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Rectal Prolapse Sarah A RESIDENT'S CORNER Rectal Prolapse Sarah A. Vogler, M.D., M.B.A. Division of Colon and Rectal Surgery, University of Minnesota, Minneapolis, Minnesota CASE SUMMARY: A 65-year–old healthy woman presents ecation.1 Although the presentation of full-thickness rec- with a 9-month history of full-thickness rectal prolapse tal prolapse is classic, the clinical evaluation and surgical that occurs with bowel movements and strenuous treatment options continue to evolve. activity. Associated symptoms include passing multiple small, soft stools daily with urgency and a constant feeling of incomplete evacuation and pelvic pressure. On PREOPERATIVE WORKUP OF RECTAL PROLAPSE examination, she develops 6 cm of full-thickness rectal A deeper understanding of the complexity of pelvic organ prolapse while straining on the commode. prolapse in women has developed with better imaging mo- Additional workup includes defecography, which dalities and integration of multidisciplinary care teams. shows a medium size rectocele and intussusception of These advances have changed the classic teaching of op- the rectal wall starting just above the rectocele. This in- erating on patients with rectal prolapse without additional tussusception progresses to full-thickness prolapse. There imaging or testing. The first step in evaluating these pa- is good vaginal apical support but development of an en- tients is to take a thorough history, with special attention given to bowel habits, pelvic symptoms, urinary symptoms, terocele (Fig. 1). and overall state of health. The medical history should fo- cus on obstetric history, previous pelvic surgery, previous CLINICAL QUESTIONS prolapse history, nonsurgical treatment of pelvic prolapse (ie, pessary or medications), and colonoscopy. The goal is • What is the preoperative workup for rectal prolapse? to elicit symptoms associated with rectal prolapse in addi- • What are the surgical treatment options? tion to symptoms of prolapse in other compartments, such as vaginal or uterine prolapse. Failure to diagnose multi- compartment pelvic floor prolapse has resulted in 10% to BACKGROUND 25% of women with urogynecologic disorders requiring a second surgery for correction of colorectal dysfunction.2 Rectal prolapse presents as protrusion of the rectum Defecography is a dynamic radiologic study examin- through the anal canal and appears as concentric rings of ing the anatomic efficiency of the pelvic organs during tissue. It can occur in men and women of all ages, but most defecation. Imaging contrast is inserted into the vagina commonly presents in parous women in the seventh to and the rectum, and the patient is asked to evacuate this eighth decade of life. Rectal prolapse can present with as- contrast during the examination. Fluoroscopy and MRI sociated symptoms of either constipation or incontinence are the 2 commonly used radiographic approaches for de- because of inefficient emptying of the rectum during def- fecography. The pros and cons of each modality are listed in Table 1.3 Ultimately, the modality that is most conve- niently available to your patient will be adequate. Review- Earn Continuing Medical Education (CME) credit online at cme.lww.com. ing the images with the radiologist is helpful to understand TM This activity has been approved for AMA PRA Category 1 Credit . the anatomic abnormalities that could impact your surgi- Financial Disclosure: None reported. cal decision-making. Defecography will depict external rectal prolapse and Correspondence: Sarah A. Vogler, M.D., M.B.A., Colon & Rectal Sur- internal pelvic organ prolapse, which includes rectocele, gery Associates, 3433 Broadway St NE, Minneapolis, MN 55413. E-mail: rectal intussusception, enterocele, sigmoidocele, and vagi- [email protected] nal prolapse. For example, a patient with rectal prolapse Dis Colon Rectum 2017; 60: 1132–1135 who reports vaginal pressure or bulge may be found to have DOI: 10.1097/DCR.0000000000000955 a large rectocele, enterocele, or loss of vaginal support with © The ASCRS 2017 vaginal prolapse. These findings are indicative of internal 1132 DISEASES OF THE COLON & RECTUM VOLUME 60: 11 (2017) DISEASES OF THE COLON & RECTUM VOLUME 60: 11 (2017) 1133 comprehensive surgical repair. A patient’s overall state of health and history of previous repairs or pelvic surgery Before evacuation can also impact the surgical options. Perineal rectosigmoidectomy is the safest surgical op- tion for patients who are relatively unhealthy and have several medical comorbidities. This perineal approach spares the patient an abdominal incision and can be done under spinal anesthesia if necessary. A levatorplasty can be done during this procedure to help support the weak pelvic floor muscles and possibly improve postoperative continence in patients who show normal pelvic floor re- laxation on EMG testing. There is minimal postoperative Midevacuation: small rectocele pain. Return of bowel function is usually fast, which al- and beginning of rectal lows for minimal interruption in diet, medications, and intussusception activity. This approach only repairs the full-thickness rectal prolapse and can have a recurrence rate as high as 20%.4 It can be combined with a colpocleisis to fix vaginal prolapse. Because more prolapse repairs are being done laparoscopically and robotically, there is building evidence that these approaches can be equally as safe as a transperi- neal approach in the elderly.5 Abdominal approaches to repairing rectal prolapse End evacuation: full are well tolerated by most patients and afford a lower re- -thickness rectal prolapse currence rate with potentially better functional outcomes and enterocele, good vaginal than a perineal repair. There have been >100 different rec- support tal prolapse repairs described, and new options continue to be introduced.6 Most abdominal surgical options can be performed laparoscopically, robotically, or in an open fashion. Currently, the most common abdominal ap- FIGURE 1. Fluoroscopic defecography. proaches include ventral mesh rectopexy, posterior suture rectopexy (with or without sigmoid resection), and poste- pelvic organ prolapse that is not always readily evident on rior mesh rectopexy.6 These options can be combined with physical examination. Some of the findings on defecog- a hysterectomy or sacrocolpopexy to treat patients with raphy may indicate that the patient would benefit from symptomatic prolapse in multiple pelvic compartments. evaluation by a multidisciplinary surgical team, which can Posterior suture rectopexy can be done minimally include urology, gynecology, and colorectal surgery. invasively. It involves posterior rectal dissection in the avascular plane, outside of the fascia propria, down to the pelvic floor. Some anterior dissection can also be per- SURGICAL OPTIONS formed in the rectovaginal septum. The rectum is then Surgical treatment for rectal prolapse has evolved and now pulled cephalad toward the sacral promontory, and several includes more minimally invasive approaches and simulta- permanent stitches are used to the secure the mesorectum neous repair of multiple pelvic compartments, sometimes to the anterior longitudinal ligament along the sacrum. with multiple surgical specialties involved. Preoperative The goal is to provide adequate tension on the rectum to imaging with defecography can help guide whether a mul- prevent recurrent prolapse but still allow for appropriate tidisciplinary approach will provide a patient with a more movement of the rectum during defecation. The estimated TABLE 1. Defecography comparison of fluoroscopy and MRI Defecography Fluoroscopy MRI Advantages Natural/upright position during evacuation Clear images of pelvic compartments and musculature Easily available with fluoroscopic equipment Exact radiographic measurements Low cost Disadvantages Imprecise image quality to assess muscle integrity Unnatural position/lying supine or lateral during evacuation High cost 1134 VOGLER: RECTAL PROLAPSE recurrence rate for posterior suture rectopexy ranges from Ventral rectopexy is a newer abdominal approach for 0% to 10%.7 repair of prolapse and was first described by D’Hoore et al It is hypothesized that, during posterior dissection in 2004.10 This approach involves opening the peritoneal for a suture rectopexy, there is division of the lateral lining along the right side of the rectum and then continu- stalks and some of the nerves that innervate the rec- ing dissection in the rectovaginal septum down to the pelvic tum, which could result in symptoms of constipation. floor. There is no posterior dissection and the lateral stalks A significant number of patients who present with remain intact, which avoids the risks of bleeding from pre- rectal prolapse already have a history of constipation sacral veins or nerve injury. Once the dissection is complete, and irregular bowel habits, and <50% describe wors- a piece of biologic or permanent mesh is secured to the le- ening of preoperative constipation.8 Thus, the Fryk- vator muscles on either side of the rectum and to the ante- man–Goldberg procedure was popularized in 1969, rior rectal wall. The mesh is then brought up and secured which combines a sigmoid resection with a posterior to the posterior wall of the vagina as a posterior colpopexy. suture rectopexy.9 The theory behind this approach is Finally, the mesh is secured to the anterior longitudinal liga- that resection of a redundant sigmoid colon will help ment at the sacral promontory. This repair focuses on re- to minimize symptoms of slow transit
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