FORT LAUDERDALE, FLA. — The key to successful treatment of true rectal prolapse is an individualized approach, and in many cases that means a multidisciplinary approach, Eric G. Weiss, M.D., said at a symposium on pelvic floor disorders sponsored by the Cleveland Clinic Florida.
That's because the majority of women with rectal prolapse have concomitant genital prolapse and/or urinary incontinence. In addition, expanding knowledge of pelvic floor function—and the evolution of the concept of the pelvic floor as a single functioning unit with anterior and posterior components—has led to a greater effort to treat these conditions simultaneously. At the Cleveland Clinic Florida, about 65% of women with rectal prolapse also have urinary incontinence, and about 34% have genital prolapse, said Dr. Weiss, a colorectal surgeon and director of surgical endoscopy at the clinic.
The evaluation of women presenting with rectal prolapse, then, should include a complete vaginal pelvic examination by a urogynecologist, he said.
The evaluation should also differentiate between hemorrhoids and rectal prolapse, which are often confused.
Many women are referred for hemorrhoids when they actually have true rectal prolapse—or full thickness prolapse of the rectum through the anal sphincters. The reverse is also true, with some women with hemorrhoids being misdiagnosed with prolapse.
Rectal prolapse will often have a target-like appearance with circular folds of tissue circumferentially protruding from the anus— often up to 10-15 cm. Hemorrhoids, which can include mucosal prolapse, have radial folds that rarely protrude more than 5 cm.
The anorectal evaluation of patients with suspected rectal prolapse should be performed in the prone jack-knife position, in which the prolapse may be immediately evident.
But in some patients it may also be necessary to perform the examination with the patient in a squatting position, with the patient pushing down to demonstrate the prolapse.
Anal sphincter tone at rest and squeezing should be evaluated to assess damage from chronic prolapse, and a digital examination is necessary to check for palpable masses.
Conditions such as fecal incontinence and constipation—the presence of which should be elicited during a thorough history—are secondary to the prolapse. These will resolve following correction of the prolapse unless they are due to another condition, such as pudendal neuropathy.
To rule out colonic pathology, perform a complete endoscopic evaluation, and colonoscopy should be considered in older patients.
When the prolapse is not demonstrable during the evaluation, defecography is useful for identifying rectoceles and other pathology that might be affecting evacuation.
If surgery is being considered, a cardiovascular assessment is important to determine if the patient is a good candidate.
The type of surgery selected depends largely on patient age and health, Dr. Weiss said.
Abdominal approaches typically are more effective, but are associated with greater morbidity. Therefore, they are typically reserved for younger patients with a good surgical risk profile. Perineal procedures are associated with more recurrences, but usually are a safer option for the elderly and other higher risk patients.
The abdominal approaches use posterior mobilization of the rectum with fixation to the sacrum. Rectopexy is most common, and other approaches include anterior resection, and combined sigmoid resection and rectopexy. Complication rates range from 15% to 29%, and mortality ranges from 0% to 2%. Recurrence rates are low, ranging from 2% to 12%.
A common complication with rectopexy is constipation, but some data suggest this may be overcome by using the combined rectopexy/sigmoid resection procedure, Dr. Weiss noted.
The perineal approach usually involves rectosigmoidectomy. Studies suggest that perineal rectosigmoidectomy outcomes are improved when levatorplasty is also performed.
In one Cleveland Clinic Florida series of 84 patients with severe fecal incontinence and rectal prolapse treated over a 7-year period, those who were treated with both had significantly lower recurrence rates and decreased incontinence scores, compared with those who underwent only perineal rectosigmoidectomy, Dr. Weiss noted.
The recurrence rate there for all perineal procedures is about 13%, compared with 5% for perineal rectosigmoidectomy with levatorplasty, and the recurrence-free interval was longer in this group of patients, he added.
Another perineal option is the Delorme procedure, which involves circumferential incision of the mucosa of the prolapsed rectal wall just above the dentate line, and circumferential dissection in the submucosal layer of the prolapsed bowel as far up as possible. This is followed by plication of the muscular layer of the prolapsed muscle and coloanal anastomosis.