The majority of patients affected by external rectal prolapse are women. The primary symptom is a full-thickness prolapse of the rectum through the anus. Initially, the rectum occasionally comes out with bowel movements. However, with time, the prolapse protrudes more frequently and can sometimes prolapse between bathroom visits, with frequent development of concomitantly increasing fecal incontinence symptoms. Other common symptoms may include constipation, rectal bleeding, and mucus discharge. A spectrum of anatomic and functional disorders of the pelvic floor have been associated with rectal prolapse, including a deep cul-de-sac of Douglas, levator ani diastasis, lax rectal wall attachments, redundant rectosigmoid colon, and impaired resting and voluntary sphincter function (Fig. 56-1). Unfortunately, few patients with rectal prolapse experience improvement of symptoms with dietary changes or pelvic floor physical therapy. Generally, surgical intervention needs to be considered.

Resection rectopexy was first described by Frykman and Goldberg in 1969. In this chapter, the open technique is described (see Chapters 63 and 64 for the minimally invasive and hand-assisted techniques, respectively). Specifically, the rectum is mobilized, the redundant sigmoid colon is resected followed by a primary colorectal anastomosis, and thereafter the rectum is straightened and suspended with suture fixation to the presacral fascia. The subsequent fibrosis that develops between the mobilized rectum and the sacrum secures the fixation.

The diagnosis of rectal prolapse should be confirmed with a careful history and physical examination. The prolapse can be diagnosed with the patient in the lateral position, but frequently the patient needs to sit on a commode to see the full extent of the prolapse.

Digital rectal, perineal, and vaginal examination should be performed, noting the degree of rectal prolapse, external sphincter and puborectalis muscle contraction, and the presence of other anorectal disorders and genital prolapse. Concomitant disorders can be diagnosed with pelvic examination (referral to urogynecology) and/or defecography.

A full-thickness prolapse must be distinguished from a mucosal prolapse, because surgical treatment options differ. A full-thickness prolapse contains all layers of the rectal wall, frequently has circular folds, and the intussusception that forms the prolapse starts inside the rectum. On clinical examination, a full-thickness external prolapse is diagnosed with protrusion of the rectum beyond the anus while the patient exercises the Valsalva maneuver in the upright, seated, or lateral decubitus position. The procidentia can sometimes be felt on digital rectal examination with the patient pushing. Some patients may have a solitary ulcer and/or distal proctitis in the distal rectum. Defecography,
with fluoroscopic or magnetic resonance imaging technique, can confirm the presence of a rectal prolapse and concomitant genital prolapse.

Patients should undergo preoperative colonoscopy to exclude colorectal neoplasia. Anal manometry can objectively assess sphincter function and the presence of a non-relaxing pelvic floor. To evaluate functional outcomes, documentation of pre- and postoperative bowel function with standardized symptom questionnaires can be useful.

Patients should undergo a preoperative risk assessment and “clearance.” Preoperative nutritional optimization can reduce postoperative morbidity, including delayed wound healing, surgical site infection, and anastomotic dehiscence. There is usually minimal operative blood loss during the procedure, but there is a potential for significant bleeding from pelvic veins. Patients should be recommended to suspend antiplatelet and anticoagulant therapy 5-7 days before the surgery. A complete mechanical and oral antibiotic bowel preparation is utilized to prevent surgical site infection and anastomotic leak.

A prophylactic dose of antibiotics should be administered intravenously within 60 minutes of the incision per the Surgical Care Improvement Project guidelines. Deep venous thromboembolism (DVT) prophylaxis should be given before induction of anesthesia. A urinary catheter is placed to allow intraoperative and postoperative fluid monitoring and to maintain the bladder deflated during the procedure.