When using dietary fiber, the response rate varies from 19% to 70%, with rectal prolapse patients seeming to benefit least from the use of bulking agents alone [19]. Most investigators have combined the use of additional dietary fiber with behavioral modification to reduce straining. Combination therapy was used successfully for symptom control in 14 of 21 patients.

Local agents may contribute to healing of the mucosa but they do not address the underlying defecatory disorder and/or anatomy. Topical steroids and sulphasalazine enemas have not been shown to be effective. In contrast, a small study has demonstrated that sucralfate enemas (2 g twice daily for 3–6 weeks) have produced symptomatic improvement and even macroscopic healing on sigmoidoscopy, but the histological changes have persisted [20].

The application of human fibrin glue has also been shown to stimulate fibroblast and vascular proliferation leading to tissue regeneration and mucosal healing. In a small study, all six subjects treated with topical fibrin, increased dietary fiber, and behavioral correction of straining had ulcer healing at 14 days. The healing remained at the 1-year follow-up. In the group of control subjects, treated with fiber and correction of straining alone, none had achieved ulcer healing by 14 days, yet half demonstrated healing at 1 year [21].

Malouf et al. [22] showed short-term benefit from using biofeedback in 8 of 12 patients, but longer-term benefit in only half this number. Jarrett et al. [23] showed that biofeedback led to a significant rise in mucosal blood flow and postulated that this showed improved extrinsic autonomic nerve activity. Binnie et al. [24] demonstrated a higher recurrence rate in 14 patients treated with surgery (posterior rectopexy) alone compared with a group of 17 who were treated with surgery and biofeedback, either before or immediately after surgery.

Boccasanta et al. [25] reported the results of STARR in patients who had all received biofeedback and remained refractory to treatment. While ulcer healing was reported as occurring in 100% in this series, 20% of patients remained symptomatic to some degree.

Success with posterior rectopexy ranges from 50% to 100% (median 70%). It should be noted that all published series report posterior rectopexy, involving posterior rectal mobilization and rectal denervation. Posterior rectopexy does not support the anterior rectal wall, the usual origin an internal prolapsed. Sitzler et al. [26] described results of SRUS at St Mark’s Hospital, Harrow, London in which 81 patients underwent surgical treatment over a 10-year period and 66 were followed up for at least 12 months. Forty-nine patients underwent posterior rectopexy, nine underwent Delorme’s procedure, two underwent anterior resection, and four patients a primary stoma. Rectopexy succeeded in 27/49 patients (55%); the procedure failed in 22 patients, and of the 19 underwent further surgery including rectal resection and colostomy formation. Eventually, 14 of these patients required permanent colostomy. For the nine patients treated initially with Delorme’s procedure there were four failures at a median follow-up of 38 months. Two of these patients ultimately required a stoma. Seven patients underwent an anterior resection as their initial treatment or as second-line therapy for SRUS, and four of these eventually required a colostomy. Anterior resection was not a successful salvage procedure. The overall stoma rate for the treatment of SRUS in this large series was 30%. Posterior rectopexy resulted in a satisfactory long-term outcome in only 55-60% of patients. The poor outcome after surgery was related to two main factors: incontinence and incomplete evacuation, probably due to rectal denervation associated with posterior rectal dissection.