18.1 Introduction

The term rectal prolapse encompasses a spectrum of disorders that result from intussusception or invagination of the rectal wall in a partial-thickness or full-thickness fashion, in varying degrees of protrusion to and through the anal sphincter complex. Early authors recognized that the underlying abnormality starts well above the pelvic floor, and described the importance of herniation of the pouch of Douglas ^{1 , 2} rather than a disorder of the physiology of the anal sphincter (▶ Fig. 18.1). An anatomic classification of the disorder provided a bit more clarity regarding the differing degrees of prolapse, ³ essentially recognizing the difference between mucosal prolapse (type I), internal intussusception (type II), and full-thickness rectal prolapse (type III). Anatomic abnormalities commonly found in rectal prolapse include diastasis of the levator ani, a deep cul-de-sac, redundant sigmoid colon, patulous anal sphincter, and attenuation of the fibrous attachments between the rectum and the sacrum. ⁴ No classification system has been universally accepted, and there is no consensus on the relative contribution of various abnormalities such as pelvic floor laxity, prior pregnancy, connective tissue disorders, and chronic constipation to the abnormality that presents as rectal prolapse.

18.2 Symptoms and Risk Factors

The symptoms associated with rectal prolapse can be quite debilitating and have a markedly negative impact on a patient’s activities of daily living. Women age 50 and older are six times more likely to present with rectal prolapse than men, ⁵ with the peak incidence in the seventh decade; multiparity in women is not a prerequisite. Young patients with rectal prolapse are more likely to have a syndrome associated with developmental delay or a psychiatric diagnosis requiring medial therapy. ⁶ Common patient complaints include fecal incontinence, seepage of mucus, bleeding, discomfort due to protrusion of tissue, and constipation. Fecal incontinence is present in up to 75% of patients with complete rectal prolapse, ⁷ but the cause of this is unclear. It makes sense that rectal eversion bypassing the anal sphincter would lead to fecal leakage, but other contributing factors likely include continuous stimulation of the rectoanal inhibitory reflex, stretch of the sphincter mechanism, and possibly stretch injury to the pudendal nerve with resultant denervation of the pelvic floor. ⁸ Patients who complain of “constipation” and the need to strain deserve a closer look, as they may actually have internal intussusception (or occult prolapse) acting as an obstruction to normal defecation.

Risk factors associated with the development of adult prolapse are the same as those that predispose patients to a weak pelvic floor. These include large birth weight of vaginally delivered babies, prior pelvic surgery, increased body mass index, chronic straining, chronic diarrhea, chronic constipation, cystic fibrosis, neurologic diseases that lead to denervation of the pelvic floor (i.e., cauda equina syndrome, spinal cord lesions), connective tissue disorders (i.e., Marfan’s syndrome, Ehlers–Danlos syndrome), dementia, and stroke. ⁹

18.3 Examination and Evaluation

The diagnosis of circumferential full-thickness rectal prolapse is unmistakable, and must be distinguished from circumferential hemorrhoidal prolapse by the trained observer (▶ Fig. 18.2). However, the seasoned physician must carefully evaluate the understated complaints associated with the spectrum of abnormalities with rectal prolapse. A thorough exam of the abdomen and perineum is indicated.

When examined prone, or in lateral decubitus position, findings commonly include absence of prolapse but a flattened perineum and patulous anus. Despite a wide-open anal canal, many patients can generate a high voluntary squeeze pressure, and this finding should be noted as it can influence the decision of operative approach. Mucus is frequently present on the perianal skin. The prolapse should be visualized directly to make an accurate diagnosis and plan surgical strategy. Asking the patient to sit on the commode and strain can often produce it. Once visualized, the configuration of the mucosal folds, length, and viability of prolapsing segment should be noted, as well as prolapse of other pelvic organs (▶ Fig. 18.3). Mucosal folds should be concentric, as opposed to the radial folds associated with circumferential hemorrhoidal prolapse. With complete prolapse, a sulcus is present between the anus and the protruding mucosa; this finding is not present in a patient with circumferential mucosal or hemorrhoidal prolapse (▶ Fig. 18.4). Proctoscopy will often show a ring of edema and erythema 5 to 6 cm from the anal verge.

The patient with internal intussusception may complain of “constipation” but on further questioning may admit to a sense of fullness, incomplete evacuation, and passage of bloody mucus. This patient may sit on the toilet for prolonged periods of time attempting to evacuate, with no satisfactory passage of stool. Those with resultant solitary rectal ulcer syndrome may develop deep ulceration of the rectal wall that causes pain and bleeding, and grossly appears similar to neoplastic change, or Crohn’s disease. Biopsies, however, will confirm benign disease, showing mucosal and muscular hyperplasia, surface erosion, and mild inflammation—occasionally called colitis cystica profunda. Exam of the perineum may reveal flattening associated with dyssynergia of the pelvic floor, while on digital rectal exam good tone but no mass is found. Straining on the commode often reveals marked perineal descent with opening of the anal orifice revealing mucosa that does not prolapse beyond the anal verge. Proctoscopy will likely reveal a ring of erythema, induration, and possibly ulceration on the anterior rectal wall, 5 to 6 cm from the anal verge.

In addition to physical exam, certain diagnostic tests can be used selectively to refine the diagnosis and expose other associated pathology. Commonly used modalities include defecography or dynamic magnetic resonance imaging (MRI), colonoscopy, and urodynamics. Defecography or dynamic MRI with contrast can clarify the presence and extent of contiguous organ prolapse, such as cystocele, enterocele, sigmoidocele, and vaginal vault. Defecography has altered management strategy in up to 40% of patients presenting with rectal prolapse. ¹⁰ The benefit of MRI compared with fluoroscopy is that it is noninvasive, there is no radiation exposure, it provides simultaneous dynamic evaluation of all pelvic organs in multiple planes, and it allows visualization of pelvic floor support structures. Dynamic MRI correlates well with fluoroscopic studies in the identification of pelvic organ prolapse. ¹¹ Depending on patient symptoms, these other organs may require treatment as well.

Colonoscopy rarely changes the management of rectal prolapse, but is important to rule out other abnormalities, especially neoplastic change. ¹² Findings visually concerning for neoplasia may be confused with solitary rectal ulcer during endoscopic evaluation. Urodynamics may be indicated to evaluate the patient with concurrent symptoms of a vaginal bulge or urinary incontinence. ¹³

The role of pelvic floor physiology testing in the evaluation of rectal prolapse is limited, but may explain the dysfunction in a chronically constipated patient, or define the anatomy of the anal sphincter in a patient with prior anal surgery who complains of fecal incontinence. Patients who complain of chronic constipation and prolapse should have pelvic floor dyssynergia ruled out with anal manometry and defecography, since they may benefit from pelvic floor physical therapy in the perioperative period. A sitz marker study to rule out colonic inertia may have a role, in addition to a complete metabolic evaluation to rule out one of the myriad causes of slow transit constipation. Delayed pudendal nerve conduction may have prognostic significance for continence, but this is not a reliable predictor of post-op control. ¹⁴ In general, patients with fecal incontinence that developed with progressive prolapse will notice improved continence once the prolapse is repaired. Those with questionable sphincter defects and a history of prior anal surgery can have the status of the sphincter complex documented prior to repair using ultrasound technology.

18.4 Treatment

Surgical treatment is the mainstay of therapy for symptomatic rectal prolapse. Nonoperative therapies may have a role in the treatment of elderly patients with severe comorbidities, but are utilized mostly to prevent the frequency and severity of the prolapse, or to assist in reducing the prolapse that is incarcerated. ¹⁵ For the patient who produces full-thickness rectal prolapse due to straining and constipation, fiber supplements and laxatives can be helpful in reducing the need to strain. Conservative methods including pelvic floor muscle training are often recommended as a first step, and may lead to an improvement in bowel symptoms. ¹⁶

The anal encirclement procedure was first described in 1891, and has evolved into a procedure that is generally used in the palliative setting. It can be performed under local anesthesia. When combined with a Delorme procedure, outcomes are improved and recurrence rates are decreased. ¹⁷ While silver wire was the original implant, other materials have been described such as a monofilament nonabsorbable suture, synthetic mesh, and braided vascular graft. The implant is buried in the ischioanal fat and tied snugly (▶ Fig. 18.4). Bulk-forming agents and laxatives will generally be required following anal encirclement.

Two other approaches, transabdominal and transperineal, are most often considered in the operative repair of rectal prolapse; the range of surgical techniques described to correct the underlying defects reflects the lack of consensus regarding the best operation. A recent review of all randomized controlled trials of surgery to date for managing adult full-thickness rectal prolapse found that the heterogeneity of objectives, interventions, and outcomes makes cogent analysis very difficult. In fact, there were insufficient data across 15 randomized controlled trials involving over 1,000 patients to say which of the abdominal or perineal approaches is most effective. ¹⁸

The recommended surgical approach is therefore patient-specific, and should be dictated by the comorbidities of the patient, the surgeon’s preference and experience, and the patient’s age and bowel function. ¹⁹ Great care should be taken to understand each patient’s symptoms, bowel habits, continence, anatomy, and preoperative expectations ²⁰ before choosing the appropriate surgical technique for a specific patient. Traditionally, for patients who have an acceptable risk profile for abdominal surgery, procedures incorporating transabdominal rectal fixation have been the procedure of choice ¹³ as they are thought to lead to a lower rate of recurrent prolapse. However, no significant difference has consistently been found in the rate of recurrent prolapse for patients treated with a transabdominal as compared to a transperineal repair. ²¹ When the patients are appropriately chosen, there is no significant difference in the rate of morbidity and mortality between a perineal or abdominal approach to repair. ²² In addition, no significant difference has been reported in randomized comparisons of perineal procedures and abdominal procedures. All surgical procedures to treat rectal prolapse have been found to result in substantial improvements from baseline in quality of life. ²³ The surgical management of external rectal prolapse has evolved, however. More surgeons currently favor an abdominal approach, and the frequency of perineal approach has decreased as evidence mounts that even elderly debilitated patients may tolerate a minimally invasive abdominal procedure. Delorme’s operation remains the most popular perineal procedure of choice, but the incidence of the use of Altemeier’s procedure has increased. ²⁴

18.4.1 Transabdominal Rectal Fixation Procedures

The goal of all transabdominal approaches to repair full-thickness rectal prolapse is to draw the prolapsed rectum up out of the pelvis and secure it to the presacral fascia; simple anterior resection without fixation has fallen into disuse as it is associated with a recurrence rate that continues to increase over time. ²⁵ A multitude of procedures have been described for transabdominal fixation, and they differ in their approach (traditional open vs. minimally invasive), extent of rectal mobilization (anterior, posterior, or both), use of mesh (synthetic or biologic), and addition of sigmoid resection. Complete and circumferential mobilization of the rectum down to the level of the pelvic floor for the repair of rectal prolapse has a high rate of postoperative constipation and obstructed defecation, ²⁶ possibly due to division of the autonomic nerves in the lateral stalks, ²⁷ so there is general agreement that limited dissection in the anterior plane, posterior plane, or both, leaving the lateral stalks intact, is preferred. Procedures tend to be performed based on surgeon preference and experience.

Suture Rectopexy

Suture suspension of the rectum to the presacral fascia with nonabsorbable sutures leads to a remarkably low rate of recurrent rectal prolapse (3–9%), ²⁸ whether performed in an open or laparoscopic fashion. ²⁹ Suture fixation was first described in 1959, ³⁰ and prevents redundant bowel from intussuscepting into the distal pelvis. The scarring and fibrosis from not only suture fixation but also complete mobilization of the rectum may play a role in the success of suture rectopexy as well. ³¹ Of those patients who complain of diarrhea and incontinence in the setting of rectal prolapse, many regain bowel control after this procedure ^{32 , 33} ; these patients do not seem predisposed to develop constipation after simple suture rectopexy, whereas approximately 15% of patients experience new constipation following rectopexy. Over half of those who are constipated before surgery are made worse. ³⁴

The concern over worsening constipation after prolapse repair has led many surgeons to combine suture or mesh rectopexy with sigmoid resection for those patients with preexisting constipation (▶ Fig. 18.5). Adding resection to simple suture suspension seems to improve functional results with minimal increase in morbidity. ²⁹ Segmental resection of the colon appears to reduce the incidence of persistent constipation in a chronically constipated patient, ¹⁹ even though segmental resection of the colon for the treatment of constipation, in the absence of prolapse, has not proven to be of benefit. One should consider ruling out colonic inertia before offering a segmental resection to insure the patient does not have dysmotility of the entire colon.

Suture rectopexy, with or without sigmoid colon resection, can also be successfully performed using minimally invasive techniques, with acceptable morbidity and recurrence rates. ³⁵ Patients who undergo laparoscopic rectopexy have been reported to have a shorter length of stay and lower surgical site infection rate than patients who have open abdominal procedures for the repair of a full-thickness rectal prolapse. ³⁶

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