PRACTICE PARAMETERS Practice Parameters for the Management of Rectal Prolapse Madhulika Varma, M.D. • Janice Rafferty, M.D. • W. Donald Buie, M.D. Prepared by the Standards Practice Task Force of the American Society of Colon and Rectal Surgeons he American Society of Colon and Rectal Surgeons of the levator ani, an abnormally deep cul-de-sac, a redun- is dedicated to ensuring high-quality patient care dant sigmoid colon, a patulous anal sphincter, and loss of Tby advancing the science, prevention, and manage- the rectal sacral attachments are commonly found.1–6 In ment of disorders and diseases of the colon, rectum, and times past, restoration of normal anatomy to treat rectal anus. The Standards Committee is composed of Society prolapse was considered a definition of success. However, members who are chosen because they have demonstrated the presence of multiple operations to correct this problem expertise in the specialty of colon and rectal surgery. This indicates that the achievement of excellent outcomes is Committee was created to lead international efforts in de- somewhat elusive. fining quality care for conditions related to the colon, rec- Women aged 50 and older are 6 times as likely as men tum, and anus. This is accompanied by developing Clinical to present with rectal prolapse.7–9 Although it is com- Practice Guidelines based on the best available evidence. monly thought that rectal prolapse is a consequence of These guidelines are inclusive, and not prescriptive. Their multiparity, approximately one-third of female patients purpose is to provide information on which decisions can with rectal prolapse are nulliparous. The peak age of inci- be made, rather than dictate a specific form of treatment. dence is the seventh decade in women, whereas the rela- These guidelines are intended for the use of all practitio- tively few men who have this problem may develop pro- ners, health care workers, and patients who desire infor- lapse at the age of 40 or less. One striking characteristic mation about the management of the conditions addressed of younger patients is their increased tendency to have by the topics covered in these guidelines. autism, syndromes associated with developmental delay, It should be recognized that these guidelines should and psychiatric comorbidities requiring multiple medica- not be deemed inclusive of all proper methods of care or tions.10 Young male patients with rectal prolapse also tend exclusive of methods of care reasonably directed to obtain- to report significant symptoms related to bowel function, ing the same results. The ultimate judgment regarding the specifically evacuation. propriety of any specific procedure must be made by the Approximately 50% to 75% of patients with rectal physician in light of all of the circumstances presented by prolapse report fecal incontinence, and 25% to 50% of the individual patient. patients will report constipation.11–15 Incontinence in the setting of rectal prolapse may be explained by the presence of a direct conduit (the prolapse) bypassing the sphincter STATEMENT OF THE PROBLEM mechanism, the chronic stretch and trauma to the sphinc- Rectal prolapse, internal intussusception, and solitary rec- ter caused by the prolapse itself, and continuous stimula- tal ulcer syndrome comprise a spectrum of anatomical ab- tion of the rectoanal inhibitory reflex by the prolapsing tissue. Pudendal neuropathy has been demonstrated in normalities involving descent of full- or partial-thickness 16 rectal wall associated with pelvic floor dysfunction. These up to one-half of patients with prolapse andmaybere- sponsible for denervation-related atrophy of the external conditions, although benign, can be extremely debilitat- 17 ing because of the discomfort of prolapsing tissue both sphincter musculature. Constipation associated with internally and externally, associated drainage of mucus or prolapse may result from intussuscepting bowel in the rec- tum creating a blockage that is exacerbated with straining, blood, and the common occurrence of fecal incontinence 13,14 or constipation. In patients with rectal prolapse, diastasis pelvic floor dyssynergia, and colonic dysmotility. METHODOLOGY Dis Colon Rectum 2011; 54: 1339–1346 DOI: 10.1097/DCR.0b013e3182310f75 An organized search of MEDLINE/PubMed and the ©The ASCRS 2011 Cochrane Database of Systematic Reviews and Clinical DISEASES OF THE COLON &RECTUM VOLUME 54: 11 (2011) 1339 1340 VARMAETAL:PRACTICE PARAMETERS FOR RECTAL PROLAPSE TABLE 1. The GRADE system: grading recommendationsa Methodologic quality of Description Benefit vs risk and burdens supporting evidence Implications 1A Strong recommendation, Benefits clearly outweigh risk RCTs without important Strong recommendation, can apply high-quality evidence and burdens or vice versa limitations or overwhelming to most patients in most evidence from observational circumstances without studies reservation 1B Strong recommendation, Benefits clearly outweigh risk RCTs with important limitations Strong recommendation, can apply moderate-quality evidence and burdens or vice versa (inconsistent results, to most patients in most methodologic flaws, indirect circumstances without or imprecise) or exceptionally reservation strong evidence from observational studies 1C Strong recommendation, low or Benefits clearly outweigh risk Observational studies or case Strong recommendation but may very low quality evidence and burdens or vice versa series change when higher-quality evidence becomes available 2A Weak recommendation, high- Benefits closely balanced with RCTs without important Weak recommendation, best action quality evidence risks and burdens limitations or overwhelming may differ depending on evidence from observational circumstances or patients’ or studies societal values 2B Weak recommendations, Benefits closely balanced with RCTs with important limitations Weak recommendation, best action moderate-quality evidence risks and burdens (inconsistent results, may differ depending on methodologic flaws, indirect circumstances or patients’ or or imprecise) or exceptionally societal values strong evidence from observational studies 2C Weak recommendation, low or Uncertainty in the estimates of Observational studies or case Very weak recommendations; other very low quality evidence benefits, risks and burden; series alternatives may be equally benefits, risk and burden reasonable may be closely balanced GRADE ϭ Grades of Recommendation, Assessment, Development, and Evaluation; RCT ϭ randomized controlled trial. aAdapted from Guyatt et al.18 Table 2. Used with permission. Trials was performed, from 1978 to June 2010, using the a toilet with or without use of an enema. Inspection of the key words “rectal prolapse,” “procidentia,” “laparoscopy,” perineum with the patient in the sitting or squatting posi- “suture rectopexy,” “mesh rectopexy, resection rec- tion is helpful for this purpose. A common pitfall in the topexy,” “perineal rectosigmoidectomy.” Selected embed- diagnosis of rectal prolapse is the potential for confusion ded references were also reviewed. All English language with prolapsing internal hemorrhoids or rectal mucosal manuscripts and studies of adults were reviewed. Recom- prolapse. Usually, these conditions are easily distinguished mendations were formulated by the primary authors and by clinical examination. Close inspection of the direction reviewed by the entire committee. The final grade of rec- of the prolapsed tissue folds will reveal that in the case of ommendation was performed using the Grades of Recom- full-thickness rectal prolapse, the folds are always concen- mendation, Assessment, Development, and Evaluation tric, whereas hemorrhoidal tissue or rectal mucosa devel- (GRADE) system18 (Table 1) and reviewed by the entire ops radial invaginations. Standards Committee. Full inspection of the perineum and complete anorec- tal examination is equally important. A patulous anus with diminished sphincter tone is usually identified. Procto- RECOMMENDATIONS scopy reveals a solitary rectal ulcer on the anterior surface Evaluation of Rectal Prolapse of the rectum in 10% to 15% of cases. In the event that the 1. The initial evaluation of a patient with rectal prolapse prolapse is still elusive, patients can be asked to photo- should include a complete history and physical examina- graph the prolapse at home. Twenty to thirty-five percent tion. Grade of Recommendation: Strong recommenda- of patients with rectal prolapse report urinary inconti- tion based on low quality evidence 1C nence, and about 15% to 30% have significant vaginal Before operative intervention, a careful history and vault prolapse.9,20 These symptoms require evaluation, physical examination should be performed. If the diagno- and potentially, multidisciplinary surgical intervention. sis is suspected from the history, but not detected on phys- 2. Additional tests such as a defecography, colonos- ical examination, confirmation can be obtained by asking copy, barium enema, and urodynamics can be used the patient to reproduce the prolapse by straining while on selectively to define the diagnosis and identify other DISEASES OF THE COLON &RECTUM VOLUME 54: 11 (2011) 1341 important pathology. Grade of Recommendation: Strong tive manometric findings nor nerve conduction velocities recommendation based on moderate quality evidence 1B have served as reliable predictors of postoperative func- If the prolapse cannot be produced during the physical tion.33 Decreased anal squeeze or resting pressures may examination,