Rectal Prolapse

A prolapse is a protrusion of some part of the bowel through and outside the anus. It may occur in childhood or in the elderly. The cause is not know, but there are many possible explanations. It may occur after excessive straining on defecation, pelvic floor muscle weakness or poor fixation of the rectum in the pelvis.t is six times more common in females, but is not necessarily relayed to childbirth.

The symptoms start as a protrusion during defecation, and later may progress to the protrusion at any time. Initially it can be pushed back in, but as it progresses it may become impossible to push back. There may be pain, or minor leakage, mucous, bleeding or major leakage and incontinence.

The condition is usually diagnosed by physical examination and inspection. If the prolapse is not present at the time, your doctor may ask you to strain on the toilet to produce the prolapse, or may organise to examine you under anaesthetic. This may be done at the same time as a colonoscopy, to rule out other colonic pathology. If symptoms of incontinence are also present, test to assess the anal muscle may also be organised.

Treatment depends on the degree of prolapse, the general health of the patient, what surgery they may have previously had, and the expertise and preference of the surgeon.

For minor (internal) prolapse bulking agents and biofeedback may be all that is necessary. The operations available are performed by the anus, or “perineal procedures”, or through the abdomen, or “abdominal procedures”. These may be open, laparoscopic or robotically performed.

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Laparoscopic Ventral Colporectopexy

This procedure can be done for full rectal prolapse, a mixture of rectal and vaginal prolapse, internal rectal prolapse and rectocoeles (prolapse of the vagina into the rectum).

This involves superficial dissection beside the rectum, carried down in the plane between the rectum and vagina, all the way down to the pelvic floor. To hold the rectum and vagina up a mesh is sutured to the lower rectum and vaginal wall, then stapled or sutured to the lower part of the sacrum.

A fleet enema may be given before the operation to empty the rectum

You may have a catheter in your bladder and or drain in over night.

After the operation you can eat and drink. Stool softeners may be commenced, so as to avoid constipation and straining.

With laparoscopic surgery the hospital stay is usually short (1-2days), although other medical or health issues may prolong the stay.

You will generally be discharged with simple analgesia and stool softeners. You should not strain or do heavy lifting for 6 weeks to allow for healing, but you can resume normal duties as soon as you feel comfortable.

Laparoscopic Rectopexy

This procedure involves dissection behind the rectum, and then pulling it up and securing it to the back of the sacrum. There are different ways to secure it, either using suture, or a mesh. No bowel is removed.

Before the operation to empty the rectum you may be given an enema, but generally no other bowel prep is required

You may wake up from the operation with a catheter and drain, which usually are left for a short period only.

After the operation you will usually be allowed to eat and drink. Laxative are often started soon after, so as to prevent constipation and straining.

Following laparoscopic surgery the hospital stay is generally short, being discharged on day 1 or 2, however, other medical conditions or health issues may prolong the stay.

On discharge you will be given simple analgesia and stool softeners (or a script to purchase these). You should not strain or do heavy lifting for 6 weeks to allow for healing, but you can resume normal duties as soon as you feel comfortable.

Perineal Procedures For Rectal Prolapse

Delormes procedure involves dissecting the lining off the prolapsed rectum and then plicating (gathering) the muscle wall with strong stitches. The extra lining is then removed and the full layer closed over.

This procedure is associated with minimal pain in the post operative period. It is associated with minimal risks, and is often performed in patients who are frail and would benefit from a more simple operation. It may also be the first choice for simple internal prolapses.

The operative risks are very low, however the recurrence rate is higher than if the repair is done abdominally.

Altmeirs procedure is an operation where the full layers of prolapsing rectum is removed. The dissection is carried out as far as possible, the bowel is divided, then joined up in the anal canal. This is usually not very painful. Because there is a join in the bowel there is a low chance of a leak, and this can sometimes a major complication. The recurrence rate is lower than that of Delormes procedure.

For these procedures fleet enema may be given before the operation to empty the rectum

You may have a catheter in your bladder in over night. This will usually be removed the next morning.

After the operation you can eat and drink. Stool softeners may be commenced, so as to avoid constipation and straining.

You will generally be discharged with simple analgesia and stool softeners. You should not strain or do heavy lifting for 6 weeks to allow for healing, but you can resume normal duties as soon as you feel comfortable.