When approaching the patient with recurrent rectal prolapse, it is important to first determine whether or not any surgery is required at all. Depending on the degree of recurrent prolapse and symptoms, observation or simple serial band ligation of mucosal prolapse has shown excellent results [7]. As with any disease process, all evaluations should begin with a thorough history and physical examination, taking into account the overall clinical condition of the patient. Special focus during history should be upon the predominant symptom associated with the recurrence (constipation or incontinence), as this answer may guide both the work-up and the preoperative counseling regarding postoperative bowel function. While this caveat is similar to primary prolapse, focus should also be on the timing of the recurrence and changes in function following the initial operation. For example, if constipation worsened following repair, this symptom could have led to increased straining and eventual recurrence. Additionally, this symptom may prompt a constipation evaluation including transit studies and defecography that may not have been required or performed at the initial evaluation. Physical examination should focus on identifying both the prolapse and concomitant pelvic floor defects, which may have contributed to the recurrence or are de novo and need to be addressed at time of recurrent repair. Necrotic or ischemic prolapse, similar to the primary repair, is readily visualized and typically requires urgent resection (Fig. 24.2). In the elective setting, a careful assessment of sphincter function is even more important for those experiencing fecal incontinence in the setting of recurrence. In certain patients, the examination may suggest the need for ultrasound evaluation to identify any potential defect that could be addressed and improved by surgery. Furthermore, depending on the severity of the incontinence and the underlying tone/nerve function, a better option for the patient may be fecal diversion instead of another prolapse repair.

Endoscopy is recommended prior to surgical repair to exclude neoplasia in those patients at risk or with unusual symptoms. Endoscopy may also be useful to exclude conditions such as a lead point or solitary rectal ulcer, an anastomotic stricture in those patients who have had a prior resection, and to determine the level of any anastomosis that may need to be resected – especially when considering a perineal resection in a patient with a prior abdominal resection rectopexy as discussed below. Adjunctive studies such as anal manometry, electromyography, pudendal nerve motor latency testing, cinedefecography, or transit time studies should be ordered based on the patient’s predominant symptoms. Additionally, they may be helpful in those patients with possible concomitant pelvic floor abnormalities such as cystocele, enterocele, or vaginal vault prolapse that may be difficult to detect on examination. Box 24.2 lists the components of a successful evaluation. Finally, it is crucial to review the prior operative note(s) to determine crucial details that may radically effect the operation, such as the use and type of mesh, extent of dissection, previous resection(s), and any technical difficulties the prior surgeon may have encountered.

Currently, there is very little reported in the literature specifically regarding the management of recurrences – with only six studies, all retrospective in nature, that directly address management of recurrent rectal prolapse (Table 24.1) [8–13]. Early studies consisted of small cohorts. Hool reported on 24 patients with recurrent rectal prolapse over a 30-year period. The time to recurrence from primary repair occurred within 2 years. The majority of these patients were treated with an abdominal approach (72% Ripsten Mesh repair). The overall rerecurrence rate for this group was 17% with 7 years follow-up. The authors noted that the majority of initial recurrences appeared as a result of a technical error, with mesh failure the most common cause [9]. Furthermore, altered preoperative bowel function, especially incontinence, was rarely altered following repair of the recurrence – an important counseling point for patients prior to recurrent repairs. Fengler et al. reported 14 patients with recurrent rectal prolapse that were treated over a 10-year period. Those authors found a slightly earlier average time to recurrence than the Hool group, at 14 months. Treatment of these patients involved either a perineal or an abdominal approach, with a follow-up of 50 months for either approach. At the end of the study, there was only one death and there was no recurrence in the remaining patients [8]. Overall, complications included one patient with mucosal sloughing that occurred between two anastomotic lines, and three patients with preoperative fecal incontinence had no resolution of symptoms. Pikarsky matched 27 cases of reoperative recurrent prolapse with an equal number of primary prolapse repair, utilizing a mixture of abdominal and perineal approaches with a mean follow-up of 24 months. The overall recurrence rate between the recurrent repair and primary repair was similar (15% vs. 11%) [10].