CLINICAL PRACTICE GUIDELINES Clinical Practice Guidelines for the Treatment of Rectal Prolapse Liliana Bordeianou, M.D., M.P.H. • Ian Paquette, M.D. • Eric Johnson, M.D. Stefan D. Holubar, M.D. • Wolfgang Gaertner, M.D. • Daniel L. Feingold, M.D. Scott R. Steele, M.D. Prepared by the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons STATEMENT OF THE PROBLEM Although rectal prolapse is a benign condition, it can be debilitating because of the discomfort of prolapsing Rectal prolapse is a disorder characterized by a full-thickness tissue both internally and externally, associated drainage intussusception of the rectal wall, which protrudes externally of mucus or blood, and the common occurrence of con- through the anus. It is associated with a spectrum of coexist- comitant symptoms of fecal incontinence, constipation, or ing anatomic abnormalities, such as diastasis of the levator both.8 Approximately 50% to 75% of patients with rectal ani, an abnormally deep cul-de-sac, a redundant sigmoid prolapse report fecal incontinence, and 25% to 50% of colon, a patulous anal sphincter, and loss or attenuation of patients report constipation.9–13 Incontinence in the set- the rectal sacral attachments. Some have hypothesized that ting of rectal prolapse may be explained by the presence the condition is associated with (and preceded by) internal of a direct conduit (ie, the prolapse), which disturbs the rectal intussusception or a traumatic solitary rectal ulcer, al- sphincter mechanism, the chronic traumatic stretch of 1–3 though these associations have never been clearly proven. the sphincter caused by the prolapse itself, and continu- Rectal prolapse is rare and is estimated to occur in ous stimulation of the rectoanal inhibitory reflex by the ≈0.5% of the general population overall, although the fre- prolapsing tissue.14 Up to one half of patients with pro- quency is higher in females and the elderly, and women lapse demonstrate pudendal neuropathy,15 which may be aged ≥50 years are 6 times more likely as men to pro- responsible for denervation-related atrophy of the exter- 4–6 lapse. Although it is commonly thought that rectal pro- nal sphincter musculature.16 Constipation associated with lapse is a consequence of multiparity, approximately one prolapse may result from intussuscepting bowel in the rec- third of female patients with rectal prolapse are nullipa- tum, creating a blockage that is exacerbated with straining, rous. The peak age of incidence is the seventh decade in pelvic floor dyssynergia, and colonic dysmotility, although women. Interestingly, although fewer men have the condi- causality versus correlation remains highly debated.11,12 tion, the age of incidence for these men is generally ≤40 The goals of surgery to correct rectal prolapse are 3-fold: years. A striking characteristic of younger patients, both 1) to eliminate the prolapse through either resection or resto- male and female, is an increased tendency to have autism, ration of normal anatomy, 2) to correct associated functional syndromes associated with developmental delay, or psy- abnormalities of constipation or incontinence, and 3) to chiatric comorbidities requiring multiple medications.7 avoid the creation of de novo bowel dysfunction. Multiple op- erations have been developed to achieve this complex 3-fold Supplemental digital content is available for this article. Direct URL goal, each with various strengths and weaknesses underscor- citations appear in the printed text, and links to the digital files are pro- ing the importance of careful patient selection and thorough vided in the HTML and PDF versions of this article on the journal’s Web patient counseling when choosing a surgical approach. site (www.dcrjournal.com). Financial Disclosure: The funding body (ASCRS) did not influence the METHODOLOGY content of this work and no other specific funding was received. These guidelines were built based on the last set of The Correspondence: Scott R. Steele, M.D., 9500 Euclid Ave/A30, Cleveland American Society of Colon and Rectal Surgeons (ASCRS) Clinic, Cleveland OH, 44915. E-mail: [email protected] practice parameters for treatment of rectal prolapse pub- 17 Dis Colon Rectum 2017; 60: 1121–1131 lished in 2011. An organized search of Medline, PubMed, DOI: 10.1097/DCR.0000000000000889 Embase, and the Cochrane Database of Collected Reviews © The ASCRS 2017 was performed from October 2011 through December DISEASES OF THE COLON & RECTUM VOLUME 60: 11 (2017) 1121 xxxxxxXXX Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited. 1122 BORDEIANOU ET AL: TREATMENT OF RECTAL PROLAPSE 2016. Retrieved publications were limited to the English to final publication. After initial completion of the article, language and human participants. The search strategies the entire committee reviewed and edited it. Final recom- were based on the concepts of rectal prolapse and internal mendations were approved by the ASCRS Chairman and intussusception as primary search terms. Searches were Vice Chairman of the Clinical Practice Guidelines Com- also performed based on various treatments for rectal mittee and then ultimately the Executive Council. prolapse, including rectopexy, suture rectopexy, resection rectopexy, ventral rectopexy, D’Hoore rectopexy, Delorme Evaluation of Rectal Prolapse procedure, and Altemeier procedure. An initial search identified 781 unique citations. These were ultimately 1. The initial evaluation of a patient with rectal prolapse categorized into subsets (see Table, Supplemental Digital should include a complete history and physical examina- Content 1, http://links.lww.com/DCR/A390). Directed tion with focus on the prolapse, on anal sphincter struc- searches of the embedded references from the primary ar- ture and function, and on concomitant symptoms and ticles were also performed in certain circumstances. Pro- underlying conditions. Recommendation: strong recom- spective, randomized controlled trials and meta-analyses mendation based on low-quality evidence, 1C. were given preference in developing these guidelines. Ul- A careful history and physical examination should be per- timately, 172 articles were carefully reviewed, and articles formed before considering any operative intervention. If a with poor control subjects or unclear study end points patient’s history suggests the diagnosis but no prolapse is were excluded. The final guideline was created using 110 detected on physical examination, the patient can be asked unique citations listed in the references below. The fi- to reproduce the prolapse by straining while on a toilet nal grade of recommendation was performed using the with or without the use of an enema or a rectal balloon. Grades of Recommendation, Assessment, Development, The perineum can then be inspected with the patient in and Evaluation system (Table 1).18 A panel of members the sitting or squatting position. One should be careful, of the ASCRS Clinical Practice Guidelines Committee however, to avoid confusing rectal prolapse with pro- worked in production of these guidelines from inception lapsing internal hemorrhoids or rectal mucosal prolapse. TABLE 1. The GRADE system: grading recommendations Benefit versus Methodologic quality Description risk and burdens of supporting evidence Implications 1A Strong recommendation, Benefits clearly outweigh risks RCTs without important Strong recommendation, can high-quality evidence and burdens or vice versa limitations or overwhelming apply to most patients in evidence from observational most circumstances without studies reservation 1B Strong recommendation, Benefits clearly outweigh risks RCTs with important limitations Strong recommendation, can moderate-quality and burdens or vice versa (inconsistent results, apply to most patients in evidence methodologic flaws, indirect most circumstances without or imprecise) or exceptionally reservation strong evidence from observational studies 1C Strong recommendation, Benefits clearly outweigh risks Observational studies or case Strong recommendation but low- or very low-quality and burdens or vice versa series may change when higher- evidence quality evidence becomes available 2A Weak recommendation, Benefits closely balanced with RCTs without important Weak recommendation, best high-quality evidence risks and burdens limitations or overwhelming action may differ depending evidence from observational on circumstances or patient studies or societal values 2B Weak recommendation, Benefits closely balanced with RCTs with important limitations Weak recommendation, best moderate-quality risks and burdens (inconsistent results, action may differ depending evidence methodologic flaws, indirect on circumstances or patient or imprecise) or exceptionally or societal values strong evidence from observational studies 2C Weak recommendation, Uncertainty in the estimates of Observational studies or case Very weak recommendations; low- or very low-quality benefits, risks and burdens; series other alternatives may be evidence benefits, risks, and burdens equally reasonable may be closely balanced Adapted with permission from Chest. 2006;129:174–181.18 GRADE = Grades of Recommendation, Assessment, Development, and Evaluation; RCT = randomized controlled trial. Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited. DISEASES OF THE COLON & RECTUM VOLUME 60: 11 (2017) 1123 Full-thickness rectal