Rectal Prolapse in

Adults
Grand Rounds
University of Kentucky
Department of Surgery
Rectal Prolapse

 Also termed ‘rectal

procidentia’
 Definition:
protrusion of the
rectum beyond the
anus
 Often associated
with incontinence
and/or constipation
Rectal Prolapse

 It is physically
uncomfortable
 Dramatic influence
on body image
 Leads many
patients to limit or
completely
eliminate social and
other activities
Rectal Prolapse

 It has a 6:1 female

to male
predominance
 Peak incidence is in
the 6th-7th decades
of life
History

 Described 3500 years ago in the Ebers

Papyrus
 One of the Coptic mummies from 400-
500 B.C. was found to have rectal
prolapse
 Honey suppositories were suggested
as one means of treatment by the
Egyptians
History

 Hippocratic Corpus (400 B.C.)

describes a technique for the
treatment of rectal prolapse…
Hippocratic Corpus

 Start by hanging the affected

individual by their heels
 Shake the patient until the gut returns
to the body cavity
 A caustic potass is then applied to the
rectal mucosa
 Bind the thighs together for three days
History

 Riolanus (1598) and Fabricus ab

Aquapendente (1648) both described
burning the external anus to cause
scarring in order to prevent rectal
prolapse.
History

 In 1617 Woodall reported that he was

able to successfully treat rectal
prolapse with an alternative method:
Apply powdered dog dung to the
prolapsed rectum
The key was that the dog who provided
the specimen had been fed bones
History

 Parey (1634) proposed that rectal

prolapse occurred due to sitting on
cold rocks and not keeping one’s
bottom warm.
 Thus, he proposed wearing breeches.
History

 Wiseman (1676) described carving two

sticks in such a way that they would
prevent prolapse during defecation.
 Morgagni (1763) constructed a truss
made of leather and iron wings to help
hold up the prolapse.
 Salmon studied rectal prolapse
extensively (1800s) and at one point
advocated placing leeches at the anal
orifice.
Rectal Prolapse-Cause

 Still debated and it is considered

multifactorial
 “The search for a single common theory for
the cause of rectal prolapse has not been
fruitful.”
 “The precipitating factors in the
development of complete rectal prolapse are
not completely understood. Various theories
have been put forth to explain the cause(s)
of the prolapse.”
Rectal Prolapse-Cause

 In the first half of the 20th century the

predominant theory as to the cause of
rectal prolapse was that it was actually
a sliding hernia.
 First proposed by Moschcowitz
Rectal Prolapse-Cause

 Hunter suggested an alternative

theory of intussusception.
 This supported by Broden and
Snellman.
Procidentia of the rectum studied with
cineradiography. A contribution to the
discussion of causative mechanism.

 Published in 1968 in DCR

 Used cineradiography to show that
rectal prolapse was due to an
intussusception
 This intussusception starts 6-10 cm
above the anal verge
Rectal Prolapse-Cause

 Multiple anatomic and physiologic

abnormalities have been shown to be
associated with rectal prolapse:
Rectal Prolapse-Anatomic
Abnormalities
 Deep cul-de-sac
 Redundant sigmoid
colon
 Poor sacral fixation
 Lax in the lateral
ligaments
Rectal Prolapse-
Physiologic Abnormalities
 Atonic levator ani
muscles
 External anal
sphincter weakness
 Non-relaxing
puborectalis
 Pudendal nerve
injury
Pudendal Nerve Injury

 Somatic nerve which comes from the

sacral plexus (L4-S1)
 It innervates the rectum and bladder
 Gives off multiple branches including
the inferior anal nerves and the
inferior rectal nerves
Pudendal Nerve Injury
Pudendal Nerve Injury

 In addition to being
associated with
fecal incontinence
pre-op, it is a
predictor of post-
operative fecal
incontinence
Pudendal Nerve Injury

 Differing authors
attribute varying
significance to it
causing rectal
prolapse
 It has however
been shown to to
be related to fecal
incontinence
Pudendal Nerve Injury

 Additionally, it has
been shown to be
predictive of fecal
incontinence after
rectal prolapse
repair
Presentation

 Primary complaint  Tenesmus

is their rectum  Bleeding
coming out  Mucus discharge
 May mistake it as  Constipation
hemorrhoids
 Fecal incontinence
 Sensation of
incomplete
evacuation
Evaluation

 Rectal prolapse can be incarcerated

and represent a surgical emergency
 So, rule out incarceration
Evaluation

 Start with a good history

-When does it occur?
-Associated symptoms
-Pay attention to patient’s general
state of health and associated medical
problems as this may influence which
surgical intervention to offer the
patient
Evaluation

 While multiparity is suggested as a

cause, up to 40% of patients with
rectal prolapse will be nulliparous
 An association with psychiatric illness
which may require chronic
therapy/intervention
 Nursing home patients represent a
number of additional patients
Evaluation

 Physical exam
-Either lithotomy, left lateral
decubitus, or prone position
-Examine the rectum and perineum
with the patient relaxed and with them
straining
-May have to have the patient sit on
the toilet and strain to cause the
prolapse
Evaluation

 Before considering surgical

intervention, assess the full colon
Evaluation
Evaluation
Evaluation

 Before considering surgical

intervention, assess the full colon
 Look for redundant sigmoid
 Identify lead point
 Evaluate colonic mucosa
 Rule out additional pathology, such as
a neoplasm which may be causing the
prolapse
Evaluation

 Anorectal manometry and pudendal

nerve terminal motor latency (PNTML)
should be considered in patients with
fecal incontinence
Evaluation

 Patients with constipation should

undergo colonic transit studies.
 This involves having the patient ingest
24 radiopaque markers.
 Sequential daily films are performed to
assess movement of the markers
 Patients with total colonic inertia will
retain at least 80% of the markers
after five days
Total colonic inertia

 It is a separate disease process and

often requires total abdominal
colectomy
Evaluation

 Additional modalities include:

 Dynamic pelvic floor MRI
 Endorectal ultrasound
 Cinedefecography
Cinedefecography

 Involves placing contrast into the

rectum, vagina, and bladder
 Allow the patient to evacuate their
bowels in a normal sitting position
 Real-time images obtained
 Can be useful to detect occult internal
rectal prolapse/intussusception
Nonoperative
Management
 High fiber diet
 Biofeedback may be helpful for
patients with internal intussusception
and inappropriate pelvic floor
contraction
 Does not play a significant role in the
treatment of rectal prolapse
Surgery

 There are over 130 described

procedures in the literature for the
treatment of rectal prolapse
 The primary dichotomy is between an
abdominal approach or a perineal
approach
Abdominal approach

 The first step is mobilization of the

rectum
 Involves dissection between the
mesorectum and the presacral fascia
 Mobilization is taken down to the level of
the levators
 Anterior mobilization should be taken to
the level of the vagina or seminal vesicles
Abdominal approach

 During rectal mobilization, we come to

our first question of debate:
 Should one take the lateral stalks of
the rectum?
 The lateral stalks contain the
parasympathetic component of the
inferior hypogastric plexus
 Taking the stalks leads to denervation
of the rectum
Abdominal approach

 Varma et al performed a prospective,

randomized assessement of this issue:
 They concluded division of the lateral
ligaments was associated with less
recurrent prolapse
 However, it was also associated with
more postoperative constipation
 Small study
Abdominal approach

 The next area to consider is rectopexy.

 Various methods of rectopexy have
been described.
Ripstein procedure

 First described in 1952

 After mobilization of the rectum is
undertaken, a piece of prosthetic
mesh is placed around the anterior
wall of the rectum
 Done at the level of the peritoneal
reflection
Ripstein procedure

 Nonabsorbable suture is used to

secure the mesh to the presacral
fascia 1 cm from the midline on each
side.
 Absorbable sutures are then used to
secure the anterior rectal wall to the
mesh.
 Finally, the cul-de- sac is obliterated
using nonabsorbable sutures
Ripstein procedure

 Has the advantage of low recurrence

rates: 0-9.6%
 Has the disadvantage of high rate of
complications: up to 52%
 One of the more disastrous
complications is mesh erosion into the
rectum
Wells’ posterior Ivalon
rectopexy
 First described in 1959
 Start with similar rectal mobilization
 Then a sheet of Ivalon (polyvinyl alcohol) is
fixed to the sacrum with nonabsorbable
sutures.
 Then it is secured to the rectum posteriorly,
leaving the anterior rectum uncovered.
 Finally, the peritoneum is closed over the
mesh.
Wells’ posterior Ivalon
rectopexy
 Low recurrence rates: 3.0-6.0%
 Morbidity rate of up to 19%
 Still, this includes complications such
as mesh erosion and resulting fistula
formation
 Recently, surgeons have abandoned
the use of Ivalon in favor of other
meshes, both absorbable and
nonabsorbable
Suture rectopexy

 In 1959, Cutait proposed suture

rectopexy without the implantation of
mesh.
 He posited that mesh was not
necessary and increased the risk of
post-operative complications.
Suture rectopexy

 He described fixing the mesorectum to

the presacral fascia with
nonabsorbable suture at the upper
third of the sacrum on both sides
 Subsequent studies showed
recurrence rates of 0-9% with an
improvement in complication rates
Suture rectopexy

 Additionally, some have suggest a

theoretical benefit of less constipation,
but this has yet to be proven
Suture rectopexy with
resection
 First described by Frykman in 1955
 Combined resection with rectopexy
 Recommended for rectal prolapse patients
with a long, redundant sigmoid colon
 It has decreased rates of post-operative
constipation
 Thus for patients with a long, redundant
sigmoid and significant pre-op constipation,
it is the procedure of choice
Suture rectopexy with
resection
 Rectopexy is generally a simply suture
rectopexy, but mesh rectopexy
combined with resection has been
described
 It is thought that the redundant
sigmoid may kink at the rectosigmoid
junction, causing both delayed
passage of intestinal contents and
increased baseline rectal pressures
Suture rectopexy with
resection
 Recurrence rates of 0-5% in all but
one study, which showed a 9%
recurrence rate
 Additional theoretical advantage of
prevention of sigmoid volvulus
 Complication rates shown to be similar
to rectopexy alone
Laparoscopy

 All open abdominal procedures have

been successfully undertaken
laparoscopically
 Two largest studies were by Ashari
and Kariv
 Both showed similar recurrence rates
and functional outcomes compared to
similar open procedures
Laparoscopy

 As expected, longer OR times but shorter

hospital stays
 Cost analysis shows decreased costs due to
shorter hospital stays
 Additional studies continue to support
laparoscopy as safe and effective for the
treatment of rectal prolpase
– Stevenson
– Xynos
– Kellokumpu
Perineal approach

 Have the major advantage of being

much less invasive and generally
associated with shorter OR times and
hospital stays
 However, they are associated with
much higher recurrence rates.
 Generally advocated for the unfit, or
frail, patient.
Anal encirclement
procedure
 First described by Thiersch in 1871
 Commonly referred to as the Thiersch
procedure
 Two small incisions are made anteriorly
and posteriorly on both sides of the anus
 After tunneling between incisions, a silver
wire is placed and serves to narrow the
anal canal
Anal encirclement
procedure
 The procedure has been since modified
to use prosthetic mesh in place of the
silver wire
 Has extremely high recurrence rates
 Also causes fecal impaction in up to 80%
of patients
 Essentially a historical procedure at this
point, although it could be theoretically
used for extremely high risk patients
Mucosal sleeve resection

 First described by Delorme in 1900

 Commonly referred to as the Delorme
procedure
 Rectum is pulled down to the extent of
the prolapse
 Elevate the submucosal layer using an
epinephrine solution
Mucosal sleeve resection

 Make a circumferential incision 2 cm

proximal to the dentate line down to
muscle
 Continue with dissection of the
mucosa proximally and
circumferentially until there is some
resistance
Mucosal sleeve resection

 Nonabsorbable sutures are placed in a

longitudinal fashion in the exposed
muscle layer
 This serves to collapse the muscle in
an accordion-like effect
 The stripped mucosa is then resected
Mucosal sleeve resection

 Finally, a mucosal
anastomosis is
created using
absorbable suture
in an interrupted
fashion
 The anastomosis is
then returned to
the anal canal
Mucosal sleeve resection

 Biggest drawback is a high recurrence

rate, which has been reported as high
as 38%
Perineal
rectosigmoidectomy
 First described by Mickulicz in 1889
 It had support in the first half of the
20th century, but fell out of favor in
the 1950s with the with the onset of
transabdominal approaches
Perineal
rectosigmoidectomy
 In 1971, Altemeier
et al published
results showing
favorable outcomes
(3 recurrences in
106 patients)
 It has
subsequently been
referred to as the
Altemeier
procedure
Perineal
rectosigmoidectomy
 The rectal prolapse is everted through
the anus and Babcock clamps are
placed
 A circumferential incision is made 1.5-
2 cm above the dentate line
 This serves to preserve the anal canal
Perineal
rectosigmoidectomy
 This differs from the Delorme
procedure in that it is full thickness
 The incision is carried through all
layers of the rectal wall
 By starting the dissection posteriorly,
one can tell that they are through all
layers of the rectal wall when they
encounter the perirectal fat and
mesorectum
Perineal
rectosigmoidectomy
 Then continue circumferentially until
the entire incision is full thickness
 Proceed proximally, ligating the
mesorectal vessels close to the rectal
wall
 Eventually the peritoneum will be
encountered, and it is divided
Perineal
rectosigmoidectomy
 Continue mobilizing the redundant
sigmoid and carefully taking all vessels
until all redundancy has been removed
 The excess colon and rectum are
eventually divided, and then a hand-
sewn or stapled anastomosis using an
EEA is performed
 Optional to close the peritoneum
Perineal
rectosigmoidectomy
 Even though Altemeier et al reported
excellent outcomes with low
recurrence rates, these results could
not be replicated
 Recurrence rates in subsequent
studies were as high as 44%
Perineal
rectosigmoidectomy
 In 1984, Gopal et al published a study
with describing an anterior
levatorplasty added to the Altemeier
repair.
 They had a one recurrence in 18
patients (6%)
Perineal
rectosigmoidectomy
 In 1994, Ramanujam et al described a
posterior levatorplasty
 They had a recurrence rate of 6%.
 The largest subsequent study looking
at perineal rectosigmoidectomy was
Chun et al with 120 patients and they
reported a 16% recurrence rate
Perineal
rectosigmoidectomy
 Levatorplasty is performed while the
colon is mobilized but before it has
been resected.
 Drawing it anteriorly or posteriorly will
allow visualization of the levator ani
muscles
 Levatorplasty is performed with
interrupted nonabsorbable sutures
Perineal
rectosigmoidectomy
 At the completion of the levatorplasty,
the surgeon should still be able to
pass a finger along side of the rectum
 In addition to decreasing recurrence,
there is some data to support that it
lowers incontinence rates
Perineal
rectosigmoidectomy
 Even with levatorplasty, recurrence
rates with perineal
rectosigmoidectomy are not equivalent
to abdominal approaches
 However, recurrent rectal prolapse
after rectal prolapse repair (abdominal
or perineal) can be treated with by
perineal rectosigmoidectomy
Conclusions

 Rectal prolapse is a complicated

disease process due to a combination
of factors
 Thorough pre-operative workup is
required to determine the appropriate
procedure
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Questions???