Clinical Practice Guidelines for the Treatment of Rectal Prolapse

STATEMENT OF THE PROBLEM Rectal prolapse is a disorder characterized by a full-thickness intussusception of the rectal wall, which protrudes externally through the anus. It is associated with a spectrum of coexisting anatomic abnormalities, such as diastasis of the levator ani, an abnormally deep cul-de-sac, a redundant sigmoid colon, a patulous anal sphincter, and loss or attenuation of the rectal sacral attachments. Some have hypothesized that the condition is associated with (and preceded by) internal rectal intussusception or a traumatic solitary rectal ulcer, although these associations have never been clearly proven.1–3 Rectal prolapse is rare and is estimated to occur in ≈0.5% of the general population overall, although the frequency is higher in females and the elderly, and women aged ≥50 years are 6 times more likely as men to prolapse.4–6 Although it is commonly thought that rectal prolapse is a consequence of multiparity, approximately one third of female patients with rectal prolapse are nulliparous. The peak age of incidence is the seventh decade in women. Interestingly, although fewer men have the condition, the age of incidence for these men is generally ≤40 years. A striking characteristic of younger patients, both male and female, is an increased tendency to have autism, syndromes associated with developmental delay, or psychiatric comorbidities requiring multiple medications.7 Although rectal prolapse is a benign condition, it can be debilitating because of the discomfort of prolapsing tissue both internally and externally, associated drainage of mucus or blood, and the common occurrence of concomitant symptoms of fecal incontinence, constipation, or both.8 Approximately 50% to 75% of patients with rectal prolapse report fecal incontinence, and 25% to 50% of patients report constipation.9–13 Incontinence in the setting of rectal prolapse may be explained by the presence of a direct conduit (ie, the prolapse), which disturbs the sphincter mechanism, the chronic traumatic stretch of the sphincter caused by the prolapse itself, and continuous stimulation of the rectoanal inhibitory reflex by the prolapsing tissue.14 Up to one half of patients with prolapse demonstrate pudendal neuropathy,15 which may be responsible for denervation-related atrophy of the external sphincter musculature.16 Constipation associated with prolapse may result from intussuscepting bowel in the rectum, creating a blockage that is exacerbated with straining, pelvic floor dyssynergia, and colonic dysmotility, although causality versus correlation remains highly debated.11,12 The goals of surgery to correct rectal prolapse are 3-fold: 1) to eliminate the prolapse through either resection or restoration of normal anatomy, 2) to correct associated functional abnormalities of constipation or incontinence, and 3) to avoid the creation of de novo bowel dysfunction. Multiple operations have been developed to achieve this complex 3-fold goal, each with various strengths and weaknesses underscoring the importance of careful patient selection and thorough patient counseling when choosing a surgical approach. METHODOLOGY These guidelines were built based on the last set of The American Society of Colon and Rectal Surgeons (ASCRS) practice parameters for treatment of rectal prolapse published in 2011.17 An organized search of Medline, PubMed, Embase, and the Cochrane Database of Collected Reviews was performed from October 2011 through December 2016. Retrieved publications were limited to the English language and human participants. The search strategies were based on the concepts of rectal prolapse and internal intussusception as primary search terms. Searches were also performed based on various treatments for rectal prolapse, including rectopexy, suture rectopexy, resection rectopexy, ventral rectopexy, D’Hoore rectopexy, Delorme procedure, and Altemeier procedure. An initial search identified 781 unique citations. These were ultimately categorized into subsets (see Table, Supplemental Digital Content 1, https://links.lww.com/DCR/A390). Directed searches of the embedded references from the primary articles were also performed in certain circumstances. Prospective, randomized controlled trials and meta-analyses were given preference in developing these guidelines. Ultimately, 172 articles were carefully reviewed, and articles with poor control subjects or unclear study end points were excluded. The final guideline was created using 110 unique citations listed in the references below. The final grade of recommendation was performed using the Grades of Recommendation, Assessment, Development, and Evaluation system (Table 1).18 A panel of members of the ASCRS Clinical Practice Guidelines Committee worked in production of these guidelines from inception to final publication. After initial completion of the article, the entire committee reviewed and edited it. Final recommendations were approved by the ASCRS Chairman and Vice Chairman of the Clinical Practice Guidelines Committee and then ultimately the Executive Council.TABLE 1.: The GRADE system: grading recommendationsEvaluation of Rectal Prolapse 1. 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. Recommendation: strong recommendation based on low-quality evidence, 1C. A careful history and physical examination should be performed before considering any operative intervention. If a patient’s history suggests the diagnosis but no prolapse is detected on physical examination, the patient can be asked to reproduce the prolapse by straining while on a toilet with or without the use of an enema or a rectal balloon. The perineum can then be inspected with the patient in the sitting or squatting position. One should be careful, however, to avoid confusing rectal prolapse with prolapsing internal hemorrhoids or rectal mucosal prolapse. Full-thickness rectal prolapse will always have concentric folds of prolapsed tissue, whereas prolapsed hemorrhoids or rectal mucosa will have radial invaginations. If the prolapse is elusive, patients can be asked to photograph the prolapse at home or undergo an echography. Full inspection of the perineum and complete anorectal examination are equally important. Usually, these will reveal a patulous anus with diminished sphincter tone. In 10% to 15% of cases, proctoscopy will show an anterior solitary rectal ulcer. Initial evaluation should also include a careful assessment of the possible coexisting symptoms of constipation and fecal incontinence. Furthermore, a careful review of symptoms pertaining to anterior compartment prolapse, such as urinary incontinence and vaginal/uterine prolapse, needs to be evaluated, because 20% to 35% of patients with rectal prolapse report urinary incontinence, and ≈15% to 30% have significant vaginal vault prolapse.6,19 Patients with multivisceral prolapse require a multidisciplinary approach.20 2. Additional testing, such as a fluoroscopy or MRI defecography, colonoscopy, barium enema, and urodynamics, may be used selectively to refine the diagnosis and identify other important coexisting pathology. Recommendation: strong recommendation based on moderate-quality evidence, 1B. If prolapse is suggested but cannot be seen during physical examination, fluoroscopic defecography, MRI defecography, or balloon expulsion testing may reveal the problem. Defecography may also reveal associated anterior pelvic floor support defects, such as cystocele, vaginal vault prolapse, and enterocele. These coexisting conditions, depending on symptoms, may require treatment as well.21,22 Patients with anterior compartment disorders and patients with urinary incontinence may benefit from urodynamics and urogynecologic examination to complete the evaluation and allow for concomitant surgical intervention to both the anterior and posterior pelvic compartments.23–25 Rarely, a neoplasm may form the lead point for a rectal prolapse.26 For this reason and because prolapse often occurs in the older population, colonoscopy should typically be performed before surgery, because this may change the operative plan. 3. Anal physiologic testing may be considered to assess and treat coexisting functional disorders associated with rectal prolapse, such as constipation or fecal incontinence. Recommendation: weak recommendation based on low-quality evidence, 2C. Constipation is commonly encountered in patients with rectal prolapse. Patients with severe constipation require special consideration in accordance with the ASCRS constipation clinical practice guideline.27,28 Patients with constipation and/or evidence of pelvic dyssynergia on testing may not be ideal candidates for certain surgical maneuvers known to exacerbate constipation after surgery, such as posterior rectal mobilization, transection of the lateral ligaments during suture rectopexy, or levatorplasty during a perineal proctectomy, as discussed further in these guidelines. Fecal incontinence, another commonly associated finding in patients with rectal prolapse, is thought to be caused by the chronic dilation of the anal sphincter preceded by years of diminished internal anal sphincter pressures. In general, because many patients with fecal incontinence secondary to rectal prolapse experience improvement in their symptoms once the prolapse is treated, rectal prolapse should be corrected as a first step in patients reporting of rectal prolapse and fecal incontinence. Patients with pre-existing fecal incontinence or incontinence thought to be attributed to a process other than prolapse should be evaluated in accordance with the ASCRS clinical practice guideline for fecal incontinence.29 If testing reveals decreased pudendal nerve terminal motor latencies, this may have postoperative prognostic significance: patients with evidence of nerve damage appear to have a higher rate of incontinence after surgical correction of the prolapse, although more studies are necessary to confirm the finding.30–32 Other maneuvers, such as additional bowel resection, may also diminish continence. In general, many patients with fecal incontinence secondary to rectal prolapse experience some improvement in their symptoms once the prolapse is treated. Thus, in general, rectal prolapse should be corrected as a first step in patients reporting rectal prolapse and fecal incontinence. Conversely, constipation-inducing maneuvers, such as transection of the lateral ligaments during suture rectopexy, may be beneficial in these situations. Nonoperative Management 1. Rectal prolapse cannot be corrected nonoperatively, although some of the symptoms associated with this condition, such as fecal incontinence, pain, and constipation, can be palliated medically. Recommendation: weak recommendation based on low-quality evidence, 2C. There are no reports of rectal prolapse being resolved through medical therapy alone. Although surgical treatment is under consideration, prolapse-associated symptoms of constipation and fecal incontinence can be treated nonsurgically to improve quality of life. Fiber and stool softeners may be used to treat constipation.33 Table sugar can be used topically to reduce edema and assist in reduction maneuvers with incarcerated rectal prolapse.34 Attention to skin care to avoid skin maceration may also be beneficial. Although none of these palliative interventions addresses the prolapse itself, they may improve patient condition and ultimate quality of life. In addition, one recent retrospective study of 139 women showed that pretreatment of incontinence symptoms before surgery led to a better improvement in postoperative continence.35 Any surgical treatment must, of course, be tailored to the patent’s overall medical condition, history of previous procedures, and patient willingness to undergo an operation. However, all of the patients who are candidates for surgical treatment of rectal prolapse–including the elderly–should be advised to act quickly, where possible, and avoid unnecessary delays and occasional bowel incarceration. Although consideration of surgical treatment should be tailored to a patent’s overall medical condition and history of previous procedures, patients who are reasonable candidates for surgical treatment of rectal prolapse, including the elderly, should be advised to avoid unnecessary delays, because avoiding surgery can lead to significant deterioration in function. In the long term, patients with rectal prolapse who do not undergo surgery and are only managed medically will develop irreversible fecal incontinence.36 In addition, allowing prolapse to continue untreated beyond 4 years may lead to higher rates of subsequent rectal prolapse recurrence, presumably secondary to a secondarily weakened pelvic floor.37 Operations for Rectal Prolapse Surgery is the main form of treatment for rectal prolapse, and many operative procedures have been described in the historical literature, including anal encirclement, mucosal resection, perineal proctosigmoidectomy, anterior resection with or without rectopexy, suture and a of procedures the use of or to the including D’Hoore ventral with a procedures are In general, these procedures of general versus which is by the comorbidities of the the preference and and the patient’s age and bowel important the of pelvic either posterior or the procedures that are in common practice and are commonly in the for Rectal Prolapse 1. In patients with the of for the treatment of rectal prolapse should typically rectal Recommendation: weak recommendation based on moderate-quality evidence, to retrospective rates after surgery for rectal prolapse are approximately one after perineal surgery, and the is associated with better functional of these overall the is by including previous as the treatment for younger and However, the to support these rates have been into A Cochrane review patients in randomized or trials no significant in prolapse and perineal A of the Cochrane review including randomized controlled trials a while the of randomized controlled trials to these A third review of randomized controlled trials patients was also to demonstrate a in rates the Some have that patient selection (ie, the that perineal surgery is to patients who may have higher rates of to poor and prolapse may rates after perineal One in which all patients were treated with perineal proctectomy, showed that after of rates of rectal prolapse in patients years of age were with of patients generally A randomized controlled of patients, the Prolapse Surgery or by the of of and to these also no significant in the rate of rectal prolapse based on the surgical However, this study been for and being Some who a perineal have to that the and rates of the are However, these studies have also been into by which that the and of the perineal have been A recent of patients a in the of in the patients treated by perineal Although many continue to when the perineal and to be careful consideration of patient comorbidities and associated bowel with the of the with the of while also coexisting bowel 2. There is evidence to that posterior rectal prolapse such as suture or resection with suture rectopexy, are better or than anterior rectal prolapse such as ventral Recommendation: strong recommendation based on low-quality evidence, 1C. rates of rectal prolapse after posterior prolapse or anterior prolapse at However, these may be with some because is ventral patients and have been studies the One patients treated with either resection or ventral and suggested improvement in functional symptoms, such as constipation, with a significant in postoperative in the patients who However, the is by significant because the study to a retrospective of of patients treated by one or the other in additional retrospective of and patients ventral versus suture without resection and rates of the of the of needs to be by surgical and patient surgical and Rectal to Rectal Prolapse 1. rectal without a or without a concomitant anterior is associated with higher rates and and is typically not Recommendation: strong recommendation based on moderate-quality evidence, 1B. is a of treatment in which the is in the the and the at the sacral and is to the It may be performed in or in with an anterior studies show that posterior not rectal prolapse when the is with a anterior resection a sigmoid are In review of patients, the rate to after and years to and with an operative of including review with an of 6 in of pelvic in with may lead to additional loss of function. the of functional for this procedure, the and and the of that can achieve better with anterior resection or posterior rectal without additional is not typically and 1. is a in the to rectal prolapse. Recommendation: strong recommendation based on evidence, to the of the in the with suture and was first described by in the to the sacral to the of the redundant appear to be in to the of the with suture and the and from the posterior rates for suture are generally to be from to at although from the Rectal Prolapse suggests that the rate may to of the is A recent randomized controlled patients of with patients an in rates in the patients treated with with posterior rectal can or 50% of patients with constipation report that their condition after rectopexy, and ≈15% of patients with no constipation constipation after the The of constipation is but it is thought to be attributed to posterior of the Patients with severe constipation and rectal prolapse should undergo more than a suture include resection suture rectopexy, ventral rectopexy, or perineal 2. resection may be to posterior suture in patients with prolapse and Recommendation: strong recommendation based on moderate-quality evidence, 1B. to the of a sigmoid resection to the suture discussed The was first described by in and was in articles in and which showed prolapse rates with an rate and rates of retrospective reports have from to and reasonable from to The of to the the rate and functional with a in In general, resection should be in patients with rectal prolapse after a previous perineal because resection in this can lead to In to the of the resection the of of and the resection of a redundant sigmoid In addition, randomized controlled trials of patients who constipation rates of postoperative constipation after resection with However, the may for rectal prolapse patients with fecal the of fecal incontinence to be when sigmoid resection is Some that sigmoid resection should not be to patients with anal on or patients with severe resection is not in with 3. of the lateral during posterior rectal may postoperative constipation but is associated with decreased Recommendation: weak recommendation based on moderate-quality evidence, The of lateral during rectal to rates for rectal but is generally associated with A recent Cochrane review of randomized controlled trials patients with and without lateral that the of the lateral was associated with rectal prolapse but more postoperative constipation, this in the patients with fecal incontinence without 1. of with of the anterior rectal to the sacral may be used for treatment of rectal prolapse but is associated with higher Recommendation: strong recommendation based on low-quality evidence, 1C. The (and many of a or the and the to the the sacral In the procedure, after of the rectum, and a of the anterior of the at the of the and were used to the to the the and both of the were to the rates from to but rates were because of the of a on the anterior rectal of the through the or and fecal a and the to include posterior of the to the with of the of the to the rates with a 20% postoperative rate of these were in significant improvement in fecal incontinence in 20% to of 2. A using a of for posterior of the may be used for treatment of rectal prolapse. Recommendation: weak recommendation based on moderate-quality evidence, The procedure, as of the using an and transection of the lateral with However, a randomized of versus suture increased rates and postoperative constipation in the with no improvement in a the study that this be Although the is no the using other such as and to be for There are no however, to the of these alone. Rectal to Rectal Prolapse 1. an to the of rectal prolapse with and Recommendation: strong recommendation based on low-quality evidence, 1C. rectopexy, developed by D’Hoore and is the only for rectal prolapse that only a limited anterior rectal The careful of the from the to the perineal with no posterior of the from the than to a of for the After this limited rectal mobilization, a ventral is performed using or The the anterior of the at the point of intussusception and the to the sacral is in to the where the is both and before to the In to being as being in the prolapse, D’Hoore an improvement in postoperative constipation and no incidence of de novo that avoiding posterior rectal to the and of the with retrospective rates to suture with postoperative A subsequent review patients treated with either posterior rectal or ventral suggested that patients ventral a rate of and a in the postoperative constipation rate estimated to be These with reports rates of postoperative have led many in to that this is the of treatment for rectal prolapse. A recent panel pertaining to this suggested using this in patients with pre-existing constipation and abnormalities in the anterior such as However, this to in the given the limited on when with more and the of These appear to be to some by a recent retrospective report of ventral patients a rate of and a rate of but additional are Additional Surgery 1. A to rectal prolapse by is associated with and with surgery and should be considered when Recommendation: strong recommendation based on moderate-quality evidence, 1B. treatment of rectal prolapse, first described in with a rectopexy, the goals as surgery, which are full-thickness rectal prolapse, bowel and and and the do not appear to studies with have rates and but to the in of of and of bowel rectal prolapse surgery to with although are no randomized controlled trials clearly of the of and and of the deep of of surgery, as with are times and increased although times may be a result of One recent randomized controlled the for ventral performed by to show in the of or in A of ventral and showed no strong benefit of one the Operations for Rectal Prolapse 1. Patients with a of full-thickness rectal prolapse can be treated with mucosal Recommendation: strong recommendation based on low-quality evidence, 1C. The Delorme procedure, for patients with a full-thickness rectal prolapse, a mucosal resection and of the studies that rates after Delorme in the of 10% to 15% may be higher than rates after but a recent randomized controlled showed that rates and functional after Delorme procedures were to perineal or The Delorme procedure, used more in patients, is generally considered Approximately to of patients experience urinary and fecal The can improve constipation and fecal incontinence, but and do One study of postoperative that and were increased from with an associated in 2. Rectal prolapse may be treated with a perineal Recommendation: strong recommendation based on low-quality evidence, 1C. the Altemeier procedure, a full-thickness resection of the prolapsed and a The can be performed without general and a and rates with However, rates of to 30% at years are and may be by the of rates after perineal be decreased using a which was in study to reduce rates from to presumably by the concomitant levator patients perineal are with more comorbidities than who are considered for There are perineal with an approach. of the randomized controlled trials the showed a significant in but both studies were The ASCRS is to patient care by the and of disorders and of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is of members who are because they have in the of and rectal committee was created to lead in quality care for to the colon, rectum, and anus. is by developing clinical practice guidelines based on the These guidelines are and not is to on which can be than to a form of These guidelines are for the use of all and patients who the of the by the in these guidelines. It should be that these guidelines should not be of all of care or of of care the The ultimate the of any be by the in of all the by the