Surgical Management of Rectal Prolapse

Section 1: Evaluation of rectal prolapse:

·       The initial evaluation of a patient with rectal prolapse should include a complete history and physical examination with focus on the prolapse, on anal sphincter structure and function, and on concomitant symptoms and underlying conditions, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·       Before surgical management of rectal prolapse, we recommend colonoscopy to identify other important coexisting pathology, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

·       We advise additional testing, such as a fluoroscopy or MRI defecography, barium enema, and urodynamics, to be used selectively to refine the diagnosis and identify other important coexisting pathology, (Conditional recommendation, moderate certainty evidence, ⁽¹⁾).

·       We advise performing anal physiologic testing to assess and treat coexisting functional disorders associated with rectal prolapse, such as constipation or fecal incontinence, (Conditional recommendation, low certainty evidence, ⁽¹⁾).

Section 2: Non-operative management:

·       Although rectal prolapse cannot be corrected non-operatively, we may advise medical palliation of some of the symptoms associated with this condition, such as fecal incontinence, pain, and constipation, (Conditional recommendation, low certainty evidence, ⁽¹⁾).

·       We advise non-operative management in external rectal prolapse as preoperative treatment for the reducible form, (Good practice statement).

·        We advise non-operative management for poor surgical candidates and those refusing surgery, (Good practice statement).

Section 3: Abdominal surgical procedures for rectal prolapse:

·       We recommend rectopexy as a key component in the abdominal approach to rectal prolapse, (Strong recommendation, high certainty evidence, ⁽¹⁾).

·       We recommend mobilization of rectum with mesh fixation of the posterior rectal wall to the sacral promontory for treatment of rectal prolapse, (Strong recommendation, low certainty evidence, ⁽¹⁾).

·       We recommend against posterior rectal mobilization without a rectopexy (with or without a concomitant anterior resection), as it is associated with higher recurrence rates and complications, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

·       We advise performing sigmoid resection with posterior suture rectopexy in patients with prolapse and preoperative constipation, (Conditional recommendation, moderate certainty evidence, ⁽¹⁾).

·       We advise against division of the lateral stalks during posterior rectal dissection because it worsens postoperative constipation, (Conditional recommendation, moderate certainty evidence, ⁽¹⁾).

·       We advise performing a minimally invasive approach to rectal prolapse by experienced surgeons as it is associated with improved morbidity and comparable recurrences compared with open surgery and should be considered when technically feasible, (Conditional recommendation, moderate certainty evidence, ⁽¹⁾).

Section 4: Perineal Operations for Rectal Prolapse:

·       We recommend for patients with a short segment of full-thickness rectal prolapse, (<5cm) to be treated with mucosal sleeve resection (Delorme procedure), (Strong recommendation, low certainty evidence, ⁽¹⁾).

·       We recommend perineal rectosigmoidectomy (Altemeier procedure), when the abdominal approach is not feasible. (Conditional recommendation, high certainty evidence, ⁽¹⁾).

·       Perineal stapled prolapse resection may be performed as an alternative to other perineal procedures, (Good practice statement).

·       We advise that anal encirclement, (Thiersch procedure) or mucosal plication is reserved for selected patients, (children, old patients with contraindication to major surgery, etc.), (Good practice statement).