rectal prolapse 5

REVIEW

Rectal prolapse

Stavros Gourgiotis & Sotirios Baratsis

Accepted: 26 July 2006 / Published online: 5 October 2006# Springer-Verlag 2006

AbstractIntroduction Rectal prolapse, or procidentia, is defined as aprotrusion of the rectum beyond the anus. It commonlyoccurs at the extremes of age. Rectal prolapse frequentlycoexists with other pelvic floor disorders, and patients havesymptoms associated with combined rectal and genitalprolapse. Few patients, a lack of randomized trials anddifficulties in the interpretation of studies of anorectalphysiology have made the understanding of this disorderdifficult.Methods of treatment Surgical management is aimed atrestoring physiology by correcting the prolapse andimproving continence and constipation, whereas in patientswith concurrent genital and rectal prolapse, an interdisci-plinary surgical approach is required. Operation should bereserved for those patients in whom medical treatment hasfailed, and it may be expected to relieve symptoms.Numerous surgical procedures have been suggested to treatrectal prolapse. They are generally classified as abdominalor perineal according to the route of access. However, thecontroversy as to which operation is appropriate cannot beanswered definitively, as the extent of a standardizeddiagnostic assessment and the types of surgical procedures

have not been identified in published series.Literature review This review encompasses rectal prolapse,including aetiology, symptoms and treatment. The English-language literature about rectal prolapse was identifiedusing Medline, and additional cited works not detected inthe initial search were obtained. Articles reporting onprospective and retrospective comparisons and case reportswere included.

Keywords Rectal prolapse . Aetiology . Symptoms . Surgery

Introduction

The classic description of rectal prolapse, or procidentia, isa protrusion of the rectum beyond the anus [1]. Complete orfull-thickness rectal prolapse is the protrusion of all of therectal wall through the anal canal; if the rectal wall hasprolapsed but does not protrude through the anus, it iscalled an occult (internal) rectal prolapse or a rectalintussusception [2, 3]. Full-thickness rectal prolapse shouldbe distinguished from mucosal prolapse in which there isprotrusion of only the rectal or anal mucosa [1–3].

Rectal prolapse occurs at the extremes of age [1, 4]. Inthe paediatric population, the condition is usually diagnosedby the age of 3 years, with an equal sex distribution. Theincidence of rectal prolapse in children with cystic fibrosisis almost 20%. In the adult population, the peak incidenceis after the fifth decade, and women are more commonlyaffected, representing 80% to 90% of patients with rectalprolapse [1, 4]. Female patients have an increasingincidence with each decade until a crest in the seventhdecade [5]. Patients with complete rectal prolapse havemarkedly impaired rectal adaptation to distension, which

Int J Colorectal Dis (2007) 22:231–243DOI 10.1007/s00384-006-0198-2

S. Gourgiotis (*)Clinical Attachment in Division of GeneralSurgery and Oncology, Royal Liverpool University Hospital,21 Millersdale Road, Mossley Hill,L18 5HG Liverpool, UKe-mail: [email protected]

S. BaratsisFirst Surgical Department,‘Evangelismos’ General Hospital of Athens,45-47 Ipsilantou Street,Kolonaki, Athens, Greece

may contribute to anal incontinence, and consequently,more than half of the patients with rectal prolapse havecoexisting incontinence [6–10]. Constipation is associatedwith prolapse in 15% to 65% of patients [1, 9, 11–14].Straining may force the anterior wall of the upper rectuminto the anal canal, perhaps causing a solitary rectal ulcerdue to mucosal trauma [1, 15].

This study reviews the pathophysiology, causations,symptoms and treatment of rectal prolapse. A PubMeddatabase search was performed. All abstracts were reviewedand all articles in which cases of rectal prolapse could beidentified were further scrutinized. Further references wereextracted by cross-referencing.

History

Complete rectal prolapse has been reported ever since theEgyptian and Greek civilizations [16]. The first writtenreport for this disorder was found in the Ebers Papyrus of1500 B.C. Even more graphic evidence of its historic natureexists in the preservation of a Coptic mummy with rectalprolapse (400–500 B.C.) [17]. The Hippocratic Corpusdescribes a method of treatment that included hanging theperson by the heels and shaking the person until the gutreturned to its place. After the prolapse was reduced, a‘caustic potass’ was applied to the rectal mucosa, and thethighs were bound together for 3 days.

Both Riolanus [18] and Fabricius ab Aquapendente [19]burned the external anus to cause scarring and thereforeprevent prolapse. In 1634, Parey [20] attributed prolapse tositting on cold stones and failure to keep the buttockswarm. His suggested treatment was the wearing ofbreeches. In 1617, Woodall [21] met with reported successby powdering the prolapsed rectum with the dry dung of adog that had been fed on bones. In 1676, Wiseman [22]suggested that two sticks be carved in such a way that theycould be used to prevent prolapse during defecation.Morgani [23], in 1763, described a truss made of softleather and iron wings to hold up the prolapse.

Salmon [24] championed the theory of a spasmodicstricture of the rectum as the cause of rectal prolapse.Mikulicz [25] popularized perineal amputation of rectalprolapse in 1888, and Lockhart-Mummery [26], in 1910,performed a perineal procedure for the treatment of rectalprolapse. In 1912, Moschcowitz [27] performed surgicalrepair of rectal prolapse inside the abdomen. The conceptthat a rectal prolapse was an intussusception was firstdescribed by Hunter in the eighteenth century [28], and itwas confirmed by Broden and Snellman in 1968 [29].

The twentieth century was the time for the developmentof more effective abdominal and perineal procedures for

rectal prolapse, and at the end of twentieth century, therewas a trend towards minimal access operation.

Causes

The search for a single common theory for the cause ofrectal prolapse has not been fruitful. In a review of theliterature, one well-documented physiologic study seeming-ly contradicts another study that is equally well performed.The lack of an international classification system makes acomparison of results between series difficult, and perhaps,the truth will be found if rectal prolapse is defined more as asymptom rather than a diagnosis.

The anatomical basis for rectal prolapse is a deficientpelvic floor through which the rectum herniates [3, 29–31].A redundant sigmoid colon lying within a deep pelvic cul-de-sac, together with a resulting acute retrosigmoid junc-tion, causes the patient to strain excessively to defecate, andthe eventual prolapse is the result of herniation through theweakened pelvic floor. This anatomical concept, which wasproposed by Moschcowitz [27], led to attempts to obliteratethe sliding hernia by obliteration of the pouch of Douglas.The high recurrence rate associated with this type ofsurgery was responsible for the demise of the ‘slidinghiatus hernia’ theory as the cause of rectal prolapse [32].

Another view is that complete rectal prolapse may be theendpoint of a spectrum. The theory that a rectal prolapse wasan intussusception was first described by Hunter [28],whereas Broden and Snellman confirmed it using cinera-diography [29]. Complete rectal prolapse was the result of acomplete circumferential intussusception starting 6–8 cmfrom the anal verge and continuing through the anal canal,everting onto the perineum [29, 33, 34]. Support for thistheory is found in articles that note that patients with rectalprolapse have lower basal and squeeze pressures withanorectal manometry than normal control subjects [35]. Thetheory is probably not correct. Mellgren et al. [36] followed38 patients with defecography for various defecation disor-ders, and their conclusion was that the risk of the develop-ment of rectal prolapse in patients with intussusception wassmall. Another study in 90 patients noted similar results [37].

Parks [38] suggested that rectal prolapse was in part dueto injury to the pudendal nerves from repeated stretching ofthe pelvic floor. Supporters of this theory note the frequentassociation between neurogenic faecal incontinence andrectal prolapse [30, 31]. Detractors of this theory emphasizethe patients who have normal innervation and rectalprolapse and the fact that incontinence often improves aftermost procedures for rectal prolapse.

Another theory supports that the lax lateral ligamentscombined with the atonic condition of the muscles of thepelvic floor and anal canal may be the cause of rectal

232 Int J Colorectal Dis (2007) 22:231–243

prolapse [29, 30]. Finally, some authors believe that thelack of normal fixation of the rectum, with a mobilemesorectum and lax lateral ligaments, can cause rectalprolapse [4, 30, 39]. With this abnormality, the smallintestine, which lies against the anterior wall of the rectum,may force the rectum out through the anal canal [29].

Symptoms, associations and evaluation

The symptoms of rectal prolapse closely mimic the warningsigns that the public is taught for rectal cancer; a mass, ableeding, a protrusion and a change in bowel habits.Earliest symptoms include a reducible protrusion that maybe associated with a mucous discharge. Early in the course,the rectal prolapse may only occur in association withbowel movements. The patient may complain of a feelingof incomplete evacuation or tenesmus. Later, after theprolapse has been present for some time, the patient mayexperience loss of control of stool because of stretching ofthe sphincter muscles and pudendal nerves. Finally, as therectum spends more time prolapsed, there may be bleeding.

In 8% to 27% of patients, rectal prolapse may be asso-ciated with concomitant pelvic floor disorders [40]. Previouspelvic surgery, obstetric trauma, elevated intra-abdominalpressure, increasing age and chronic constipation areknown to be aetiological factors for both genital and rectalprolapse [40]. In these patients, denervation of the pelvicfloor muscles is observed, [40] whereas high rates of pelvicorgans prolapse and urinary incontinence have beendescribed in patients with Marfans syndrome and Ehlers–Danlos disease due to laxity of pelvic organ supportivetissues [41]. Gonzalez-Argente et al. [42] reported that thepatients operated on for rectal prolapse had high prevalencerates of urinary incontinence (58%) and genital prolapse(24%). Altman et al. [41] observed that 48% of the patientswith rectal prolapse suffered from genital prolapse, whereas31% of patients suffered from urinary incontinence.

Bladder stones were identified as one of the firstproblems associated with rectal prolapse in adults. Later,other urologic problems were discovered to be associatedwith rectal prolapse including phimosis, urethral strictureand prostatic enlargement or obstruction. Problems associ-ated with the gut that have also been associated with rectalprolapse include constipation, diarrhoea, pinworm andpolyps. In addition, motility disorders arising from abnor-malities of the spinal cord such as spina bifida areassociated with a higher than expected incidence of rectalprolapse. Bulimia nervosa [43] and progressive systemicsclerosis have also been associated with rectal prolapse[44]. Problems that are traditionally associated withchildren with rectal prolapse include cystic fibrosis,whooping cough, tuberculosis and nutritional disorders.

There have been reports of blunt abdominal trauma ofsufficient force to cause acute rectal prolapse [45] and reportsof spontaneous rupture of long-standing rectal prolapse [46]and of rupture during attempted reduction [47].

The complete history and a physical examination arerequired. An assessment of specific risk factors should beconsidered. A screening evaluation of the colon withendoscopy or barium enema is recommended in adults toexclude coexisting conditions such as diverticular disease,which may influence the choice of procedure. Finally, apreoperative evaluation for rectal prolapse requires testingof the pelvic floor and colon transit. Common testingoptions include cinedefecography (to check movement ofthe pelvic floor and look for unsuspected pathologicfeatures) [48], anorectal manometry (to measure thepressure generated by the sphincter muscles), electromyog-raphy (to check for denervation) and colon transit studies (itis postulated that an increased sigmoid transit time is asignificant factor in the cause of incontinence that isassociated with prolapse) [12].

Non-operative treatment

The idea of treating patients without operation has greatappeal because many patients with rectal prolapse areelderly or carry high operative risk. However, non-operative treatment has been shown to produce onlytemporary or symptomatic relief.

There have been reports of the reduction in incarceratedrectal prolapse with the use of table sugar [49]. The goal ofthis technique would be to reduce the oedema of the tissuesso that the rectum can be returned to its normal anatomiclocation and a more elective procedure could be considered.

‘Transindolor’ [50] was used early in 1960s for the treat-ment of patients who had little or no ability to voluntarilycontract the sphincter. The battery-operated unit was report-ed to simulate the sphincter and then allow it to rest beforethe next surge. It was reported to have improved the restingtone and voluntary contractions of the sphincter muscles.

Finally, biofeedback was used to improve postoperativefunction but was not reported for use as primary therapy[51].

Surgical treatment

More than 100 different operative procedures have beendescribed for rectal prolapse [52–58]. The aim of treatment isto control the prolapse, restore continence and preventconstipation or impaired evacuation [30, 39]. This goal canbe achieved by resection or plication of the redundant boweland/or fixation of the rectum to the sacrum [30, 39]. A strong

Int J Colorectal Dis (2007) 22:231–243 233

and functional pelvic floor may be restored by plicating thepuborectalis anterior to the rectum [30]. The rationale forrectal fixation is to keep the rectum attached in the desiredelevated position until it becomes fixed by scar tissue. Inincontinent patients, the patulous sphincter ani begins toregain its tone approximately 1 month after the procedure,and full continence is generally restored within 2 to3 months [58].

The operative procedures are classified as abdominal[52–54] or perineal [55–57], according to the route ofaccess. Abdominal operations involve dissection andfixation of the rectum and may include sigmoid/colonicresection. Perineal operations may include repair of thepelvic floor/anal sphincters with or without bowel resec-tion. Although there are proponents for each approach,there have only been few comparative trials, and to date,there are no guidelines as to which operation should beused in any given clinical situation.

Abdominal procedures

Improvements in anesthetic techniques have created theopportunity to approach the treatment of rectal prolapsefrom inside the abdomen. A summary of the outcomes ofabdominal procedures (suture rectopexy, posterior meshrectopexy, Ripstein procedure and suture rectopexy withand without resection) is shown in Tables 1, 2, 3 and 4.

Suture rectopexy

This operation, first described by Cutait in 1959 [59],involves a thorough mobilization and upward fixation ofthe rectum. The mobilization and subsequent healing byfibrosis tend to keep the rectum fixed in an elevatedposition as adhesions form, attaching the rectum to the pre-sacral fascia [1]. There was no reported mortality, and

recurrence rates ranged from 0% to 27%, [8, 59–63]; themajority of reports claimed rates ranging from 0% to 3%,with most of the reports showing an improvement in faecalcontinence. The influence on constipation was variable,with different studies showing improvement, deteriorationor no effect on constipation.

Loygue et al. [64] modified this procedure. In thisvariation, the mobilized rectum is suspended from thelongitudinal ligament in front of the sacral promontory bystrips of nylon. A total of 257 patients underwent thisprocedure, with two postoperative deaths and an uneventfulrecovery in 96% of patients. The recurrence rate was 4.3%.

Posterior mesh rectopexy

The sponge rectopexy was first described by Wells in 1959[65]. This technique is especially popular in the UK. Afterrectal mobilization, a prosthetic material or mesh is insertedbetween the sacrum and the rectum, sutured into the rectumand then sutured into the periosteum of the sacralpromontory. The strong fibrous reaction between therectum and the sacrum restores the normal anorectal angle.Mortality rates ranged from 0% to 3% [61–67], andrecurrence rates were reported at 3% [13, 61–67]. Improve-ment in continence occurred in 3% to 40%, but there was amixed response of constipation to this type of rectopexy [7,13, 61, 67–70].

Other non-absorbable synthetic meshes have replacedthe sponge, and more recently, absorbable meshes havebeen introduced. A number of authors [54, 71–73] haveshown that the use of both absorbable and non-absorbablemeshes achieved similar results. The mortality rate was 0%to 1%, and the recurrence rates were 0% to 6% for bothabsorbable [54, 71, 72] and non-absorbable [7, 10, 39, 54,69, 71, 72, 74] meshes. A number of studies have evaluatedthe efficacy of absorbable mesh in posterior mesh recto-pexy. Winde et al. [71] assessed 47 patients with rectal

Table 1 Rectal prolapse:results after suture rectopexy

NS not stated

Author/year No. of patients Mortality(%)

Continence(%)

Constipation(%)

Recurrence(%)

OpenCarter, 1983 32 0 NS NS 1Novell, 1994 32 0 15 31 1Graf, 1996 53 0 36 30 5Khanna, 1996 65 0 75 83 0Briel, 1997 24 0 67 NS 0LaparoscopicKessler, 1999 32 0 NS NS 2Bruch, 1999 32 0 64 76 0Kellokumpu,2000

17 0 82 70 2

Heah, 2000 25 0 50 14 NSBenoist, 2001 18 0 77 11 NS


prolapse in whom they compared two types of absorbablemeshes (polyglycolic acid and polyglactin) and notedmortality and recurrence rates similar to those with othernon-absorbable meshes. Galili and Rabau [72] comparedpolyglycolic acid and polypropylene in the treatment ofrectal prolapse in 37 consecutive patients and producedsimilar results with both types of meshes. These resultshave been reproduced by others [54, 73, 75, 76].

One of the chief concerns about the insertion of foreignmaterial is the incidence of sepsis. Sepsis has been reportedin 2% to 16% of patients with prosthetic rectopexy [29, 30,67, 71, 73, 75, 77–79]. Polyvinyl alcohol sponge placementcarries an increased risk of infectious complications [77,78]. Many authors reported that the infection rate associatedwith polytetrafluoroethylene mesh was 0% and that associ-ated with absorbable material without resection was 0%,whereas the presence of resection increased the mortality rateto 1%. In patients with polyvinyl alcohol sponge rectopexy,the infection rate was 3% without resection and increased to3.7% in the presence of resection. Insertion of a mesh duringrectopexy without resection appears to be reasonable, as itwas associated with a 0% or very low mortality [71, 73, 75,80]. Because the main predisposing factor for infection of

the implant is an infected pelvic haematoma, drainage ofthe pre-sacral pelvic region during surgery is recommended[61, 71, 75]. However, if sepsis occurs, removal of theforeign material is advisable [71–73, 77–79]. Furthermore,in the presence of an anastomosis in patients having asynchronous resection, the theoretical risk of infection isincreased [61, 75].

Ripstein procedure (anterior sling rectopexy)

This operation was first described by Ripstein in 1952 [58].After complete mobilization of the rectum, an anterior slingof fascia lata or synthetic material is placed in front of therectum and sutured to the sacral promontory. The rationaleis to restore the posterior curve of the rectum to minimizethe effect of increased intra-abdominal pressure. Theoperation provides a firm anterior fascial support in patientswith atrophic pelvic structures and restores the normalanatomic position of the rectum. Mortality rates rangedbetween 0% and 2.8% and recurrence rates between 0%and 13%, and there was a trend towards improvement incontinence and a mixed response to constipation [7, 14, 57,71, 74, 75, 81, 82].

Table 2 Rectal prolapse:results after posterior meshrectopexy

NS not stated

Author/year No. ofpatients

Mortality(%)

Continence(%)

Constipation(%)

Recurrence(%)

OpenPenfold, 1972 101 0 22 NS 3Morgan, 1972 150 4 42 58 3Keighley, 1984 100 0 64 NS 0Mann, 1988 59 0 25 39 NSSayfan, 1990 16 0 75 75 NSLuukkonen, 1992 15 0 53 100 0Winde, 1993 47 0 17 NS 0Novell, 1994 31 0 3 48 2Scaglia, 1994 16 0 19 14 0Galili, 1997 37 0 NS NS 1Yakut, 1998 48 0 NS NS 0Aitola, 1999 96 1 26 24 6Mollen, 2000 18 NS NS NS 0LaparoscopicHimpens, 1999 37 0 92 38 0Darzi, 1995 29 0 NS NS 0Boccasanta, 1999 10 0 NS 0 0Benoist, 2001 14 0 10 21 NS

Table 3 Rectal prolapse:results after Ripstein procedure

NS not stated


Mortality(%)

Continence(%)

Constipation(%)

Recurrence(%)

Winde, 1993 47 0 23 17 0Tjandra, 1993 142 1 18 NS 10Scaglia, 1994 16 0 23 NS 0Schultz, 2000 69 0 20 37 1


To limit the incidence of obstruction, McMahan andRipstein modified the procedure to include posteriorfixation of the mesh to the sacrum [83]. In this situation,the lateral mesh is anteriorly sutured to the rectum, with agap deliberately left between the ends to obviate narrowing.Intraoperative rigid proctoscopy can help determine thesnugness of the wrap and caliber of the rectal lumen.

Male patients exhibit a higher incidence of recurrentprolapse because of technical difficulties with a narrowpelvis [12, 84, 85]. In 1988, Roberts et al. [84] reviewedtheir experience with the Ripstein procedure in 135patients; they noted a 52% complication rate, the mostserious complication being pre-sacral haematoma, whichoccurred in 8% of cases. The overall recurrence rate was10%. However, the recurrence rate in men was three timesthat in women (24% vs 8%, respectively). They postulatedthat the reason for a high failure rate in men might bedifficulty in mobilizing the rectum in the narrow malepelvis. Technical difficulties at the time of the originaloperation were implicated in 50% of cases of male patientswith recurrence [84].

Resection

The concept of rectosigmoid resection is based on theobservation that after low anterior resection, a dense area offibrosis forms between the anastomotic suture line and thesacrum, securing the rectum to the sacrum [30]. Otheradvantages include resection of the abundant rectosigmoid,which avoids torsion or volvulus; achieving a straightercourse of the left colon and little mobility from thephrenocolic ligament downwards, which acts as yet anotherfixative device [1, 30, 52, 86–88]; and relief of constipationin a selected group of patients [30]. It is well suited topatients with a long redundant sigmoid and a long historyof constipation [88]. However, sigmoid resection alone for

rectal prolapse has not been popular and is confined tostudies before 1980.

Resection and rectopexy

Originally described by Frykman [89] in 1955, theprocedure of abdominal rectopexy and anterior resectionattempts to treat the most common anatomic problems thatare associated with rectal prolapse. The addition of sigmoidresection to rectopexy combines the advantages of mobi-lization of the rectum, sigmoid resection and fixation of therectum. Most of the series describe resection rectopexy inwhich resection is combined with suture rectopexy. Fewstudies have addressed a combination of resection andposterior mesh rectopexy; the mortality rates ranged from0% to 6.7% [14, 39, 54, 69, 72, 90–92], with an associatedrecurrence rate of 0% to 5% [39, 54, 69, 90, 92–94]. Therewas an overall reduction in constipation, which was at-tributed to resection of the redundant sigmoid colon. Con-tinence was also improved in most patients. Luukkonen etal. [54] in a comparative study between rectopexy withsigmoidectomy vs rectopexy alone showed that sigmoidresection did not increase morbidity but tended todiminish postoperative constipation, possibly by causingless outlet obstruction. McKee et al. [53] showed thatpatients with rectal prolapse who underwent abdominalrectopexy alone had a high incidence of constipation.They also showed that patients having rectopexy alonehad a higher pressure in the rectum for a given volume ofisotonic sodium chloride solution infused. They postulatedthat this was due to kinking between the redundantsigmoid colon and the rectum at the rectosigmoidjunction, and that the addition of sigmoidectomy appearedto alleviate this possibly by removing the redundant loopof colon that may kink and cause delay in the passage ofintestinal content.

Table 4 Rectal prolapse:results after suture rectopexywith and without resection

NS not stated


Mortality(%)

Continence(%)

Constipation(%)

Recurrence(%)

OpenFrykman, 1969 80 NS NS NS 0Sayfan, 1990 13 0 66 80 NSLuukkonen, 1992 15 1 33 60 0Tjandra, 1993 18 0 11 56 NSDeen, 1994 10 0 90 NS 0Huber, 1995 42 0 44 18 0Yakut, 1998 19 0 NS NS 0Kim, 1999 176 NS 55 43 9LaparoscopicStevenson, 1998 34 0 70 64 0Xynos, 1999 10 0 100 NS NSBenoist, 2001 16 0 100 0 NS


Anterior resection

It was first described by Muir in 1955 [22]. His rationalewas that a dense reaction has been noted at the level ofanastomosis after other low anterior resections.

Theuerkauf et al. [95] noticed a 4% mortality rate and4% recurrence rate after anterior resection, with improve-ment of continence in 63% of cases, whereas Schlinkert etal. [96] reviewed their experience with anterior resection forcomplete rectal prolapse, with a 9% recurrence rate, a 1%mortality rate and a 50% improvement in continence.Cirocco and Brown [11] performed anterior resection in41 patients with complete rectal prolapse. All of theseauthors claimed that the advantages of this operation werethat it was familiar and frequently performed, did notrequire a foreign body or rectal suspension and hadwithstood long-term scrutiny in terms of both recurrenceand associated complications.

Place of prosthetic meshes in rectopexy

Insertion of a foreign material during rectopexy is com-monly performed with the assumption that this materialevokes more fibrous tissue formation than ordinary suturerectopexy [30]. There is evidence that complete encircle-ment of the rectum (Ripstein procedure) may lead toerosion of the foreign material with subsequent fistulaformation and stenosis in approximately 7% of patients[30]. Furthermore, Kuijpers [30] re-operated on fourpatients who had had posterior rectopexy with T-shapedpolytetrafluoroethylene mesh several years previously.None of the patients had actual prolapse recurrence, butboth of the ‘horizontal’ legs of the mesh had retracted to thepromontory and were ineffective as a fixation device.Kuijpers believed that the purpose of using an implant toevoke an intense fibrous tissue formation is not alwaysachieved by using prosthetic material. Penfold and Hawley[66] conceded that the polyvinyl alcohol sponge tends tofragment but persists in human tissues for 5 years. Indeed,many authors [97] now believe that rectal fixation by sutureonly seems sufficient, with reported recurrence rates of 3%or less [1, 30, 60, 81].

Role of division of ligaments

The left colon and rectum receive retrograde innervationfrom neural efferent running through the lateral ligaments;thus, lateral ligament division during rectopexy has beensuggested to denervate the rectum, causing postoperativeconstipation [70, 80]. Brazzelli et al. [98] performed ameta-analysis of articles reporting on surgery for rectalprolapse. They concluded that division, rather than preser-vation, of the lateral ligaments was associated with less

recurrent prolapse but more postoperative constipation,although these findings were found in small numbers. Themajor limitation of this meta-analysis was that only twostudies (one of which was an abstract) addressing lateralligament division or preservation were included in themeta-analysis. In summary, it would appear that preserva-tion of ligaments is associated with an improvement incontinence and a reduction in constipation.

Perineal procedures

Numerous procedures have been described for the perinealtreatment of a rectal prolapse. They have the advantage thatthey are less invasive for unfit patients but have a highrecurrence rate [91]. This is unfortunate because thepostoperative functional results, particularly with regard toconstipation, are better than those reported after abdominalrectopexy [99, 100]. There are two widely used perinealprocedures: the Delorme procedure and perineal rectosig-moidectomy (Altemeier operation). The stapled transanalrectal resection is a new perineal approach to symptomaticrectocele and intussusception with limited data. TheThiersch procedure, which entails encircling and therebynarrowing the anal canal, does not eradicate prolapse butmerely prevents its further descent by providing mechanicalsupport, and hence, it is associated with a high recurrencerate (33–44%) [1, 4, 30, 101, 102]. A summary of the out-comes of perineal procedures is shown in Tables 5 and 6.

Delorme operation

This procedure was described by Delorme in 1900 [103] andincludes a stripping of the mucosa of the prolapsed rectumand sutured plication of the remnant bare muscle, whichcollapses the wall like an accordion. The mucosa is then re-approximated to seal the anastomosis. It has an additionaladvantage of excision of a concomitant rectal ulcer if present[99]. This procedure can be performed with the use of localanesthesia, if needed, on even the highest-risk patients [57,99, 104]. It is ideal for a low or a small prolapse.

Many studies reported mortality rates of 0% to 4% andrecurrence rates of 4% to 38% [57, 82, 99, 105–108].Factors associated with failure for the Delorme procedureinclude proximal procidentia with retro-sacral separation ondefecography, faecal incontinence, chronic diarrhoea andmajor perineal descent (>9 cm on straining). In the absenceof these factors, the Delorme procedure provided asatisfactory and durable outcome [109].

The most important disadvantage of the Delormeoperation is that the procedure does not fix the rectum tothe sacrum or repair the pelvic floor, and the pleated muscleat the anal verge may provide a false sense of security whenconsidering the potential for recurrence.


Perineal rectosigmoidectomy

Although first performed by Mickulicz [25] in 1889 andlater advocated by Miles [110] in 1933 and Gabriel in 1948[111], this procedure is most commonly associated withAltemeier et al. in 1971 [112]. It involves a full-thicknessexcision of the rectum and, if it is possible, a portion of thesigmoid colon. It has gained general acceptance for use inelderly patients in North America [85].

The reported overall mortality rates ranged from 0% to5% and recurrence rates from 0% to 16% [94, 107, 113–116]. Postoperatively, patients have minimal pain, oralintake can generally be commenced within 24 to 48 h aftersurgery and bowel function returns within a few days ofsurgery [85]. The potential complications include anasto-motic bleeding and pelvic sepsis, and although leakage isuncommon, tension and poor blood supply can causeanastomotic dehiscence [85].

Perineal rectosigmoidectomy is well suited for malepatients; patients with incarcerated, strangulated or evengangrenous prolapsed rectal segment; and patients who havehad recurrence after another transperineal repair [85, 115, 116].There is general agreement that perineal rectosigmoidectomyis often the best operation for extremely elderly patients orindividuals with profound comorbidity, in whom an abdom-inal procedure might be contra-indicated [56, 116, 117]. It is

also suitable for the elderly or high-risk patients withincontinence because a concomitant levatorplasty can beperformed [12, 85, 117].

Stapled transanal rectal resection

Longo [118] introduced the stapled transanal rectal resec-tion (STARR) technique, suggesting a transanal resection ofthe rectal wall for the treatment of symptomatic rectoceleand symptomatic distal intussusception based on the stapledhaemorrhoidectomy procedure. It involves the transanal useof two circular staplers: the first stapler (anteriorly) reducesthe intussusception and the size of rectocele, whereas thesecond one (posteriorly) corrects the intussusception.

There are only few published studies about the STARRprocedure. Ommer et al. [119] reported 14 patients whounderwent this procedure; during the mean follow-up time(19±9 months), only one patient with intussusception haddefecation disorder again 6 months postoperatively.Boccasanta et al. [120] compared the STARR procedurewith the simple transanal stapled mucosal resection inaddition to a perineal levatorplasty. They observed that theSTARR group showed a significantly low pattern ofpostoperative pain and that 88% of the STARR grouppatients had an excellent/good outcome at 20 months.Finally, a prospective multicentre trial with 90 patients

Table 5 Rectal prolapse:results after Delorme procedure

NS not stated


Mortality(%)

Continence(%)

Constipation(%)

Recurrence(%)

Tobin, 1994 43 0 50 NS 11Oliver, 1994 41 1 58 NS 8Senapati, 1994 32 0 46 50 4Lechaux, 1995 85 1 45 10 11Kling, 1996 6 0 67 100 1Agachan, 1997 8 0 NS NS 3Pescatori, 1998 33 0 NS 44 6Yakut, 1998 27 0 NS NS 4Watts, 2000 101 4 25 13 30Liberman, 2000 34 0 32 88 0

Table 6 Rectal prolapse:results after Altemeierprocedure

NS not stated


Mortality(%)

Continence(%)

Constipation(%)

Recurrence(%)

Takesue, 1999 10 0 NS NS 0Ramanujam, 1994 72 0 67 NS 4Deen, 1994 10 0 80 NS 1Williams, 1992 56 0 46 NS 6Johansen, 1993 20 1 21 NS 0Agachan, 1997 32 0 NS NS 4Altemeier, 1971 106 0 NS NS 3Kim, 1999 183 NS 53 61 29Prasad, 1986 25 0 88 NS 0


reported that the STARR procedure is a safe and effectivetechnique in the treatment of outlet obstruction caused bythe combination of intussusception and rectocele [121].

Laparoscopic procedures

Laparoscopic procedures changed the way that surgeonsview operation. The goal of the laparoscopic surgicalapproach to the treatment of rectal prolapse is to providethe low recurrence rate of the abdominal approach with arecovery period that is more like the perineal approach.Any traditional abdominal procedure for the treatment ofrectal prolapse can be recreated with the use of laparoscopictechnique. Otherwise, any comorbid condition that wouldpreclude the use of general anesthesia becomes a contra-indication to laparoscopy. These conditions often includechronic obstructive pulmonary disease and severe coronaryartery disease. Conditions that are specific contra-indica-tions to laparoscopy include coagulopathy, severe liverdisease, known formidable intra-abdominal adhesions andpregnancy, whereas conditions that are relative contra-indications include large mesenteric lymph nodes or athickened mesentery, patient obesity, fistula and anyprocedure that would require the removal of a largespecimen.

Compared with laparotomy, laparoscopic rectopexy hasthe advantages of reduced pain, shortened hospital stay,early recovery and early return to work [122]. Theprocedure involves either suture or posterior mesh recto-pexy, with or without resection. It has gained popularitybecause it is relatively simple and easily accomplished andbecause resection with anastomosis is avoided [1, 22, 68,87, 90, 101, 123–126]. The mortality for laparoscopicrectopexy ranged between 0% and 3%, with recurrencerates ranging from 0% to 10% in follow-up of between8 and 30 months [22, 68, 87, 90, 101, 122–127]. Thesestudies have demonstrated that this approach is as effectiveas the open method in the treatment of rectal prolapse, andthe effect on continence and constipation depends on thetype of rectopexy performed.

Boccasanta et al. [126] compared the functional andclinical results of laparoscopic rectopexy with those of theopen technique in two similar groups of patients withcomplete rectal prolapse. The laparoscopic approach wasassociated with a reduction in postoperative hospitalization,without a significant prolongation of operative time and thehigher cost of surgical materials. Solomon et al. [128]concluded that the laparoscopic technique had short-termbenefits in terms of return to normal diet and mobility,earlier discharge from the hospital and less morbidity.These results were paralleled by a reduced neuroendocrineand immunologic stress response. No long-term differences

in constipation, recurrent prolapse or improvement incontinence scores between open and laparoscopicapproaches were identified.

Stevenson et al. [87] studied their laparoscopic-assistedresection and rectopexy experience. They felt that thistechnique was feasible and safe, with a functional outcomeand recurrence rates equivalent to the reports of openprocedures. Xynos et al. [113] and Kellokumpu et al. [122]compared open and laparoscopic resection rectopexy andconcluded that resection rectopexy for rectal prolapse canbe performed safely via the laparoscopic approach. Asummary of the outcomes of laparoscopic procedures(suture rectopexy, posterior mesh rectopexy and suturerectopexy with and without resection) is shown in Tables 1,2 and 4.

Simultaneous surgical treatment of combined rectaland genital prolapse

In the literature, very few series have reported a combinedsimultaneous treatment of both rectal and genital prolapse.Ayav et al. [129] proposed a simultaneous transabdominaltreatment: genital prolapse was treated by colpohystero-pexy, and rectal prolapse was treated by mesh or suturedrectopexy associated with sigmoid resection. After amedian duration of 17 months follow-up, only one out ofeight patients had a postoperative evacuation problem andfaecal incontinence. Tancer et al. [130] suggested a colpo-recto-sacropexy, whereas Zhioua et al. [131] reported acolpopexy plus a mesh rectopexy for the treatment ofcombined conditions in six and two patients respectively,but there was no mention of functional results. Dekel et al.[132] argued that the vaginal hysterectomy for genitalprolapse followed by the Altemeier procedure for the rectalprolapse were easy and safe to perform in ten patients withboth conditions. Although there was no recurrence, theyreported a gas incontinence rate of 30% at 18–24 monthsfollow-up.

Choice of procedure

The modern literature focuses on the decision to weigh bothpatient factors and procedures factors. The primary need toremove the prolapse should take into consideration thepossibility of coexisting slow transit constipation, postop-erative rectal compliance and the presence of pelvic floordenervation. The possibility of postoperative sexual dys-function in men is also important. The patient’s age, cardiacand pulmonary risk factors, prior abdominal surgicalprocedures, pelvic irradiation, immune function, coagulop-athy and liner function are basic concerns before operation.


Colon transit, electromyographic evaluation and anorectalmanometry pressure studies are patients’ factors that areimportant considerations for postoperative function.

We believe that patients who are fit for surgery withoutcomorbidity should be offered abdominal rectopexy, as it isnow associated with very low mortality rates. In our view,although abdominal operations have a higher morbidity, thefit patient is presumably capable of withstanding compli-cations and should be given the best chance to cure theprolapse. Suture rectopexy is capable of giving goodresults, and the addition of the posterior mesh does notoffer additional advantage; rather, it has the disadvantage ofintroducing a foreign body. There seems therefore little tochoose between suture rectopexy and posterior meshrectopexy. The placement of foreign materials, such aspolypropylene or Marlex mesh, Ivalon sponge or Teflonsuspension, is associated with an increased risk of infection,stenosis and constipation. Finally, there is the risk that thehypogastric plexus might be affected when the mesh isstapled to the pre-sacral fascia. Conversely, a suturerectopexy provides distinct advantages: it does not useforeign material, and therefore, sigmoid resection can besafely performed without increasing the postoperative riskof infection or constipation.

The advantage of adding a resection to the rectopexyseems to be a reduction in constipation. This proceduretherefore seems suited to patients with a redundant sigmoidcolon and a history of constipation. The Ripstein procedurehas been associated with problems of constipation thateither persist or postoperatively worsen.

Preservation of the ligaments seems to have theadvantage over their division in terms of continence andconstipation. There are far fewer studies addressing theinfluence on resting and squeeze pressures after bothapproaches, but there seems to be a benefit to thepreservation of ligaments. Further studies are required toassess the efficacy of division and preservation of lateralligaments in these operations. However, for now the choiceof division and preservation of ligaments depends on thesurgeon’s experience and preference.

In the elderly and high-risk patients, perineal approachessuch as the Delorme procedure or perineal rectosigmoi-dectomy (the Altemeier procedure) are preferred. TheDelorme procedure may be useful if there is insufficientlength of prolapse to perform a perineal rectosigmoidec-tomy [54, 96]. Perineal rectosigmoidectomy is well suitedfor patients with incarcerated, strangulated and gangrenousrectal prolapse, whereas abdominal rectopexy cannot beused for these situations, even in fit patients.

Laparoscopic surgery has the advantages of less pain,shorter hospital stay, early recovery and early return towork as compared with laparotomy. Apart from theseadvantages, the results are similar to those with the open

procedures irrespective of the method used (suture, resec-tion or posterior mesh). Therefore, where expertise isavailable, this approach may be preferred.

The problem of recurrence is one of the most importantissues of prolapse surgery. However, such patients need tobe clinically re-examined so that it can be assessed whetherthese recurrences are incomplete or complete. Previouslyreported results of both open and laparoscopic resection–rectopexy series have a comparable outcome, with accept-able recurrence rates.

Additionally, the issue of whether surgery is indicated inpatients with incomplete or internal rectal prolapse iscontroversial [8]. Some authors believe that surgery forrectal prolapse is indicated only if clinical outlet obstruction(e.g. sigmoidoceles, rectoceles) is associated. If internalprolapse is an isolated finding, without associated disorders,patients obviously do not benefit from surgery, andconsequently, surgery cannot be advised.

Conclusions

Despite its being a relatively uncommon condition, theunderlying pathophysiology and treatment of rectal pro-lapse continue to generate much interest. Medical andsurgical literature documents a slow progress, with im-provement noted in many facets of care. Many of thereported series have concentrated on recurrence rates ratherthan functional outcome, and all have reported only a shortfollow-up. We know that prolapse has a spectrum ofphysiologic presentations and that the centre of pelvic floordisorders evaluation is the key to understanding the profileof individual patients. Defecography and colon transitstudies may also reveal information that is important forplanning the surgical approach.

Three approaches are now available for the treatment ofrectal prolapse. Abdominal procedures are ideal for youngfit patients, whereas perineal procedures are reserved forolder frail patients with significant comorbidities. Resultsafter all abdominal procedures are comparable. The use oflaparoscopic techniques may permit surgeons to performprocedures that were limited to the traditional approach,with much lower impact on the patient.

Suture rectopexy seems adequate in curing rectalprolapse. The superiority of mesh rectopexy has not beendemonstrated, and meshes add a foreign body and increasethe risk of infection. Suture and mesh rectopexies are stillpopular with many surgeons, and the choice depends on thesurgeon’s experience and preference. Whereas sigmoidresection alone and anterior resection are obsolete, laparo-scopic rectopexy has results equivalent to or better thanthose of open rectopexy. Laparoscopic suture rectopexy ispreferable because it is simple and easy to perform. Perineal


procedures are useful for patients who are not fit forabdominal procedures. Perineal rectosigmoidectomy seemsbetter than the Delorme procedure, and if possible,levatorplasty should be added.

The STARR procedure is likely to become one standardprocedure in the future. Randomized trials and longerfollow-up are necessary to confirm the published goodperioperative and postoperative results.

In patients with combined simultaneous genital and rectalprolapse, a multidisciplinary pelvic floor surgical approachat the time of surgical treatment for rectal prolapse isrequired. The collaboration between urologists or gynaecol-ogists with special training in pelvic floor dysfunction andcolorectal surgeons may help overcome the simultaneousproblems inherent in pelvic floor disorders.

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