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420
M. Farmer
26. Asciutto G, Mumme A, Marpe B, Koster O, Ascuitto KC, Geier B. MR venography in the
detection of pelvic venous congestion. Eur J Vasc Endovasc Surg. 2008;36:491–6.
27. Freedman J, Ganeshan A, Crowe PM. Pelvic congestion syndrome: the role of interventional
radiology in the treatment of chronic pelvic pain. Postgrad Med J. 2010;86:704–10.
28. Payne RA, O’Conner RC, Kressin M, Guralnick ML. Endoscopic ablation of Hunner’s lesions
in interstitial cystitis patients. Can Urol Assoc J. 2009;3:473–7.
29. Smith CP, Radziszewski A, Somogyi GT, Boone TB, Chancellor MB. Botulinum toxin A has
antinociceptive effects in treating interstitial cystitis. Urology. 2004;64:871–5.
30. Zabihi N, Mourtzinos A, Maher MG, Raz S, Rodriguez LV. Short-term results of bilateral
S2-S4 sacral neuromodulation for the treatment of refractory interstitial cystitis, painful blad-
der syndrome and chronic pelvic pain. Int Urogynecol J Pelvic Floor Dysfunct.
2008;19:553–7.
31. Comiter CV. Sacral neuromodulation for the symptomatic treatment of refractory interstitial
cystitis: a prospective study. J Urol. 2003;169:1369–73.
32. Chiarioni G, Nardo A, Vantini I, Romito A, Whitehead WE. Biofeedback is superior to elec-
trogalvanic stimulation and massage for treatment of levator ani syndrome. Gastroenterology.
2010;138:1321–9.
33. Nicosia JF, Abcarian H. Levator syndrome. A treatment that works. Dis Colon Rectum.
1985;28:406–8.
34. Park DH, Yoon SG, Kim KU, et al. Comparison study between electrogalvanic stimulation and
local injection therapy in levator ani syndrome. Int J Colorectal Dis. 2005;20:272–6.
35. Rao SSC, Poulson J, Mata M, Zimmerman B. Clinical trial: effects of botulinum toxin A on
levator ani syndrome: a double blind. Placebo controlled study. Aliment Pharmacol Ther.
2009;29:985–91.
36. De Parades V, Etienney I, Bauer P, Taouk M, Atienza P. Proctalgia fugax: demographic and
clinical characteristics. What every doctor should know from a prospective study of 54 patients.
Dis Colon Rectum. 2007;50:893–8.
37. Katsinelos P, Kalomenopoulou M, Christodoulou K, et al. Treatment of proctalgia fugax with
botulinum A toxin. Eur J Gastroenterol Hepatol. 2001;13:1371–3.
38. Bouquet J, Moore N, Lhuintre JP, Boismare F. Diltiazem for proctalgia fugax. Lancet.
1986;28:1493.
39. Wright JE. Trial of inhaled salbutamol for proctalgia fugax. Lancet. 1991;9:359.
40. Hompes R, Lindsey I. Chronic anorectal pain: a pathophysiological approach. In: Lindsay I,
Nugent K, Dixon T, editors. Pelvic fl oor disorders for the colorectal surgeon. Oxford: Oxford
University Press; 2011.
41. Benson J, Griffi s K. Pudendal neuralgia, a severe pain syndrome. Am J Obstet Gynecol.
2005;192:1663–8.
42. NICE Guidance. Spinal cord stimulation for chronic pain of neuropathic or ischaemic origin.
2008.
http://www.nice.org.uk/nicemedia/pdf/TA159Guidnace.pdf .
43. Robert R, Labatt JJ, Bensignor M, et al. Decompression and transposition of the pudendal
nerve in pudendal neuralgia: a randomized controlled trial and long term evaluation. Eur Urol.
2005;47:403–8.
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S.R. Brown et al. (eds.), Contemporary Coloproctology,
DOI 10.1007/978-0-85729-889-8_29, © Springer-Verlag London Limited 2012
29.1 Introduction
Rectal prolapse is a condition that has puzzled surgeons for many centuries. Ancient
documents, including the Old Testament, give accurate descriptions of the condi-
tion. Surgical treatments for rectal prolapse emerged at the end of the nineteenth
century, some of which have stood the test of time, although most remain historical
curiosities. There is a voluminous literature on rectal prolapse, a PubMed search
will identify nearly 3,000 articles focused on rectal prolapse. However, there is little
level 1 evidence, with few properly powered randomized trials to provide a scien-
tifi c evidence base to guide treatment [ 1 ] . This chapter on rectal prolapse gives an
overview of current thinking on this condition while accepting that many questions
remain unanswered.
29.2 What Is Rectal Prolapse?
Full-thickness rectal prolapse is fairly obvious when seen (Fig. 29.1 ), but is harder
to defi ne. Most colorectal surgeons would consider the term rectal prolapse (or pro-
cidentia) to imply circumferential, full-thickness protrusion of the rectal wall
through the anus. The presence of rectal prolapse implies loss of fi xity of the rectum
within the pelvis and should be distinguished from rectal mucosal prolapse, which
J. G. Williams , B.Sc., M.B.B.Ch., FRCS, M.Ch.
Department of Colorectal Surgery ,
Royal Wolverhampton Hospitals NHS Trust ,
New Cross Hospital, Wednesfi eld Road ,
Wolverhampton, West Midlands,
WV10 0QP , UK
e-mail: graham.williams4@nhs.net
Chapter 29
Rectal Prolapse
J. Graham Williams
422
J.G. Williams
arises when there is disruption of submucosal connective tissue, allowing the
mucosa to slip down from the rectum and into the anal canal. In most patients with
mucosal prolapse, the rectum remains reasonably well supported within the pelvis.
For this reason, rectal mucosal prolapse is likely to be a separate condition and will
not be considered further. Confusion can arise in patients who have evidence of
intussusception of the rectum that does not transgress the anal canal (so-called inter-
nal rectal prolapse or rectal intussusception). In a few patients, this will eventually
progress to overt, full-thickness prolapse. However, in the majority of patients,
intussusception remains within the rectum (see Chap. 28 ).
29.3 What Is the Etiology of Rectal Prolapse?
Despite being recognized for centuries, the etiology of rectal prolapse remains
uncertain and is likely to be multifactorial [ 2 ] . What is well known are the pelvic
changes seen in a patient with rectal prolapse (Fig. 29.2 ). All operations performed
for rectal prolapse aim to correct one or more of these abnormal features. However,
it is most likely that these features arise as a consequence of the prolapse and are not
responsible for development of the prolapse in the fi rst place.
Rectal prolapse is predominantly a condition seen in older female patients. This
raises the possibility that pelvic fl oor failure, secondary to vaginal delivery, plays an
Fig. 29.1 Large, full
thickness prolapse in an
elderly female, about to be
repaired by a perineal
procedure (patient in prone
jack-knife position)
423
29 Rectal Prolapse
important etiological role. However, many elderly women affl icted by rectal pro-
lapse are nulliparous, and other etiological factors need to be considered.
There is some evidence to support a theory that patients with rectal prolapse have
abnormalities of connective tissue structure, predisposing them to loss of fi xation of
the rectum and eventual prolapse [ 3 ] .
Although less common, rectal prolapse is seen in infants where it is likely that
disordered bowel function, leading to chronic straining, plays a major part in the
etiology of rectal prolapse. Indeed, correcting constipation usually resolves the
problem. In male patients (who are usually younger than female patients), it is likely
that the support to pelvic structures afforded by the prostate is responsible for the
low incidence in this group.
Thus, although the exact pathogenesis of rectal prolapse is uncertain, it is likely
to be multifactorial, with the relative importance of the assorted implicated factors
varying in different groups of patients.
Incontinence of faeces is a common association with rectal prolapse, suggesting
that pelvic fl oor failure may be relevant in the etiology. Anorectal investigations usu-
ally reveal very low sphincter pressures at rest and on attempted squeeze, but intact
anal sphincters on ultrasound. Fecal incontinence associated with rectal prolapse has
a number of other possible causes. The quoted incidence of fecal incontinence in
these patients ranges from 30% to 90%, which suggests that the defi nition of pro-
lapse varies from study to study. It is important to differentiate true fecal incontinence
Pathological anatomy found
in rectal procidentia
1. Diastasis of Levator Ani
3. Redundant rectosigmoid 4. Patulous anal sphincter
5. Loss of horizontal position
of rectum and its sacral
attachments
Normal
2. Abnormally deep cul-de-sac
Fig 29.2 Schematic representation of the various anatomical abnormalities seen in full thickness
rectal prolapse. It is likely that most of these arise as a consequence of the prolapse. Most opera-
tion for rectal prolapse aim to correct at least one of these abnormalities
424
J.G. Williams
form simple soiling that occurs when fecal material coating the lower rectum is
brought out onto the underwear or pad each time the prolapse appears. Chronic inhi-
bition of internal sphincter contraction through the rectoanal inhibitory refl ex has
been postulated as a cause of fecal incontinence, but it seems more likely that stretch-
ing of the sphincter by the prolapse is the cause of incontinence, and this would
explain why control gradually improves in most patients after successful repair.
29.4 How Is a Patient with Rectal Prolapse Assessed?
The diagnosis of rectal prolapse is usually suggested by a history of a fl eshy mass
protruding from the anus on defecation or walking. However, sometimes, this his-
tory is not forthcoming, especially in elderly, confused patients, and other features
such as mucus discharge, blood on the underwear, poor anal control, and a bearing
down sensation should raise the suspicion of a prolapse.
A careful history of bowel function and anal control should be taken. Constipation
is a common association, and this should be explored as profound constipation, with
very infrequent bowel actions, suggests associated slow-transit constipation, most
prevalent in younger female patients.
Anal control should be assessed by direct questions: simple soiling as the pro-
lapse emerges should be differentiated from true fecal incontinence.
The patient’s health and mobility should be gauged from specifi c questions.
Observation of the patient during history taking and while they get on the examina-
tion couch will provide useful, but subjective information as to their relative fi tness
for surgery and help determine the most appropriate surgical approach.
Inspection of the perineum is all that is required to confi rm the diagnosis, pro-
vided the prolapse is visible. Confusion can arise between full-thickness rectal pro-
lapse and mucosal prolapse, but the two conditions can usually be separated by
features noted on simple clinical examination (Box 29.1 ).
Often, the prolapse is not visible on inspection with the patient resting on the
couch. Clues as to the diagnosis include a patulous anus, easily opened on separating
Box 29.1: Differentiating Clinical Features of a Mucosal Prolapse
and a Rectal Prolapse
Feature Rectal mucosal prolapse Full-thickness rectal prolapse
Size Usually small protrusion
Larger protrusion (plum or
larger)
Position Often not circumferential Whole circumference
involved
Mucosal folds Radial orientation Circumferential orientation
Thickness by
palpation
Mucosal folds only Muscle layer palpable
425
29 Rectal Prolapse
the buttocks, and a blob of mucus on the anal verge. Asking the patient to bear down
may reveal the prolapse, but maneuvers may be required such as asking the patient
to squat or even inserting a couple of glycerin suppositories and asking the patient
to open their bowels.
Having established the diagnosis, consideration should be given to imaging the
colon, especially in older patients, as other colonic pathology may coexist. Barium
enema, while safer and less invasive than colonoscopy, is often diffi cult to perform
because a patulous anus makes retention of the balloon catheter diffi cult for the
patient. Patients with profound constipation should be assessed by a transit study –
either a simple radiopaque marker study, or by clearance of ingested isotope from
the colon. Anorectal physiology tests and endoanal ultrasound scanning seldom
provide useful information, except in younger patients with associated disorders of
bowel function, where results of these studies help build up a full picture of colonic,
rectal, and anal function.
29.5 How Is Rectal Prolapse Treated?
29.5.1 Nonsurgical Treatment
Nonsurgical treatment has little to offer the majority of patients with rectal prolapse.
Once the rectum has prolapsed, it usually continues to do so with increasing fre-
quency, gradually getting larger. Simply replacing the rectum in the pelvis is futile.
The situation is different in infants, where reduction of the prolapse, strapping the
buttocks, and a bowel management regime will usually resolve the condition over a
period of time. Another nonsurgical approach in children which can be successful is
reduction of the prolapse and injection of a sclerosing agent into the presacral space
via a transperineal approach, under general anesthetic.
29.5.2 Surgical Repair
Over 100 surgical procedures have been described to correct rectal prolapse: many
of these are minor variations of other procedures. Most of the myriad procedures
described have been abandoned, but the history of the evolution of surgery for rectal
prolapse makes fascinating reading and has been covered elsewhere in numerous
review articles and textbooks [ 4, 5 ] .
Operations for rectal prolapse can be divided into:
(a) Those that aim to fi x or suspend the rectum back within the pelvis (rectopexy in
all its forms)
(b) Those that excise the unsupported rectum and redundant sigmoid colon (ante-
rior resection or perineal rectosigmoidectomy)
(c) Those that reduce the prolapse and confi ne it to the pelvis by anal plication
(Thiersch’s operation – now abandoned) or rectal plication (Delorme’s operation)
426
J.G. Williams
Three surgical approaches can be employed:
1. Traditional open abdominal surgery
2. Laparoscopic abdominal surgery
3. A perineal procedure
Each approach has its advantages and disadvantages, but the emergence of lap-
aroscopic procedures has muddied the distinction between open operations for fi tter
younger patients and perineal operations for older, frailer patients.
29.5.2.1 Rectal Fixation (Rectopexy)
The principle of rectopexy is simple: the rectum is mobilized and returned to its
correct anatomical position within the pelvis. The rectum is then fi xed in place by a
variety of techniques, most usually by posterior fi xation to the presacral fascia.
Previously, the commonest method of fi xation was using foreign material. In the
USA, this typically took the form of Marlex mesh. Initially, the procedure involved
supporting the rectum against the sacrum with a sling of mesh attached to the pre-
sacral fascia (Ripstein’s operation) [
6 ] . However, this approach was found to be
associated with signifi cant postoperative constipation arising from obstruction to
the rectum from the sling [ 7 ] . A subsequent modifi cation of the procedure to avoid
this problem involved a partial wrap of the rectum with two sides of a piece of mesh
which had been previously attached to the presacral fascia [ 8 ] . In the UK, a similar
approach was employed, where the mobilized rectum was partially encircled by
Ivalon sponge, which had been fi xed to the presacral fascia [ 9 ] . The Ivalon sponge
was thought to produce a severe tissue reaction, which would fi x the rectum to the
sacrum. As well as functional problems, one major drawback of the mesh and
sponge rectopexy was the potential for deep-seated infection of the mesh. It is partly
for this reason, as well as the fact that mesh is not required to produce adequate fi xa-
tion, that these operations have been all but abandoned [ 10 ] .
A second approach to fi xing the rectum within the pelvis is to suspend it from the
sacral promontory. Initially, this was achieved using strips of fascia lata attached to
the sacral promontory and the anterior wall of the rectum (Loygue’s operation) [ 11 ] .
This operation was slow to gain in popularity, despite good published results on a
large series of patients. Subsequent modifi cation involved the substitution of fascia
lata with strips of synthetic mesh. One advantage of this approach is that colposus-
pension can be incorporated in patients with combined rectal and gynecological
prolapse. A more recent modifi cation of this procedure is to confi ne dissection to
the rectovaginal septum, opening a pocket down to the perineal body and avoiding
any lateral and posterior dissection [ 12 ] . Mesh is then attached to the perineal body
from above and to the anterior rectal wall and, where necessary, the posterior wall
of the vagina. Closure of the pelvic peritoneum over the mesh recreates the pouch
of Douglas. This operation is ideally suited to a laparoscopic approach because of
limited access in the depths of the rectovaginal septum [ 13, 14 ] , but some surgeons
perform this operation through a small transverse incision. The operation is also
427
29 Rectal Prolapse
feasible in male patients. The advantages of this operation include avoidance of risk
of bleeding from presacral vessels, avoidance of denervation of the rectum, and less
risk of damage of pelvic autonomic nerve supply. Published results, to date, are
good, particularly as regards functional outcome.
The principles of sutured rectopexy are set out in Box
29.2 .
There are several unresolved issues around rectopexy. The fi rst of these is the
extent of mobilization of the rectum. Full rectal mobilization will ensure that the
whole of the prolapse has been reduced and that following rectopexy, there will be
no residual redundancy of the rectum. However, complete rectal mobilization will,
by defi nition, result in division of all the lateral nerve supply (parasympathetics) to
the rectum, and this may affect the function of the rectum and rectal sensation. The
only trial to look at this issue suffered from small numbers but did show that recur-
rence of rectal prolapse was more likely if the lateral stalks to the rectum were pre-
served [ 15 ] . On the other hand, although recurrence was less if full mobilization
was performed, patients were more likely to suffer with a new evacuatory disorder
after surgery. Thus, the extent of mobilization is a compromise between long-term
control of the prolapse and altered bowel function.
The second issue is whether resection of the sigmoid should be combined with
rectopexy. The rationale behind sigmoid resection is threefold. Many patients with
rectal prolapse have a degree of constipation, which might be resolved by sigmoid
resection. Full rectal mobilization increases redundancy of the sigmoid colon, which
may lead to poorer colonic function following rectopexy. Thirdly, Frykman and
Goldberg (who popularized resection rectopexy) postulated that sigmoid resection
Box 29.2 : The Principles of Suture Rectopexy
Position of patient Lloyd Davies, steep head down
Incision
Lower transverse or laparoscopic ports
Mobilization of rectum Performed in presacral plane (TME plane)
posteriorly to pelvic fl oor (anterior and lateral
dissection, see text)
Fixation of rectum to
sacrum
Open – two or three 0 Prolene sutures through
mesorectum of midrectum, presacral fascia in
midline, and back through mesorectum, tied
snugly without damaging rectum or blood
supply
Laparoscopic – mesorectum attached to sacrum in
midline with laparoscopic tacks or sutures
Concomitant sigmoid
resection
See text
Closure of peritoneum Not required
428
J.G. Williams
will straighten the colon and help suspend the rectum from the splenic fl exure, in
theory helping to reduce the likelihood of recurrence [ 16 ] . However, like many of
the issues in rectal prolapse surgery, there is little evidence to support these theories
and guide management. Certainly, the idea that sigmoid resection reduces recur-
rence by supporting the rectum is nothing more than conjecture and does not have
any scientifi c basis. While it is accepted that rectal mobilization increases redun-
dancy of the sigmoid, it is far from certain that this has any relevance to postopera-
tive bowel function or risk of recurrence. The notion that sigmoid resection will
lessen the risk of postoperative constipation and improve bowel function is attrac-
tive, although the evidence available does not confi rm this and the effect of sigmoid
resection on bowel function appears variable.
Where bowel resection may play a part is in the patient with associated slow-
transit constipation. These patients are usually female and tend to be younger than
rather than that the usual patient affl icted with rectal prolapse. Clues in the history
include very infrequent bowel movement (less than once per week) and no episodes
of loose motions. Confi rmation of slow-transit constipation requires some form of
colonic transit study. An isotope transit study is usually performed, but a simple
shapes study will suffi ce. In patients with proven slow-transit constipation and full-
thickness rectal prolapse, rectopexy alone is unlikely to suffi ce, and one strategy is
to combine rectopexy with subtotal colectomy. However, results can be unpredict-
able, and the patient needs careful counseling about the range of possible outcomes,
especially the risk of frequent loose stools and incontinence.
Where some form of colonic resection is deemed a necessary part of surgery for
rectal prolapse, consideration needs to be given to how colectomy will be performed.
Ideally, the anastomosis should be performed at a comfortable level in open and
laparoscopic surgery. The aim of rectopexy is to retain the rectum to preserve the
storage function of the rectum. Thus, it is usual to leave a long rectal stump onto
which the proximal end of bowel is anastomosed. However, it should be remem-
bered that when full rectal mobilization is performed, many of the small vessels
entering the lower rectum from the pelvic side walls are divided. For this reason, it
is the author’s routine to preserve the inferior mesenteric vessels during rectal mobi-
lization and perform close dissection of the colon to be removed, thus preserving a
good proximal blood supply to the rectum and lessening the risk of anastomotic
failure. This is not a view held universally, and some surgeons are happy to divide
the inferior mesenteric vessels and perform a conventional resection.
What Are the Results of Rectopexy?
Transabdominal rectopexy is associated with a low recurrence rate. There are a
large number of series reported in the literature with recurrence rates ranging from
0% to 12% (Table
29.1 ).
Interpretation of these results requires some caution. Most series report crude
recurrence rates with no account being taken for duration of follow-up. Furthermore,
details of how recurrence was assessed and defi ned are often absent, with some
429
29 Rectal Prolapse
series relying of telephone interview of patients, rather than specifi c examination of
the perineum with the patient straining. One of the surprises of the UK PROSPER
trial of rectal prolapse was the higher than expected incidence of mucosal prolapse
after abdominal rectopexy. However, this is likely to be a more realistic recurrence
rate than some of the previously reported series because of the systematic approach
to follow up in this trial.
Functional results of rectopexy are even harder to interpret. Most studies report
improvement in anal control following successful correction of prolapse by rectopexy,
sometime with dramatic improvement in continence. However, defi nitions of inconti-
nence vary from study to study as well as the thoroughness that anal control was
assessed before and after surgery. Furthermore, confusion can arise between true anal
incontinence and simple soiling occurring each time the rectum comes out and brings
with it any fecal matter lying within the lower rectum. Despite this, most surgeons
would agree that transabdominal correction of rectal prolapse improves anal control.
Constipation following abdominal rectopexy is common, reported in up to 50%
of patients in some series. For Ripstein’s sling rectopexy, this was thought to be a
simple mechanical problem caused by restriction of the rectal lumen by the anterior
sling of mesh. However, similar rates of constipation have been reported after pos-
terior mesh rectopexy performed without restriction to the rectal lumen, and it is
likely that other factors, such as rectal denervation, play an important part in the
etiology of postoperative constipation.
29.5.2.2 Rectal Excision
Anterior Resection
At fi rst glance, removing the prolapsing rectum might be considered a solution to
the problem. The arguments in favor of anterior resection as a treatment for rectal
prolapse are threefold. Firstly, it removes the affected part of the distal colon and
rectum and resolves redundancy of the rectum and sigmoid. Secondly, fi brosis aris-
ing in the postoperative period helps fi x the remaining rectum and colon within the
pelvis and thus reduces the risk of recurrent prolapse. Thirdly, colorectal surgeons
are familiar with this operation, performing it regularly for rectal cancer.
Table 29.1 Results of rectopexy
Author Date Technique No.
Follow-up
(months) Recurrence
Graf et al. [
17 ] 1996 Suture (open) 53 97
5 (9%)
Khana et al. [
18 ] 1996 Suture (open) 65 65 0
Kessler et al. [
19 ] 1999 Suture (laparoscopic) 32 48 2 (6%)
Keighley and Shouler [
20 ] 1984 Mesh (open) 100 24 0
Galili and Rabau [
21 ] 1997 Mesh (open) 37 44 1 (3%)
Zittel et al. [
22 ] 2000 Mesh (laparoscopic) 29 22 1 (4%)
Laubert et al. [
23 ] 2010 Suture (laparoscopic) 152 48 10 (11.5%)
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