Current diagnostic tools and treatment modalities for rectal prolapse

Abstract

Rectal prolapse is a circumferential, full-thickness protrusion of the rectum through the anus. It is a rare condition, and only affects 0.5% of the general population. Multiple treatment modalities have been described, which have changed significantly over time. Particularly in the last decade, laparoscopic and robotic surgical approaches with different mobilization techniques, combined with medical therapies, have been widely implemented. Because patients have presented with a wide range of complaints (ranging from abdominal discomfort to incomplete bowel evacuation, mucus discharge, constipation, diarrhea, and fecal incontinence), understanding the extent of complaints and ruling out differential diagnoses are essential for choosing a tailored surgical procedure. It is crucial to assess these additional symptoms and their severities using preoperative scoring systems. Additionally, radiological and physiological evaluations may explain some vague symptoms and reveal concomitant pelvic disorders. However, there is no consensus on or standardization of the optimal extent of dissection, type of procedure, and materials used for rectal fixation; this makes providing maximum benefits to patients with minimal complications difficult. Even recent publications and systematic reviews have not recommended the most appropriate treatment options. This review explains the appropriate diagnostic tools for different conditions and summarizes the current treatment approaches based on existing literature and expert opinions.

Keywords: Colorectal surgery; Constipation; Diagnosis; Fecal incontinence; Minimally invasive surgical procedures; Rectal prolapse.

Figure 1

Progression of external prolapse out of the anal canal. A-C: Prolapse becomes more evident with straining.

Figure 2

Differential diagnoses of rectal prolapse. A: Prolapsing hemorrhoids; B: Anal canal mass.

Figure 3

Dynamic magnetic resonance defecography images. A: Magnetic resonance imaging during rest; B: The red arrow indicates slight rectal intussusception and advanced pelvic prolapse present during straining; C: Pubococcygeal, M and H lines. The yellow line reveals severe rectocele accompanying pelvic prolapse.

Figure 4

A patient with external rectal prolapse who underwent an alternative procedure. A: External rectal prolapse; B: Altemeier procedure.

Figure 5

Laparoscopic and robotic ventral mesh rectopexy. A: Laparoscopic mesh placement before peritoneal closure; B: Robotic mesh placement before peritoneal closure.