Introduction
Rectal prolapse is a benign but debilitating anatomic abnormality involving full-thickness descent of the rectum toward and sometimes through the anal canal ( Fig. 34.1 ). The procidentia may be occult and exhibit internal intussusception or may manifest as the full thickness of rectal wall external to the anal sphincters. The true cause of rectal prolapse is unknown, despite its long and extensive presence in medical history and literature. Numerous operations have been described in the literature since 1889, when Mikulicz described his series of six patients undergoing perineal excision for prolapse, and great variation in surgical management and approach still exists among major institutions. In this chapter, we discuss the etiology, epidemiology, clinical features, evaluation, common surgical techniques, results, and our experience regarding rectal prolapse.
Etiology
A renowned English colorectal surgeon, Hugh Lockhart-Mummery of St. Marks’ Hospital in London, wrote in 1972, “It is interesting to note that we still know so little about the cause of such a common condition.” Many aspects of rectal prolapse remain unclear, including its true cause. There are two main theories regarding the cause of prolapse. In the early 1900s, it was thought that rectal prolapse was a sliding hernia that protrudes through a defect in the pelvic fascia at the level of the anterior rectal wall. The most current and accepted theory, however, was proposed by after they demonstrated with cine-defecography that full-thickness prolapse starts as an internal intussusception of the rectum with a lead point proximal to the anal verge. Years later, radiopaque markers were applied to the rectal mucosa in studies to demonstrate this phenomenon in real time and support the current theory that rectal prolapse is due to internal intussusception of the rectal wall.
There are many anatomic pathologies that may relate to rectal prolapse: a deep peritoneal cul-de-sac or pouch of Douglas, enterocele, loss of posterior rectal fixation, a patulous anal sphincter, diastasis of the levator ani, redundant rectum and sigmoid colon, and loss of the rectum’s horizontal position may all contribute in part to the pathology. The ideal rectal prolapse repair should correct as many of these abnormalities as possible. To attain this goal, each abnormality is not addressed individually but rather they are addressed in unity to repair the many components contributing to the intussusception.
Pathophysiology
Patients with rectal prolapse may report varying symptoms related to bowel habits. Up to 75% of patients with rectal prolapse complain of fecal incontinence, whereas 25% to 50% report constipation in the setting of rectal prolapse. The precise pathophysiological condition behind these varying symptoms is not completely defined, although some causative factors have been identified. and demonstrated that incontinence in patients with rectal prolapse may be related to denervation of pelvic floor musculature, supporting a pudendal neurogenic cause. Rectal prolapse itself may directly traumatize the anal sphincters as they are constantly stretched by the prolapsed segment. A prolapsed segment of rectum may act to stent the sphincters in an open position, thus providing a direct conduit that results in leakage and incontinence.
Constipation in the setting of prolapse may be caused by intussusception of the rectum, colonic dysmotility, slow transit, or inappropriate puborectalis contraction. Prolapse repairs may increase or decrease constipation. Whether division of the lateral stalks during rectopexy increases postoperative constipation has been greatly debated. noted that division of the lateral ligaments during surgery is associated with increased postoperative constipation, leading to the recommendation of unilateral lateral stalk preservation. Other studies investigating the incidence of constipation after preservation of lateral stalks reveal that, although constipation may slightly improve, recurrence rates are increased as well.
Epidemiology
Rectal prolapse is a relatively uncommon phenomenon; however, the true incidence and prevalence are unknown primarily due to underreporting, especially in the elderly population. It can occur at any age, although the peak age of incidence for women is in the seventh decade. Rectal prolapse can often be seen in children younger than 3 years, where malnutrition and cystic fibrosis appear to be predisposing factors. Gender distribution is equal in children. In adults, rectal prolapse is more common in women, who are six times more likely to suffer from prolapse than are men. Although rectal prolapse is often associated with multiparity, nearly one-third of women with rectal prolapse are nulliparous. Male patients, although they represent a very small portion of this population, generally develop prolapse at a younger age than female patients (younger than 40). There is also an association between younger presentation and psychiatric conditions requiring multiple medications, such as autism and developmental delay.
Clinical Features
Patients with rectal prolapse generally present with fecal soilage, prolapse of tissue through the anal sphincter complex, mucoid discharge, and bleeding. Prolapse exposes rectal mucosa externally that can secrete a significant amount of mucus, leading to perianal soilage, excoriation, and pruritis. Bleeding is a result of mucosal trauma or venous congestion. Patients with internal (occult) prolapse experience sensations of incomplete rectal evacuation, tenesmus, and rectal pain.
Rectal prolapse is associated with comorbidities that include senile dementia, neurological disorders, infectious disorders, connective tissue disorders, and bulimia nervosa. In addition, rectal prolapse is associated with straining, constipation, previous gynecological surgery, and anal incontinence. Straining in men and younger women may displace the anterior wall of the upper rectum against the anal canal and cause trauma, leading to ulceration, irritation, and bleeding and ultimately the development of a solitary rectal ulcer. reported that 18% of patients with prolapse reported straining and 42% had constipation, consistent with the 15% to 65% reported in the literature. Solitary rectal ulcer was found in 12% of patients with rectal prolapse. Previous gynecological surgery is often present in the setting of rectal prolapse; we found 35% of our patients had undergone a previous hysterectomy and 38% of our patients were incontinent.
A complete assessment of female patients with rectal prolapse should include evaluation for constipation, urinary and fecal incontinence, and other pelvic floor disorders such as uterine prolapse, rectocele, cystocele, or enterocele. Staged or combined surgical correction of pelvic floor disorders, should they exist concurrently, is imperative for resolution of symptoms.
Evaluation
Evaluation of patients with rectal prolapse should begin with a complete history and physical examination. A careful evaluation is essential to confirm the diagnosis and to provide information to determine the best surgical approach. Age, level of activity, comorbid conditions, and living conditions are important issues in determining the best approach to surgery in each patient. A neurological, obstetrical, and surgical history, including prior hysterectomy and prolapse repairs, should be performed in all women. Symptoms related to fecal and urinary incontinence and constipation should be especially emphasized.
Occasionally, rectal prolapse is not externally visible on initial examination. Examination of the patient in a squatting position or with Valsalva maneuver on a commode may be needed to reproduce the prolapse. During inspection, it is important to differentiate full-thickness rectal prolapse (concentric folds) from prolapsing internal hemorrhoids (radial invaginations).
A thorough anorectal examination begins with inspection of the perianal skin, noting signs of excoriation from itching or mucus soiling. The anocutaneous reflex should be tested. Digital anorectal examination includes an assessment for anal sphincter defects, along with resting and squeeze pressures. Occasionally, the prolapsing segment can be felt on digital examination. Associated vaginal prolapse such as rectocele (posterior vaginal prolapse), cystocele (anterior vaginal prolapse), or enterocele (prolapse of small intestine, usually at the vaginal apex or posterior vagina) should be identified, if present.
Proctoscopy or flexible sigmoidoscopy is needed to exclude the possibility of a neoplasm and allows the opportunity to identify solitary rectal ulcers or other mucosal abnormalities. Because a significant portion of patients with prolapse have associated constipation, incontinence, or other pelvic floor disorders, it is worthwhile to include selected motility and pelvic floor studies in the evaluation of these patients if needed.
Colon transit marker study, defecography, or anal manometry may be informative but must be individualized; patients without associated symptoms may not require any further workup other than proctoscopy.
Colonic transit marker studies may be important in patients with severe constipation. This test measures the time it takes for markers to traverse the colon. After patients swallow a set number of radiopaque markers, serial abdominal radiographs are used to evaluate the passage of these markers. Patients with prolonged colon transit time may benefit from colon resection with rectal preservation and rectopexy.
When outlet obstruction or pelvic support disorders are suspected, defecography should be performed. It may show that the sigmoid colon prolapses into the anal canal with straining, or it may show internal (occult) intussusception that does not go through the anal canal. It is also useful on the occasion when prolapse is not reproducible on examination.
Anal physiological testing may be performed preoperatively and includes anal manometry, endorectal ultrasound to evaluate sphincter muscle, and pudendal nerve testing. These studies rarely affect decision-making in the initial operative planning but may help predict postoperative outcomes and set realistic postoperative goals for these patients. found normal anal pressures in continent patients with rectal prolapse; however, incontinent patients had decreased resting and squeeze anal pressures. Many patients with prolapse-associated fecal incontinence have nerve damage believed to be due to traction injury of the pudendal nerves caused by the rectal prolapse. Continent prolapse patients may not show manometric or electromyographic signs of denervation. Studies from and showed that patients who remained incontinent after rectal prolapse repair had significantly lower resting and squeeze pressures preoperatively than did those whose incontinence improved postoperatively. In general, patients with fecal incontinence in the setting of rectal prolapse experience improvement of symptoms after repair, but debate exists as to how reliable these tests are in predicting the actual outcome in individual patients.
Nonsurgical Options for Prolapse
No studies exist that compare operative repair with nonoperative therapy for rectal prolapse, nor are there definitive nonoperative alternatives to correct this condition. Aggressive treatment of constipation, if present, with medications may lessen symptoms. Applying table sugar to the prolapsed segment draws edema out of the segment and may facilitate reduction of the prolapse. Placing the patient in Trendelenburg position and administering intravenous benzodiazepines may ease reduction as well. However, none of these nonsurgical options will definitively repair prolapse, and surgery continues to be the preferred treatment of prolapse.
Common Surgical Repairs for Prolapse
There are more than 300 procedures described to treat rectal prolapse, and new techniques are continually introduced in the literature. Despite this, there is no single operation that preferred over the rest, and choosing the most appropriate procedure depends on individual patient factors. These factors include medical comorbid conditions, risk of recurrence, bowel function (fecal incontinence and constipation), degree of prolapse, and presence of associated pelvic disorders. Regardless of approach, the goals of any prolapse surgery are to treat the prolapse and to address associated constipation or incontinence.
Procedures for rectal prolapse can be classified into two main categories: perineal and transabdominal repairs. Perineal repairs are less invasive, cause less perioperative pain and morbidity, and are associated with reduced lengths of stay. They are favored for frail, elderly patients, but at some institutions, perineal repairs are favored for healthy patients, too. This approach does carry a risk of infection and complications related to the suture line or wound. In addition, the perineal approach is known for recurrence rates that are four times higher than those of transabdominal operations; thus, the abdominal approach is favored for medically fit patients who could tolerate this operation. A transabdominal repair requires general anesthesia and may have more devastating complications such as anastomotic leak, abdominal sepsis, stricture, and adhesions. The introduction of minimally invasive approaches since the 1990s has added a new dimension to transabdominal prolapse surgery and has been shown to reduce postoperative convalescence, making this approach more appealing.
Our preference for all repairs is to have patients undergo full mechanical bowel preparation. We give perioperative intravenous antibiotics according to Surgical Care Improvement Project guidelines to provide prophylaxis against enteric flora. All patients have a Foley catheter in place for bladder drainage and pneumatic compression stockings during surgery.
Perineal Repairs
Mucosal Sleeve Resection (Delorme Procedure)
Although the mucosal sleeve resection was first described in 1900, it was not commonly used until Uhlig and Sullivan reported their experience in 1979. Because the technique is simple and can be done under regional or local anesthesia, it is considered optimal for severely debilitated patients. We prefer to perform the operation with the patient in the Kraske position; however, it can also be done in lithotomy position. After positioning the patient, the perineum and vagina are prepared with an aseptic solution. We place sutures in four quadrants around the perianal skin to evert the anus. Other surgeons may prefer retractors such as Lone Star or Hill Ferguson, or Pratt bivalve speculums, to enhance visualization. The operation commences by injecting 1:100,000 epinephrine solution circumferentially into the submucosal plane just proximal to the dentate line. This allows delineation of the dissecting plane and diminishes blood loss. Using electrocoagulation, the dissection begins in circumferential manner 1 to 1.5 cm above the dentate line ( Fig. 34.2 ), creating a plane between the submucosa and the internal anal sphincter. Once this plane is started, the free edge of mucosa and submucosa is tagged with sutures for ease in handling and in creating traction for easier dissection. Continuing in a circumferential direction and using liberal amounts of injectable saline in the plane between the submucosa and the muscular cuff, scissors are used to divide the attachments (we prefer fistula scissors) and to deliver the submucosa and mucosal cuff out of the rectum and anus. Penetrating blood vessels encountered during the dissection can be treated with electrocoagulation. It is important to maintain strict hemostasis during the dissection to avoid hematomas after the procedure. The dissection continues until the rectal mucosa cannot be pulled down any farther; usually 10 to 15 cm can be mobilized. During this phase of the operation, we use copious amounts of antibiotic solution such as tetracycline to irrigate the surgical field. After the dissection is completed, the rectal muscle is plicated with suture such as no. 2-0 Polyglactin 910 suture on a UR-6 needle (Vicryl; Ethicon, Inc., Somerville, NJ). A total of eight sutures are spaced circumferentially for this plication. The dissected mucosa is excised and the proximal line of resection is approximated to the distal incision line. Interrupted sutures of No. 2-0 Vicryl on a UR-6 needle work well for this circumferential suture line ( Fig. 34.3 ).
Prolapse recurrence after the Delorme procedure varies from 10% to 15% in different series. The procedure is well tolerated in high-risk patients but still carries a risk for complications of bleeding, urinary retention, and fecal impaction in up to 12% of patients. In general, constipation and fecal incontinence tend to improve after surgery, the latter perhaps due to the rectal muscular wall plication that creates a bulky, donut-like circumferential mass around the upper anal canal.
Perineal Rectosigmoidectomy (Altemeier Procedure)
Perineal rectosigmoidectomy was first described in 1889 by Mikulicz; in 1952, Altemeier and coworkers described excellent results in elderly debilitated patients. This approach involves a full-thickness removal of the rectum and sigmoid colon via the perineum with a sutured or stapled coloanal anastomosis. It is associated with a shorter hospital convalescence and lower complication rate (10%) and can be completed without general anesthesia. Thus, patients undergoing this procedure for prolapse are usually older and exhibit more comorbidities than do those undergoing transabdominal procedures. A potential disadvantage is loss of the rectal reservoir, especially in elderly patients. Additionally, in patients who have undergone previous rectal or sigmoid resections, care must be exercised in performing this operation as the inferior mesenteric vessels may have been previously ligated and the blood supply to this area may have been altered. Many consider this to be the preferred procedure for incarcerated or gangrenous prolapse.
The Altemeier procedure can be performed with the patient in either lithotomy or Kraske position under general or regional anesthesia. We prefer the patient in the Kraske position as illumination of the pelvis is superior, and it allows excellent view of the operative field by all assistants. First, the prolapse is established by gentle traction with the use of Allis or Babcock clamps. The submucosa is injected with 1:100,000 epinephrine solution. A circumferential incision is made 1.5 to 2.0 cm above the dentate line ( Fig. 34.4 ) with electrocautery or a scalpel. The incision is deepened through the muscular layer until perirectal fat is encountered ( Fig. 34.5 ). Mesorectal vessels are ligated ( Fig. 34.6 ), proceeding in a circumferential manner. As the dissection continues in the cephalad direction, a hernia sac may be encountered anteriorly and opened and the abdominal cavity may be entered. When no additional bowel can be delivered without tension, the bowel is marked, as this will become the line of transsection. At this stage, particularly in incontinent patients, a levatorplasty can be performed by placing sutures such as no. 2-0 polypropylene suture (Prolene; Ethicon, Inc.) anteriorly to loosely approximate the levators ( Fig. 34.7 ). Some surgeons prefer to also place sutures in the levator muscle posteriorly. The prolapsed rectal segment is transsected ( Fig. 34.8 ). An anastomosis is created with circumferential full-thickness interrupted No. 2-0 Vicryl sutures ( Fig. 34.9 ).
