Evaluation and Management of Rectal Prolapse

Evaluation and Management of Rectal Prolapse

Meghan L. Good

Nitin Mishra


Rectal prolapse (rectal procidentia) has been described for centuries and is defined by the circumferential full-thickness protrusion of all layers of the rectum through the anal sphincter complex beyond the anal verge. Diagnosis can be made by physical exam and must be differentiated from prolapsing hemorrhoidal tissue. Rectal intussusception, also known as occult or internal prolapse, likewise involves all layers of the rectum infolding down into the anal canal but not beyond. Therefore, rectal intussusception is not visible on inspection. Partialthickness prolapse, or mucosal prolapse, involves protrusion of a redundant layer of rectal or anal mucosa.

The reported incidence of rectal prolapse is low at 0.25%, with a clear predominance in elderly multiparous women suffering from long-standing constipation.1 Although its pathophysiology is not well defined, rectal prolapse is associated with attenuation of the supportive tissues surrounding the rectum. Commonly, patients are noted to have a deep peritoneal cul-de-sac, weak pelvic floor and/or sphincter musculature, and rectal redundancy. Chronic straining during defecation as a result of anatomic or functional disorders of elimination has been implicated in the etiology. A higher incidence of psychiatric disorders has been noted in patients with rectal prolapse compared to the general population.2 Additionally, although rare, neurologic disease, connective tissue disorders, and schistosomiasis may contribute.1

A number of operations, from both perineal and transabdominal approaches, have been described for the treatment of rectal prolapse, alluding to the lack of an ideal procedure. A history of prior pelvic or perineal surgery increases operative risk and should be considered when determining surgical approach. Age, comorbid conditions, functional activity level, and fecal continence are also important components of decision-making for individualized treatment.

This chapter describes the clinical features, evaluation, common surgical repairs, recurrence, and outcomes of patients with rectal prolapse.


The majority of patients with rectal prolapse will present with a history of a mass protruding from the anus, or the feeling of “sitting on a ball.” The prolapse is often triggered by an episode of straining during defecation, but in more severe cases can occur with prolonged standing or ambulation. The prolapsed tissue usually retracts on its own, but may require manual pressure to reduce and in more severe cases can become incarcerated. An acute rectal prolapse may present with ulceration, bleeding, incarceration, strangulation, or gangrene. Symptoms of chronic rectal prolapse include constipation, tenesmus, mucus discharge, bleeding, fecal incontinence, fecal staining, pruritus, and perianal skin excoriation due to chronic moisture. Intermittent severe pain may be present secondary to spasm of the levator ani muscles. A feeling of fullness in the pelvis or incomplete evacuation requiring splinting and positioning maneuvers to eliminate may indicate internal prolapse or other sequelae of pelvic floor dysfunction such as enterocele, cystocele, or rectocele.

Treatment should be tailored based on the physical severity as well as the psychological impact of rectal prolapse. A detailed history of bowel function is essential. Constipation, which is present in up to 70% of patients, increases the risk of recurrence.1 It often precedes the onset of rectal prolapse by many years and may result from internal rectal intussusception leading to obstruction, pelvic floor dyssynergia, and colonic dysmotility. A thorough history may identify other causes of constipation and excessive straining, such as inadequate dietary fiber intake, sedentary lifestyle, medications, and medical conditions. Fecal incontinence can be found in the majority of patients and usually appears late in the course of rectal prolapse as a result of weakening of the anal sphincter muscles. If fecal incontinence is severe and associated with lack of anal squeeze on exam, the patient should be counselled regarding the risk of complete fecal incontinence following surgical correction of the prolapse. In such cases, creation of an ostomy should be discussed as an option.


Physical Exam Findings

Patients often will present with digital photographs that allow for confirmation of the diagnosis. Otherwise, if not apparent during external exam, the prolapse can often be elicited in the office by having the patient bear down in a squatting position on the commode. Administration of a fleet enema can help protrude the prolapsed rectum. It is important to make the distinction between rectal prolapse and prolapsing internal hemorrhoids, which may mimic the appearance of rectal prolapse on physical exam. The telescopic protrusion of a single long tube with concentric mucosal folds is diagnostic of rectal prolapse, whereas prolapsing hemorrhoids will appear as separate bundles of tissue with radial invaginations (Fig. 59.1).

An anorectal exam should be performed in the prone jackknife position or lateral Sims position if the patient is unable to kneel. In the absence of grossly visible prolapse, a patulous anus, fecal smearing, and lichenification of the anoderm due to chronic perineal moisture are suggestive of rectal or mucosal prolapse. Scars due to previous perineal surgery should be noted. A digital rectal exam is crucial to assess for masses, evaluate for enterocele, cystocele, and rectocele and to determine the adequacy of anal sphincter tone.

Diagnostic Studies

Visualization of full-thickness prolapse with the presence of circumferential mucosal folds via patient photographs, or physical exam, is diagnostic of rectal prolapse. If protrusion of the rectum is not clinically evident, defecography can be useful in making the diagnosis. Defecography, using either traditional fluoroscopy or dynamic magnetic resonance imaging, can demonstrate rectal prolapse as well as outlet obstruction and is useful to assess pelvic floor function.

It is important to exclude mucosal pathologies such as rectal cancer, polyps, or a solitary rectal ulcer, which may act as lead points for rectal prolapse. Therefore, a full colonoscopy should be performed for all patients to rule out mucosal abnormalities as well as to evaluate for synchronous tumors. If a history of severe constipation is elicited, a nuclear gastrointestinal (GI) transit study should be obtained to rule out GI motility disorders. Patients with slow colonic transit may benefit from colonic resection in conjunction with rectopexy.

We do not routinely perform anorectal manometry for patients with rectal prolapse, but do provide all patients with instructions for anal sphincter strengthening exercises after surgical repair. All patients should be followed postoperatively to determine the need for any further treatment if fecal incontinence persists despite a 6-month or longer course of dietary measures and regular sphincter strengthening exercises.


A wide variety of surgical repairs have been described for rectal prolapse, underscoring the lack of an ideal procedure. Operative techniques are traditionally divided by approach: perineal or transabdominal. The two main perineal procedures are the Delorme procedure and the Altemeier procedure (perineal rectosigmoidectomy).
Mucosal prolapse and short segment full-thickness prolapse can be managed by the Delorme procedure, whereas the Altemeier procedure can be used for any degree of protrusion. Perineal stapled prolapse resection (PSPR) is a relatively new perineal procedure. Transabdominal repair can be completed via laparotomy, laparoscopy, or robotic technique and consists of fixation of the rectum in its normal anatomic position with or without colonic resection.

The first procedures described for rectal prolapse were performed via a perineal approach. With its introduction in 1955, transabdominal repair became the standard of care for patients who could tolerate laparotomy. Those who could not (frail, older adults) underwent perineal repair. The advent of laparoscopy and robotic surgery allowed for avoidance of the trauma of a laparotomy, thereby reducing surgical stress and allowing for more rapid recovery. Determination of operative approach should take into account patient age, comorbid conditions, previous abdominal or perineal operations, risk of recurrence, presence of fecal incontinence or constipation, and presence or absence of incarceration.

Perineal Approach

The ability to perform perineal repairs under local, spinal, or general anesthesia allows these procedures to be tailored according to anesthetic risk and is the reason this approach has historically been chosen for frail elderly patients with comorbidities. In addition, a perineal repair is a useful alternative to a transabdominal procedure in patients with a hostile abdomen.

Complications after perineal repairs are related to the coloanal anastomosis in the majority of cases and include bleeding, anastomotic leak/dehiscence, pelvic abscess, and stricture.

Anal encirclement

The Thiersch procedure, or anal encirclement, is reserved for extremely frail patients with limited life expectancy or prohibitive risk for anesthetic complications. First described in 1891, the Thiersch procedure involves manually reducing the prolapse, followed by narrowing of the anal canal by circumferential placement of suture, synthetic mesh, or even vascular graft. This procedure provides a mechanical barrier to further descent but does not eradicate existing prolapse and has the potential for serious morbidity including fecal impaction, erosion of the material, or pelvic sepsis.3 When performing this procedure, it is important to place a dilator or finger in the anal canal while tying the stitch/securing the material so that stenosis and fecal impaction are avoided.

Mucosal sleeve resection (Delorme)

First described in 1900 by Delorme, a mucosal sleeve resection is a good option for patients with mucosal prolapse or minor full-thickness prolapse. A partial-thickness circumferential incision is made through the mucosa 1 to 2 cm proximal to the dentate line. The mucosa is then dissected free from the underlying muscularis to the level of the apex of the protruding bowel. The cylinder of mucosa is then excised, the denuded muscle is plicated longitudinally, and the mucosa is reapproximated.

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May 1, 2023 | Posted by in GYNECOLOGY | Comments Off on Evaluation and Management of Rectal Prolapse

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