:773778.
91. Mehmood RK, Parker J, Bhuvimanian L, et al. Short-term outcome of laparoscopic versus robotic ventral mesh rectopexy for full-thickness rectal prolapse: is robotic superior? Int J Colorectal Dis. 2014;29:11131118.
92. van Iersel JJ, Paulides TJ, Verheijen PM, Lumley JW, Broeders IA, Consten EC. Current status of laparoscopic and robotic ventral mesh rectopexy for external and internal rectal prolapse. World J Gastroenterol. 2016;22:49774987.
93. Mäkelä-Kaikkonen J, Rautio T, Pääkkö E, Biancari F, Ohtonen P, Mäkelä J. Robot-assisted vs laparoscopic ventral rectopexy for external or internal rectal prolapse and enterocele: a randomized controlled trial. Colorectal Dis. 2016;18:10101015.
94. Ramage L, Georgiou P, Tekkis P, Tan E. Is robotic ventral mesh rectopexy better than laparoscopy in the treatment of rectal prolapse and obstructed defecation? A meta-analysis. Tech Coloproctol. 2015;19:381389.
95. Lieberth M, Kondylis LA, Reilly JC, Kondylis PD. The Delorme repair for full-thickness rectal prolapse: a retrospective review. Am J Surg. 2009;197:418423.
96. Senapati A, Nicholls RJ, Thomson JP, Phillips RK. Results of Delorme’s procedure for rectal prolapse. Dis Colon Rectum. 1994;37:456460.
97. Tsunoda A, Yasuda N, Yokoyama N, Kamiyama G, Kusano M. Delorme’s procedure for rectal prolapse: clinical and physiological analysis. Dis Colon Rectum. 2003;46:12601265.
98. Watkins BP, Landercasper J, Belzer GE, et al. Long-term follow-up of the modified Delorme procedure for rectal prolapse. Arch Surg. 2003;138:498502.
99. Altemeier WA, Culbertson WR, Schowengerdt C, Hunt J. Nineteen years’ experience with the one-stage perineal repair of rectal prolapse. Ann Surg. 1971;173:9931006.
100. Altomare DF, Binda G, Ganio E, De Nardi P, Giamundo P, Pescatori M; Rectal Prolapse Study Group. Long-term outcome of Altemeier’s procedure for rectal prolapse. Dis Colon Rectum. 2009;52:698703.
101. Azimuddin K, Khubchandani IT, Rosen L, Stasik JJ, Riether RD, Reed JF 3rd. Rectal prolapse: a search for the “best” operation. Am Surg. 2001;67:622627.
102. Pescatori M, Zbar AP. Tailored surgery for internal and external rectal prolapse: functional results of 268 patients operated upon by a single surgeon over a 21-year period*. Colorectal Dis. 2009;11:410419.
103. Chun SW, Pikarsky AJ, You SY, et al. Perineal rectosigmoidectomy for rectal prolapse: role of levatorplasty. Tech Coloproctol. 2004;8:38.
104. Habr-Gama A, Jacob CE, Jorge JM, et al. Rectal procidentia treatment by perineal rectosigmoidectomy combined with levator ani repair. Hepatogastroenterology. 2006;53:213217.