Recent advances in the management and investigation of rectal prolapse

1. Definitions

• Full-thickness (complete) prolapse, or procidentia: a circumferential, full-thickness protrusion of the rectum through the anus (Schwartz).
• Internal prolapse (intussusception): the rectal wall invaginates but does not protrude. Schwartz says this is probably better called internal intussusception.
• Mucosal prolapse: a partial-thickness protrusion, usually linked to haemorrhoids.
• Epidemiology: women are affected about 6 times more often than men, with a peak in the 7th decade (Sabiston, Schwartz, Bailey & Love).
• Risk factors (Sabiston):
  • lax rectal attachments
  • a deep cul-de-sac
  • a redundant sigmoid colon
  • connective tissue disease (Marfan, Ehlers-Danlos), which brings earlier onset and a higher recurrence risk
• Clinical features:
  • A full-thickness prolapse has concentric mucosal folds. Prolapsing haemorrhoids have radial folds (Sabiston Fig 97.33).
  • The anal sphincter is patulous.
  • About 50% of adults have faecal incontinence (Bailey & Love).

2. Investigations: current approach

3. Management

Principles

• Surgery is the primary treatment for full-thickness prolapse. Schwartz notes more than 100 operations have been described.
• Fix the rectum, and resect redundant sigmoid if needed.
• Match the operation to the patient's fitness, sex, and bowel function (constipation versus incontinence).

Abdominal procedures (lowest recurrence)

• Recurrence: below 10% in Bailey & Love and Schwartz. Sabiston gives below 10% at 10 years, against 16-30% for perineal repair.
• Posterior suture rectopexy:
  • It may worsen constipation.
  • Adding sigmoid resection ("resection rectopexy") helps constipation but adds anastomotic risk (Bailey & Love).
• Ventral mesh rectopexy (D'Hoore). This is the key advance (Bailey & Love, Sabiston, Schwartz).
  • Only the anterior rectum is dissected, down to the pelvic floor in the rectovaginal septum.
  • The lateral stalks are preserved, and mesh is fixed to the anterior rectum and the sacral promontory.
  • Sabiston reports lower postoperative constipation than traditional suture rectopexy, probably because the autonomic supply is preserved.
  • Bailey & Love report success of 70-80%, with better constipation and incontinence scores and an overall complication rate of about 10%.
  • Complications include recurrence, bleeding, pelvic pain and dyspareunia.
  • Mesh erosion or infection occurs in 2-4%, and more often with polyester mesh (Bailey & Love).
• Minimally invasive delivery: Laparoscopic and robotic approaches are now standard (Schwartz, Bailey & Love Fig 79.12b).
• Frailty and young men: Bailey & Love note a perineal approach may be preferred in the very frail, and in young men because of the pelvic autonomic nerve risk.

Perineal procedures (for high-risk patients)

• Altemeier perineal rectosigmoidectomy:
  • It is a full-thickness excision with coloanal anastomosis.
  • It is the operation of choice for incarcerated or necrotic prolapse, after attempts to reduce the oedema (sugar, sedation or nerve block) (Sabiston).
• Delorme:
  • It is mucosal stripping with plication of the muscle.
  • It suits short-segment prolapse, but recurrence is about 30% at 5 years (Bailey & Love).
• Thiersch wire: now largely obsolete, because of sepsis, stenosis and obstructed defecation (Bailey & Love, Schwartz).
• Advantages: minimal pain, early mobilisation, regional anaesthesia possible.

Internal prolapse and SRUS

• Internal prolapse: the options are internal Delorme or laparoscopic ventral mesh rectopexy (Bailey & Love).
• SRUS:
  • Start with fibre, defecation training and biofeedback.
  • Surgery is for those who fail this treatment, and results are poorer than for external prolapse (Bailey & Love, Schwartz).

4. Recent advances beyond the textbooks

1. Robotic ventral mesh rectopexy.
   • A 2025 Delphi consensus standardises the technique:
     • a right-sided peritoneal incision
     • preservation of the hypogastric plexus and ureter
     • superficial anterior-only dissection
   • A review chapter reports that meta-analyses suggest less blood loss, shorter stay and fewer complications than laparoscopy. It says long-term functional and recurrence data are still needed (Springer chapter).
2. Mesh choice and safety.
   • Polyester is discouraged because of erosion risk.
   • Mesh-related complications are about 1.4% in a 6,269-patient review. Overall complications are about 9.2% (as quoted in the Delphi paper).
   • A meta-analysis of synthetic versus biologic mesh addresses the choice of material.
   • NICE (HTG475) says laparoscopic ventral mesh rectopexy for internal rectal prolapse needs special arrangements for governance, consent and audit or research. This follows the Cumberlege Report mesh concerns also noted in Bailey & Love.
3. Guideline position. The ASCRS guideline summary recommends transabdominal fixation when risk is acceptable (2B). It says there is insufficient evidence that posterior repairs are better or worse than ventral mesh rectopexy. Ventral mesh rectopexy has acceptable short- and long-term complication rates (1C). Posterior mobilisation without rectopexy is not recommended (1B) (ASCRS summary).
4. Trial data tempering the textbook recurrence figures. The Swedish Rectal Prolapse Trial randomised 134 patients between perineal and abdominal approaches.
   • Quality of life and bowel function improved in all groups, with no significant differences between procedures.
   • Three-year recurrence was higher than previously reported: 58% for Delorme, 50% for Altemeier, 21% for suture rectopexy and 10% for resection rectopexy. These recurrence differences were not significant.
   • The trial was small and underpowered, so it does not overturn the lower recurrence usually quoted for abdominal repair.
5. Special groups.
   • Males: a 2024 meta-analysis covers surgical outcomes in men.
   • Constipation: a stepped-wedge RCT tested laparoscopic ventral mesh rectopexy in adults with chronic constipation.
   • Children: a 2024 RCT compared mesh versus suture rectopexy for persistent complete prolapse.
6. Choosing the operation. A 2025 review addresses which procedure suits which patient. The best operation is therefore tailored to fitness, sex, symptom pattern (incontinence or constipation), and the patient's priorities.

Quick exam summary

• Investigate with colonoscopy to exclude a lead-point lesion. Add defecography (fluoroscopic or MR), manometry and transit studies according to symptoms.
• Fit patient: laparoscopic or robotic ventral mesh rectopexy, or suture rectopexy. Add sigmoid resection if constipated and not incontinent.
• Frail patient or incarcerated prolapse: Altemeier perineal rectosigmoidectomy, or Delorme for short segments.
• Watch for mesh complications, with polyester worst. Also watch for recurrence after perineal repair.