Rectal Prolapse Repair

What is a Rectal Prolapse Repair Surgery?

A rectal prolapse can affect men, women and children. It can occur as a result of weak pelvic floor muscles, allowing the rectum to drop downwards until it can eventually protrude inside out from the anus. The pelvic floor muscles can weaken as a result of many things, including excess body weight, straining due to constipation, or childbirth.

The surgical treatment of a rectal prolapse is similar to that of a pelvic organ prolapse with one significant difference – your surgeon can gain access to the prolapse via the anus / perineum, rather than the vagina.


Is Surgery Right For You?

Although embarrassing, it is important that you seek treatment for your rectal prolapse as early as possible. To avoid it worsening, permanently protruding and causing irreparable nerve damage.

Surgery is usually reserved for patients who have a prolapsed rectum that is permanently visible outside of the anus - an external rectal prolapse. Although not life threatening, it can be painful and embarrassing. In some cases the prolapse will only occur during a bowel movement and can be manually pushed back up. But as it can be associated with faecal incontinence, the inability to control gas and bowel movements, treating the prolapse is essential in maintaining an acceptable quality of life.

If you suffer from a milder, internal rectal prolapse, then you will be advised to make lifestyle changes to prevent your prolapse getting worse. You may also be prescribed bulking laxatives to help you empty your bowels without needing to strain. Surgery is not often favoured due to the potential complications associated with undergoing any pelvic surgery, often resulting in damage to other pelvic organs and the associated nerves around and in the anus. Surgery is rarely selected as the treatment for children due to these risks.

Read more about non-surgical treatments for a rectal prolapse on our Treating a Prolapse Without Surgery page.


What Types of Rectal Prolapse Surgery Are Available?

The type of rectal prolapse repair surgery that you have will depend on your personal circumstances including your age, health and the severity of the prolapse. Some surgeries will not be available to you as they are limited by your surgeons experience and skill:

  • Open abdomen surgeries - Most pelvic surgeries are performed through an incision in your abdomen. These tend to have higher success rates and lower recurrence rates, as they allow for easier access. However, as it is an open method of surgery, they often lead to complications such as bleeding.
  • Minimally invasive abdomen surgeries - Laparoscopic (keyhole surgery) and robotic surgeries are favoured over abdominal open surgeries as they have quicker recoveries, leave minimal scarring and have similar success rates to open abdomen surgeries. They do, however, require more experience and skill from the surgeon. Robotic surgeries are not yet very widely available.
  • Anus / perineum entry surgeries - Older patients, and those suffering from other severe medical conditions, are more likely to have the surgery completed through the anus or perineum as it generally leads to a faster and less painful recovery. Perineal approaches are generally less favoured than anal. Although they have fewer complications and pain, with a quicker recovery, they do have a higher recurrence rate of up to 10%.

Pelvic organ prolapse surgery can be completed under general anesthesia, under a spinal block (which is similar to an epidural injection used in childbirth) where the lower part of the body is numbed, or a combination of local anesthesia and intravenous relaxing medication. Your surgeon will discuss these options with you and recommend the one that is most suitable.

Ahead of a rectal surgery, you will undergo a colonoscopy to rule out other conditions that could be causing your symptoms or could change the required surgery. If you are suffering from multiple prolapses, then procedures to repair them all during one surgery will be planned. If any other conditions are found during the procedure they may also be repaired (where possible and previously agreed) during the same operation. To learn about other prolapse repair surgeries, visit our Vaginal Repair Surgery page.


Rectopexy

This surgery can be performed through an incision in your abdomen or through a laparoscopic (keyhole) procedure. You rectum is separated from the pelvic walls, pulled up and secured to the back of the pelvis (sacrum) at several points. During and after your recovery, scarring at these points will further support the rectum. If the prolapse is a result of chronic and historical constipation, you may also have a portion of damaged colon removed during the surgery, to improve bowel function.

A synthetic mesh can be used in this procedure, to provide extra support to the new position of the rectum. This is currently only recommended within the context of research as current evidence is insufficient in proving its safety and success.

Prolapse recurrence is low following this procedure, at 2-5%. However there is a high chance that some symptoms remain after the surgery, even if to a lesser degree. There is also a risk that you still experience incontinence or constipation, and in some cases these are actually made worse.


Rectosigmoidectomy

This surgery is performed through via the anus and can be one of two methods:

  • Perineal Altemeier – The prolapse will be forced outside of the body, and then divided. Excess rectum and colon tissue will be removed, and the remaining colon is sewn or stapled to the anus.
  • Perineal Delorme – Also known as mucosal sleeve resection, this procedure is usually carried out on short rectal prolapses. Your surgeon will remove the lining of the rectum and the whole organ is then folded in on itself and shortened to help strengthen it. This surgery sees a 40-50% improvement in incontinence.

To reduce the risk of fecal incontinence being worsened by the removal of part of the rectum, the pelvic floor muscles can also undergo a levatoroplasty - where they are sewn closer together.


Anal Encirclement (Thiersch wire)

This approach involves your surgeon placing a rigid band around the anus under the skin, to act as a physical barrier to the rectum, preventing it from prolapsing down into the anus.

This procedure is seldom performed, it can lead to faecal impaction (a severe hardening of the stools leading to chronic constipation), erosion from the synthetic material, and infection. Importantly, this procedure does not treat the underlying issue.


What Are the Risks and Potential Complications?

As with any pelvic surgery, there are a number of risks to consider. Alongside the recognised risks of going under anaesthesia, we have listed some of the risks associated specifically with the surgical treatment of a rectal prolapse:

  • 15% risk of new or worsened constipation and severe pain that could be caused by a bowel obstruction
  • bleeding - occasionally requiring a blood transfusion or re-operation
  • deep vein thrombosis (DVT) blood clots originating in your lower leg which can move to your lungs
  • infection
  • damage to the anus, rectum, any other pelvic organ or the tissues and nerves that surround the area
  • a fusing of the rectum to the vagina – called a fistula
  • the prolapse returning
  • narrowing of the anal canal
  • sepsis, from any synthetic materials that have been used infecting the bowel
  • temporary or permanent faecal incontinence
  • leaks from the join in the rectum - potentially life threatening
  • 1-2% risk of sexual dysfunction - men may choose to bank sperm prior to undergoing surgery

If you’re experiencing signs of any of the above, or anything else that worries you, then make an appointment to see your doctor straight away.


How Long Does it Take to Recover from Rectal Prolapse Repair Surgery?

Your total recovery time will depend on your age and how healthy you are. However, most people are fully recovered in around four to six weeks.

You will remain in hospital until you can pass wind, use the toilet and eat. If you had perineal surgery this will likely be within three days. Abdominal surgeries require a longer hospital stay, of up to seven days. Usually, patients will keep a catheter in for only the start of their stay in hospital. You are likely to experience more pain and be prescribed laxatives to help you have a bowel movement. You will also be closely monitored to catch early signs of bleeding or infections.

During your recovery at home you may be on a low fibre diet. You may also be prescribed with mild laxatives, to aid bowel movements and reduce the pressure put on your wounds.

You will have one or two follow-up appointments with your surgeon in the following month, to check how you are healing. Following this you will need to book an appointment if you notice any recurrence or are experiencing any other issues.


What Are the Alternatives to Surgery?

If you have a rectal prolapse that causes the rectum to either temporarily or permanently protrude visibly out of the anus, then it is likely that surgery is your only option.

However, whether you have surgery or not, there are some lifestyle changes that you can make that can help your recovery:

  • Maintain your weight – Being overweight puts extra pressure on the pelvic floor muscles.
  • Avoid constipation – Eating a diet high in fibre means that you’re less likely to suffer constipation. Staying well hydrated with six to eight glasses of water a day will also help. Using a toilet stool puts us in a more natural position, with our knees in a higher, squat like position and this causes less strain on the pelvic floor.
  • Perform Kegel / pelvic floor exercises daily – Kegel, or pelvic floor, exercises are designed to strengthen the pelvic floor muscles which can help keep a rectal prolapse from returning. Use an electronic pelvic toner to make the process easier and more targeted.


Sources

American Society of Colon and Rectal Surgeons. (2018). Diseases and Conditions. Rectal Prolapse Expanded Version. [online] American Society of Colon and Rectal Surgeons, 2018 [viewed 27/03/2018]. Available from: https://www.fascrs.org/patients/disease-condition/rectal-prolapse-expanded-version

Baig, M. K. Maddiba, T. E. Wexner, S. D. (2005). Archives of Surgery / JAMA Surgery. Surgical management of rectal prolapse. [online] 140(1), p 63-73. [viewed 28/03/2018]. Available from:https://www.ncbi.nlm.nih.gov/pubmed/15655208

Baig, M. K. Sajid, M. S. Siddiqui, M. R. (2010). Colorectal Disease. Open vs laparoscopic repair of full thickness rectal prolapse: a re-meta-analysis. [online] 12(6), p 515-525. [viewed 28/03/2018]. Available from: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1463-1318.2009.01886.x

BUPA. (2018). Rectal Prolapse. [online] BUPA, 2018 [viewed 28/03/2018]. Available from: https://www.bupa.co.uk/health-information/directory/r/rectal-prolapse

Gabr, K. Ismail, M. Shalaby, R. (2010). Journal of Pediatric Surgery. Laparoscopic management of persistent complete rectal prolapse in children. [online] 45(3), p 533-539. [viewed 28/03/2018]. Available from: http://www.jpedsurg.org/article/S0022-3468(09)00726-X/pdf

Guy's and St Thomas' NHS Foundation Trust. (2017). Perineal Repair of Rectal Prolapse. [online] Guy's and St Thomas' NHS Foundation Trust, 2018 [viewed 28/03/2018]. Available from: https://www.guysandstthomas.nhs.uk/resources/patient-information/gi/Perineal-repair-of-rectal-prolapse.pdf

Hull and East Yorkshire Hospitals NHS Trust. (2017). Patients Leaflets: Colonoscopy. [online] Hull and East Yorkshire Hospitals NHS Trust, 2017 [viewed 27/03/2018]. Available from: https://www.hey.nhs.uk/patient-leaflet/colonoscopy/

Rakinic, J. (2017). Rectal Prolapse Treatment & Management. [online] Medscape, 2017 [viewed 28/03/2018]. Available from: https://emedicine.medscape.com/article/2026460-treatment

Shin, E. J. (2011). Journal of the Korean Society of Coloproctology. Surgical Treatment of Rectal Prolapse. [online] Journal of the Korean Society of Coloproctology, 2011 [viewed 28/03/2018]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3053504/