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

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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 constipation. supporting the anterior wall of the rectum and obliterating In addition, removing the sigmoid colon will allow the retovaginal septum. Thus, it allows for repair of a large the splenic flexure to act as a backup point of support rectocele, deep rectal intussusception (which can continue and fixation to prevent downward drooping and sub- on to full thickness prolapse), sigmoidocele, and enterocele. sequent recurrent rectal prolapse. This procedure in- The advantage of this repair is that multiple points of pelvic volves the additional morbidity associated with a colon weakness or prolapse can be corrected. In theory, there is no resection. However, recurrence rates mirror that of a division of lateral stalks or pelvic nerves and thus less risk of posterior rectopexy without resection. The impact of postoperative constipation. The estimated recurrence rate the sigmoid resection on symptoms of constipation is for ventral rectopexy is 3% to 5%.11,12 This repair can also be variable in the surgical literature.8 A sigmoid resection combined with hysterectomy and sacrocolpopexy in cases is not recommended in patients with symptoms of fe- of multicompartment pelvic organ prolapse. cal incontinence or those with low resting and squeeze Either biologic or permanent mesh is used during pressures on manometry testing. It is important to re- a ventral rectopexy, which carries the associated risks of member that if recurrent rectal prolapse occurs after a mesh migration, detachment, infection, or erosion. The resection with rectopexy, then performing a perineal overall risk of a mesh complication is 2% to 3%, and in the rectosigmoidectomy is not an option because of the most recent series by Consten et al,12 <1% of these mesh risk of creating an ischemic segment of the rectum be- complications required surgical repair. In theory, the risk tween the colorectal anastomosis and the transperineal of infection or erosion may be lower with biologic mesh. coloanal anastomosis. The advantage of performing a mesh repair is that the Posterior mesh rectopexy (modified Well’s proce- mesh provides more robust support for repair of pelvic dure) involves doing the same pelvic dissection as a pos- prolapse in comparison with native tissue repairs. Thus, terior suture rectopexy. However, instead of just placing the risk of a mesh complication must be weighed against sutures between the mesorectum and anterior longitu- the effectiveness of this repair and the lower risk of pro- dinal ligament, a piece of mesh is placed in this space. lapse recurrence. The mesh is sutured to the anterior longitudinal liga- ment and then partially wrapped around the posterior CONCLUSION rectum and sutured to the mesorectum and right side of the rectum. This procedure still involves division of the Rectal prolapse is surgically correctable. Several factors im- lateral stalks and thus a risk of postoperative constipa- pact operative decision-making, including overall health, tion. It is not recommended to combine this repair with previous history of pelvic surgery, clinical symptoms, and a sigmoid resection given the presence and location of findings on defecography. A multidisciplinary treatment mesh, which has an increased risk of becoming infected team can provide a comprehensive approach to treatment because of the risk of contamination during placement of rectal prolapse in combination with repair of prolapse or anastomotic leak. in other pelvic compartments. DISEASES OF THE COLON & RECTUM VOLUME 60: 11 (2017) 1135

EVALUATION AND TREATMENT ALGORITHM

Sacrocolpopexy with rectopexy Multicompartment prolapse (cystocele, Medically fit for an Multidisciplinary Ventral mesh rectocele, abdominal operation evaluation rectopexy enterocele, sigmoidocele, vaginal prolapse) Defecography Low pressures on manometry or Isolated rectal incontinence prolapse Normal Constipation manometry Rectal prolapse

Sigmoid resection with Posterior mesh rectopexy Suture rectopexy suture rectopexy

Perineal rectosigmoidectomy (Altemeier procedure) EMG normal with levatorplasty EMG High risk for an testing abdominal operation EMG shows Perineal rectosigmoidectomy nonrelaxation (Altemeier procedure)

Expert Commentary on Rectal Prolapse Madhulika G. Varma, M.D.

Section of Colorectal Surgery, University of California, San Francisco, California

r Vogler has provided a succinct but comprehen- ering surgery. I have come to rely on my initial office history sive review of the workup and surgical treatment and physical examination to determine who needs additional Dof rectal prolapse. It is my pleasure to provide testing. For women with symptoms from the anterior com- a few professorial pearls to complement her excellent partment, defecography is essential. With a complete workup work. There are >100 operations for rectal prolapse, and that includes evaluation and input on treatment from a urogy- this speaks to the difficulty in finding a perfect solution necologist, a definitive combined surgery incorporating both to this condition. Over the course of time, the critical is- the anterior and posterior compartments can be considered. sues that determine outcome have remained the same: However, if a patient’s history and physical examination do not they are the recurrence rate and changes in bowel func- demonstrate any signs of other anatomic or functional abnor- tion after surgery. Different operations have been created malities and the prolapse is clinically apparent, then I do not to try to balance these outcomes in the best way possible. In the end, whether a perineal or abdominal approach is think that manometry or defecography is helpful unless you used, the sigmoid colon is removed, mesh is placed, an are trying to establish a baseline for future bowel function. anterior or posterior repair is performed, or a minimally Knowing that objective measures of pelvic physiology rarely invasive approach is used is related to the perspective of change when functional improvements are seen, I am not sure the surgeon. this baseline assessment is all that helpful either. Patients with One key advance in our approach to rectal prolapse has preoperative fecal incontinence can improve once the prolapse been to realize the importance of addressing both the anterior is no longer dilating the anal canal, and patients with constipa- and posterior compartments of the pelvic floor when consid- tion can improve when the prolapse is not blocking the anal 1136 VOGLER: RECTAL PROLAPSE

canal. Therefore, for isolated rectal prolapse, my preference is to if the mesh complications can truly be avoided then this move directly to repair. If patients have worsening or de novo may be our best option. However, I am not ready to jump fecal incontinence or constipation after surgery, then I first try on the bandwagon until I see more long-term results. Each to use conservative measures, including dietary modification, of the previous 100 operations for rectal prolapse were medication, or supplements. If this is not adequate, then I will initially associated with superlative results, but over time proceed with pelvic physiology testing and biofeedback. their pitfalls were exposed. I am sure that with time we will Another key advance in the surgical treatment of have a more pragmatic view of this operation and consider rectal prolapse has been the use of minimally invasive its use by balancing the factors noted above. techniques to reduce morbidity of abdominal surgery, and that makes the option of an abdominal approach REFERENCES more feasible for a majority of patients. There is no question that these repairs are uniformly less likely to 1. Steele SR, Varma MG, Prichard D, et al. The evolution of evalu- have recurrence compared with a perineal approach, ation and management of urinary or fecal incontinence and and the removal of the rectal reservoir in the perineal pelvic organ prolapse. Curr Probl Surg. 2015;52:92–136. approach greatly contributes to poor bowel function af- 2. Peters WA 3rd, Smith MR, Drescher CW. Rectal prolapse in ter surgery. Laparoscopic and robotic approaches have women with other defects of pelvic floor support. Am J Obstet allowed more patients to undergo a successful operation Gynecol. 2001;184:1488–94. 3. Maglinte DD, Hale DS, Sandrasegaran K. Comparison between with minimal morbidity. I have almost completely aban- dynamic cystocolpoproctography and dynamic pelvic floor MRI: doned the use of the perineal rectosigmoidectomy, be- pros and cons–which is the “functional” examination for anorectal cause even the most elderly patients can tolerate general and pelvic floor dysfunction? Abdom Imaging. 2013;38:952–973. anesthesia and do well with a minimally invasive opera- 4. Altomare DF, Binda G, Ganio E, De Nardi P, Giamundo P, Pes- tion. If an elderly patient also has a very patulous anus catori M; Rectal Prolapse Study Group. Long-term outcome and I think that an anterior levatoroplasty could help, I of Altemeier’s procedure for rectal prolapse. Dis Colon Rectum. may consider a perineal approach. 2009;52:698–703. Lastly, the advent of biologic mesh and the use of 5. Wijffels N, Cunningham C, Dixon A, Greenslade G, Lindsey I. ventral rectopexy have been the latest advances in surgery Laparoscopic ventral rectopexy for external rectal prolapse is safe xxx for rectal prolapse. As with all new techniques, the results and effective in the elderly: does this make perineal procedures ob- have been very inspiring, and we are still awaiting more solete? Colorectal Dis. 2011;13:561–566. 6. Formijne Jonkers HA, Draaisma WA, Wexner SD, et al. Evalua- long-term data to evaluate the morbidity of using mesh xxx tion and surgical treatment of rectal prolapse: an international for all repairs and the durability of the latest crop of bio- survey. Colorectal Dis. 2013;15:115–119. logic meshes. The use of mesh for rectal prolapse repairs 7. Madiba TE, Baig MK, Wexner SD. Surgical management of rec- XXX has typically been influenced by institutions of training tal prolapse. Arch Surg. 2005;140:63–73. and the surgeons who are teaching these techniques to 8. Tou S, Brown SR, Malik AI, Nelson RL. Surgery for com- colorectal fellows. Thus, bias toward one repair or another plete rectal prolapse in adults. Cochrane Database Syst Rev. relates to where you learned to treat rectal prolapse. Hav- 2008;(4):CD001758. ing been trained to avoid mesh for rectal prolapse repair, 9. Frykman HM, Goldberg SM. The surgical treatment of rectal I am certainly biased against it and have seen numerous procidentia. Surg Gynecol Obstet. 1969;129:1225–1230. complications in my career of mesh erosions, infections, 10. D’Hoore A, Cadoni R, Penninckx F. Long-term outcome of lap- and strictures that have required complex operations. The aroscopic ventral rectopexy for total rectal prolapse. Br J Surg. biologic meshes are meant to avoid these pitfalls, but the 2004;91:1500–1505. 11. Samaranayake CB, Luo C, Plank AW, Merrie AE, Plank LD, Bis- natural history of their use for ventral hernias indicates sett IP. Systematic review on ventral rectopexy for rectal pro- that they often disintegrate and fail. Newer versions of lapse and intussusception. Colorectal Dis. 2010;12:504–512. these meshes are meant to address these issues, but we 12. Consten EC, van Iersel JJ, Verheijen PM, Broeders IA, Wolthuis have yet to see the long-term results that will indicate that AM, D’Hoore A. Long-term outcome after laparoscopic ventral these are superior products. I do think that the functional mesh rectopexy: an observational study of 919 consecutive pa- results of the ventral rectopexy are very compelling, and tients. Ann Surg. 2015;262:742–747.

Correspondence: Madhulika G. Varma, M.D., Section of Colorectal Surgery, University of California, San Francisco, 550 16th Street, 6th Floor, San Francisco, CA 94158. E-mail: [email protected]

Dis Colon Rectum 2017; 60: 1136–1137 DOI: 10.1097/DCR.0000000000000954 © The ASCRS 2017