Rectal prolaps

Rectal prolaps is an intussuseption or invagination of the recto sigmoid with subsequent prolaps of the bowel through the anus. The condition is always associated with an elongated left large bowel and a slackening and descent of the pelvic floor. Frequently associated manifestations like vaginal prolaps or urinary incontinence are further indication for pelvic floor insufficiency. see figure


Most patients are female and beyond menopause. Prolaps of intestine through the anus with soiling of the underwear, chronic constipation, emptying problems and fecal incontinence due to the permanent stretching of the anal muscles are the main symptoms.


Causes of rectal prolaps are a congenital prolongation of the left colon, slackening and decent of the pelvic floor due to hormonal changes and deterioration of nerval stimulation of the pelvic floor muscles. Damage to the nerves during normal vaginal delivery is discussed as possible cause.


Treatment of rectal prolaps is exclusively by operation. There are many different operative techniques described in the literature. Following the recommendations of the American Society of Colon and Rectal Surgeons I favor two techniques which are used for two subgroups of patients.


In very old patients with a high operative risk:
Transanal resection of the prolapsed intestine (Altemeier). The prolapsed bowel is resected from below through the anus and reconnected. This can be done in 20 minutes and is not very cumbersome for the patient. The functional result is clearly inferior to other techniques and therefore I reserve this operation only for the high risk patients


In the younger patients with normal operative risk:
Transabdominal rectopexy and resection of the sigmoid (Frykman-Goldberg). Here the prolapsing bowel is pulled back into the abdomen and fixed to the sacrum by sutures. The excess sigmoid is resected in order to straighten the bowel and prevent further intussuseption. Usually this also improves constipation. Recurrence with this technique is rare. see figure