External rectal prolapse and uterine prolapse upon straining
In males the condition is unrelated to age. There is a variable association with psychiatric illness .
Symptoms include the sensation of a lump protruding during defecation. Either spontaneous reduction occurs at the end of straining, or there is the need to manually reposition the prolapsed rectum.
Mucous discharge and soiling are common. Anal bleeding with tenesmus and pain could reveal a solitary rectal ulcer.
Symptoms related to anorectal dysfunction are common and differ: constipation (obstructed defection), predominant in younger patients, and fecal incontinence, occurring most often in aged patients. Some degree of fecal incontinence is noted in about 60–80 % of patients. The development of fecal incontinence in rectal prolapse is multifactorial: mechanical stretch of the sphincters, pudendal neuropathy, repetitive stimulation of the rectoanal inhibitory reflex, and impaired rectoanal motility all result in a low resting anal pressure .
Constipation is present preoperatively in up to 60 % of patients. Most patients have a pattern of obstructed defecation. Slow-transit colonic constipation is rarely seen in this clinical setting .
Rectal prolapse should be differentiated from mucosal anal prolapse, anterior mucosal prolapse, and prolapsing hemorrhoids (Fig. 12.2). A solitary rectal ulcer, especially the exophytic polypoid type should be differentiated from a rectal adenocarcinoma.
Differential diagnosis: circular mucosal prolapse
A complete examination of the pelvic floor should be performed to assess the presence of a descent of the middle and/or anterior pelvic compartment. A pathologic descent of the pelvic floor (descending perineum syndrome) should be noted, as this can contribute to persistent postoperative dysfunction.
If the prolapse is not visible during the clinical examination, the patient should be asked to sit on a commode and bear down to reproduce the prolapse.
12.2.3 Technical Investigations
In general, flexible endoscopy is advisable to exclude a neoplasm or a lead point lesion as a cause of the prolapse. A finding of extensive diverticular disease also could influence the type of surgery.
Isolated erythema or ulceration of the anterolateral rectal wall is the cardinal feature of solitary rectal ulcer syndrome, and biopsy can reveal a typical histology with fibrous obliteration of the lamina propria.
Although clinically evident, colpo-cysto-defecography or dynamic magnetic resonance imaging of the rectum can provide additional information on the extent of prolapse of other pelvic compartments. This could be helpful in tailoring the surgical approach. Anorectal manometry has added value only in the setting of clinical research.
A radiopaque marker study is appropriate in patients with a history suggesting slow-transit constipation. It should be noted that nearly one-third of the patients with outlet delay constipation present with delayed overall large-bowel transit .
12.2.4 Surgical Repair
The aim of surgical treatment is to correct the prolapse, restore continence, and prevent postoperative constipation. Some anatomic features are constant findings and reflect the rationale for some of the surgical approaches: full-thickness intussusception, a deep pouch of Douglas, defective fixation of the rectum to the sacrum, a redundant sigmoid colon, and a weakened pelvic floor and anal sphincter muscles.
A large number of operations for rectal prolapse have been described, reflecting their defectiveness. No particular scientific reason seems to explain the popularity of a specific approach, and the surgeon’s choice is mostly based on anecdotal and/or personal experiences.
These operations can be categorized as either abdominal or perineal. Table 12.1 provides an overview of techniques that have been used.
Defecographic grading of a prolapse
Proximal one-third of the vagina
In the anal canal
Above the pubococcygeal line
At the pubococcygeal line
Below the pubococcygeal line
>4 cm Descent upon straining
Based on a Cochrane Database systematic review, abdominal approaches seem to result in a reduced prolapse recurrence rate. Residual incontinence is less frequent after abdominal approaches. Postoperative constipation, on the other hand, seems to be linked to mesh rectopexy, especially when lateral ligament ligation (extensive rectal mobilization) is performed. Bowel resection during rectopexy was associated with lower rates of postoperative constipation. Nevertheless, the limited number of relevant trials, their small sample sizes, and other methodological weaknesses severely limit their usefulness for guiding practice .
It seems appropriate that surgeons master a perineal as well as an abdominal technique. All abdominal procedures should be performed laparoscopically, which can result in shorter hospital stays and lower costs .
Laparoscopic ventral mesh rectopexy has gained wide spread acceptance in Europe and has become the procedure of choice fit patients requiring prolapse repair.
220.127.116.11 Perineal Approaches
Perineal approaches are generally reserved for patients who are too frail to withstand an abdominal approach or general anesthesia. Perineal procedures can be performed under regional anesthesia (a spinal or sacral block) and in the lateral decubitus position.
Delorme Mucosectomy 
This technique was described in 1900 by the French military surgeon Edmond Delorme. It involves stripping the mucosa of the prolapsed rectum (sparing the muscular tube). A circular incision starts about 1 cm cephalad to the dentate line (to safeguard the internal anal sphincter). The submucosa is infiltrated with a diluted adrenaline solution, which facilitates the dissection. By placing interrupted sutures around the circumference, the muscle layer is plicated; this reduces the prolapse above the anal canal. The mucosal sleeve covers the plication and is anastomosed to the anal canal (Fig. 12.3).
Schematic representation of a Delorme mucosectomy and rectal muscle wall plication (From Mann CV, Glass RE, Surgical Treatment of Anal Incontinence, 2nd edition. London: Springer-Verlag; 1997)
This technique is better adapted to treat smaller rectal prolapses. A modified technique has been proposed, adding a postanal repair to reduce the enlarged hiatus .
In contrast to the Delorme procedure, a full-thickness resection of the prolapse is performed (rectum, rectosigmoid) with a coloanal anastomosis (Fig. 12.4). The prolapse is everted and a full-thickness incision is performed 1.5 cm above the dentate line.
Intraoperative steps of the Altemeier procedure
Opening the pelvic pouch allows the surgeon to palpate in order to determine whether a redundant loop of sigmoid colon should be resected. All mesenterial vessels should be ligated with care. The colon should reach the line of anastomosis without any tension. Septic complications and suture-line dehiscence are rare, probably because of the weakness of the remaining sphincter.
Outcomes of Perineal Procedures
Recurrence rates after Delorme mucosectomy vary from 4 % to 38 %; these values certainly reflect the duration of follow-up and patient selection. In a large series of 101 primary procedures, Watts and Thompson  showed that a cumulative recurrence rate of about 40 % at 5 years can be expected. An even higher incidence of recurrence (60 % at 2 years) was recorded for repeat Delorme procedures.
The incidence of recurrence rates after the Altemeier procedure is lower and varies between 0 % and 15 %. Recurrence probably reflects inadequate resection .
Perineal procedures have yielded poor functional outcomes with respect to fecal incontinence and urgency. The resection or plication of the rectal reservoir (in a situation of already-reduced sphincter function) further jeopardizes fecal continence . Recovery of fecal continence is unpredictable.
Perineal colonic pouch
To overcome this problem, Yoshioka et al.  suggested constructing a colonic J-pouch of the peranaly mobilized sigmoid.
In addition to the classical Altemeier procedure, posterior or anterior buttressing has been proposed. The muscular edges of the puborectal muscle can be identified, allowing either a posterior or anterior levatorplasty to be performed using nonabsorbable sutures. This reduces the hiatus (postanal repair). In an interesting study, Agachan et al.  demonstrated that after perineal rectosigmoidectomy with levatorplasty not only were incontinence scores improved, recurrence was also reduced.
Choice of Perineal Operation
Perineal procedures are indicated in frail, old patients with extensive morbidity. Smaller prolapses can be treated by Delorme mucosectomy. In larger prolapses, a perineal resection with dorsal levatorplasty is advisable. In the rare scenario of an incarcerated and gangrenous rectal prolapse, a perineal resection is indicated; abdominal rectopexy cannot be performed.
In young, healthy, male patients the use of a Delorme procedure is certainly worth considering because it avoids the risk for pelvic autonomic nerve injury.
18.104.22.168 Abdominal Approaches
Preservation of the rectal ampulla is important to allow recovery of fecal continence. Most abdominal suspension techniques rely on the same surgical principle: mobilization of the rectum, reduction of the prolapse, and fixation of the elevated rectum to the sacrum. Fixation can be performed using either sutures or mesh. The mesh can be placed in different positions, and the type of mesh can vary (synthetic vs. biological). A resection of a redundant sigmoid colon can be added.
This technique was first described by Cutait  in 1959. Nonresorbable sutures are used to fix the mesorectum of the elevated rectum to the presacral fascia and sacral promontory.
Suture Rectopexy with Sigmoid Resection
This procedure is also referred to as the “Frykman-Goldberg procedure”  and is still very popular in the United States. The procedure was initially intended to reduce the recurrence rates of suture rectopexy by resecting the redundant sigmoid colon. It significantly reduces the incidence of postoperative constipation, but adding a resection potentially increases the risk for complications.
Posterior Mesh Rectopexy
In the original Wells procedure , a polyvinyl alcohol sponge (Ivalon) was inserted posterior to the mobilized mesorectum to stimulate inflammatory adhesion-fixation of the bowel to the presacral fascia. Later the same procedure was performed using polypropylene or Teflon mesh (Fig. 12.5).
Classical mesh rectopexy: Wells procedure (a). Ripstein procedure (b) (From Mann CV, Glass RE, Surgical Treatment of Anal Incontinence, 2nd edition. London: Springer-Verlag; 1997)
Anterior Sling Rectopexy
In the Ripstein procedure , an anterior sling of fascia lata or synthetic material is positioned in front of the rectum and sutured to the sacral promontory. To overcome the risk of bowel obstruction, a modified technique (McMahan-Ripstein)  includes a posterior fixation of the mesh to the presacral fascia; the lateral mesh is anteriorly sutured to the rectum, deliberately leaving an anterior gap (Fig. 12.5).
Lateral Mesh Rectopexy
Laparoscopic Ventral Mesh Rectopexy (or Rectocolpopexy)
Laparoscopic ventral mesh rectopexy (LVR) was first described by D’Hoore and Penninckx . The laparoscopic dissection is limited to the anterior aspect of the rectum (rectovaginal septum), avoiding the risk of autonomic nerve damage. A synthetic mesh is sutured to the anterior aspect of the rectum to avoid further intussusception and fixed to the sacral promontory. If the uterosacral ligaments are lax, they can be hooked to the same mesh. Any descent of the vaginal vault can be restored by performing a colpopexy using the same mesh. The peritoneum is closed over the synthetic mesh to elevate the neo-Douglas and to avoid further adhesion to the mesh. The unique position of the mesh further reinforces the rectovaginal septum. It therefore can be used in the presence of a complex rectocele (Fig. 12.6).
Laparoscopic ventral mesh recto(colpo)pexy
The same procedure can be performed in male patients. Dissection is limited to the level of the seminal vesicles, and no attempt is made to dissect posterior to the prostate. Care should be taken to avoid any damage to the hypogastric nerve at the site of the sacral promontory.
Outcome of Classical Rectopexy
Certainly, abdominal rectopexy provides a patient the best chances of maintaining or regaining fecal continence. Unfortunately, postoperative constipation is a significant problem and has consistently been reported to occur in up to half of patients .
Outcome of LVR
Based on the safety of the technique (conversion to laparotomy rate of 2.9 %), a low long-term recurrence rate, and favorable long-term functional outcomes (low de novo constipation), LVR emerges as an efficient procedure for the treatment of patients with total rectal prolapse. It has gained wide acceptance as the procedure of choice in Europe.