Rectal Prolapse Management

Emergency vs. Elective Management

For hemodynamically unstable patients with strangulated or perforated rectal prolapse, proceed immediately to surgery without delay 1, 2
For incarcerated prolapse without ischemia or perforation in stable patients, attempt gentle manual reduction under sedation in Trendelenburg position before proceeding to elective surgery 1, 3, 4
Non-operative reduction techniques include topical granulated sugar, hypertonic solutions, submucosal hyaluronidase injection, or elastic compression wrapping to reduce edema 2, 3, 4
Do not delay surgical management if manual reduction fails or if signs of gangrene/perforation develop 1, 2

Obtain colonoscopy or flexible sigmoidoscopy in all patients with rectal prolapse to rule out colorectal malignancy, as these patients have a 4.2-fold increased risk of rectosigmoid cancer compared to age-matched controls 1, 3, 4
Perform contrast-enhanced CT scan in complicated cases to assess for bowel obstruction, perforation, peritonitis, or prolapse of other pelvic organs, but do not delay surgery in unstable patients 1, 3

Abdominal rectopexy is associated with significantly lower recurrence rates (0-8%) compared to perineal approaches 5
Avoid bowel resection in patients with preexisting diarrhea or incontinence, as these symptoms may worsen 5
Division of lateral ligaments reduces recurrence but increases postoperative constipation risk 5

Asymptomatic grade 1-2 rectal prolapse does not require surgery; manage with pelvic floor biofeedback therapy to correct underlying dyssynergia 5, 6

Do not assume anatomic correction correlates with symptom improvement—symptoms may persist despite successful anatomic repair, as underlying functional disorders are not corrected by surgery alone 5, 6
Posterior rectopexy causes severe constipation in 50% of patients 5