27 Rectal Prolapse

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Introduction

The term rectal prolapse can be associated with three different clinical entities: full-thickness rectal prolapse, mucosal prolapse and internal rectal intussusception. Full-thickness rectal prolapse is the most commonly recognised type and is defined as protru- sion of the full thickness of the rectal wall through the anus. In mucosal prolapse, only the rectal mucosa protrudes from the anus. Internal intussusception may be a full thickness or a partial rectal-wall disor- der, but the prolapsed tissue does not pass beyond the anal canal and does not pass out of the anus. This chapter focuses on full-thickness rectal prolapse with specific regard to associated faecal incontinence.

Faecal incontinence is the most common symp- tom in patients with full-thickness rectal prolapse, apart from the presence of the prolapse itself. It affects 50–80% of patients [1–3]. Of those who complain of faecal incontinence, about one third will continue to be incontinent after rectopexy [4–7]. The cause of the ongoing incontinence may be a result of anal sphincter disruption from dilatation by the prolapsing bowel or from a pudendal neuropathy caused by repeated traction on the pudendal nerves during prolapse or both [8, 9].

Women with rectal prolapse outnumber men by ten to one [10, 11]. Amongst women, the incidence rises with age, with more than 50% of female patients with prolapse being over the age of 70 years [12]. This is not mirrored in men [13, 14]. The incidence of prolapse does not appear to be confined to parous women, with one third of elderly patients with prolapse being nulliparous [15, 16]. Nulliparae appear to be less likely to suffer from incontinence (22%) when compared with those who have had a vaginal delivery (85%) [17]. It is rare for men with a prolapse to suffer from incontinence.

Rarely, children can develop a rectal prolapse;

usually before the age of 3 years. The evaluation and treatment of children with rectal prolapse is different from that for adults and will not be discussed.

Rectal prolapse is an intussusception of the rec-

tum through the anal sphincters and often has other associated abnormalities especially related to a weak pelvic floor [18]. A deep pouch of Douglas, lax later- al ligaments and/or loss of attachment of the rectum to the sacrum are commonly present and lead to genital prolapse in 25% of patients [12] and urinary incontinence in 30% [17, 19, 20].

Symptoms and Signs

Typically, patients complain of prolapse, mucus dis- charge, bleeding and either incontinence or constipation. The diagnosis of full-thickness rectal prolapse, although suggested by the history, needs to be con- firmed on examination to rule out partial-thickness rectal prolapse, prolapsing haemorrhoids and the like. Ideally, the patient should be placed on a toilet or commode and encouraged to bear down in order to demonstrate the prolapse, as embarrassment and fear of soiling often prevents demonstration of the prolapse in the consultation room. Incontinence should be specified, as mucus or minor soiling from the surface of the prolapsing rectum is often reported as faecal incontinence.

Investigations

Investigation should be targeted to the individual, with the underlying principle being one of selecting a procedure that will best correct the rectal prolapse whilst addressing both any problems associated with concurrent pelvic floor insufficiency and functional disturbances, if present.

Flexible Sigmoidoscopy

Flexible sigmoidoscopy should be carried out to exclude a solitary rectal ulcer, rectal polyp, tumour or mucosal disease. Colonoscopy may be carried out if more proximal colonic pathology is suspected, and

Rectal Prolapse

Michael E.D. Jarrett

27

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transit studies may be useful in patients with constipation to elicit whether a resection rectopexy is indicated.

Defecating Proctography

Defecating proctography is not routinely required if a full-thickness rectal prolapse is evident clinically, although it may be used to predict return of continence. A narrow anorectal angle during pelvic floor contraction, minimal pelvic floor descent during contraction and a long anal canal at rest and during contraction all increase the chance of return of continence after prolapse fixation [21].

Anal Manometry

Anal manometry is not routinely carried out in all patients with rectal prolapse. However, in patients with associated faecal incontinence, it has some predictive value in identifying patients who are likely to remain incontinent following rectal prolapse repair [22]. Patients with rectal prolapse have a reduced resting anal canal pressure [4, 5, 23, 24]. Those with rectal prolapse and incontinence have both reduced resting and squeeze pressures, which improve significantly following operation. Patients who remain incontinent after surgery have a significantly lower preoperative resting anal pressure and maximum voluntary contraction pressure than do patients who improve or regain continence. Preoperative resting anal pressure below 10 mmHg and maximum voluntary contraction pressure below 50–60 mmHg are associated with persisting incontinence after surgery [25, 26].

Pudendal Nerve Terminal Motor Latency

Pudendal nerve terminal motor latency (PNTML) is being carried out less and less. Although it is often prolonged in patients with associated incontinence, its relevance to further management is not well understood.

Endoanal Ultrasound

Endoanal ultrasound often reveals an early thick- ened internal anal sphincter and submucosa [27]

and, with long-standing prolapse, a torn or even fragmented internal anal sphincter and/or external sphincter [28, 29]. The feeling is that the internal sphincter thickens initially in response to the prolapse in order to try to contain it but eventually fails from traumatic disruption. In the incontinent patient, baseline endoanal ultrasound and physio- logical measurements are useful to ascertain the like- lihood of ongoing problems of faecal incontinence following rectal prolapse fixation.

Operative Intervention

Operative treatment is usually indicated for full- thickness rectal prolapse if the primary problem is not one of excessive straining. More than 100 different procedures have been described to treat the con- dition [30] but can be broadly divided into those that are abdominal (open or laparoscopic) or perineal in approach. The latter are often favoured for the frail and the infirm and in young males to minimise operative trauma and the risk of nerve damage. Conti- nence restoration rates are similar between the two

Table 1.Large studies (>50 patients) involving open abdominal repair of full-thickness rectal prolapse

Study Patients Procedure Improved Recurrence

continence (%) rate (%)

Morgan [31] 150 Ivalon 52 3.2

Penfold and Hawley [2] 95 Ivalon 55 3

Mann and Hoffman [32] 51 Ivalon 38 0

McCue and Thomson [33] 53 Ivalon 38 3.8

Keighley et al. [3] 86 Marlex 64 0

Launer et al. [34] 54 Ripstein 12

Holmstrom et al. [35] 97 Ripstein 39 4.1

Tjandra et al. [36] 142 Ripstein 48 8

Watts et al. [16] 102 Resection 77 1.9

Kim et al. [37] 161 Resection 55 5

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groups. In the larger studies (>50 patients), 38–77%

of patients achieved improved continence with an abdominal procedure, as did 40–83% of those following a perineal procedure (Tables 1 and 2). It would seem that with prolapse resolution, continence restoration follows suit independent of the procedure undertaken. Recurrence rates, however, do vary markedly, and one would anticipate that with prolapse recurrence, incontinence would also recur.

Laparoscopic procedures give a wide range of improved continence, with from 31–90% of patients getting improvement. Recurrence rates seem similar to those of open abdominal surgery (Table 3).

Persistent Postoperative Incontinence

If a full-thickness rectal prolapse is treated quickly and effectively, there is a good chance that continence will be restored. The management of persistent postoperative incontinence, however, remains a dif- ficult problem in what is often an elderly population, and treatment needs to be tailored accordingly.

Conservative Therapy

Treatment of persistent faecal incontinence is prima- rily conservative. Initially, dietary advice and titra-

tion of antidiarrhoeal medication such as loperamide or codeine phosphate are suggested. This aims to firm the patient’s stool but not render them consti- pated, thus allowing the continence mechanism to have conditions such that it can work to the best of its ability. Physical and behavioural therapy [48–51]

(e.g. pelvic floor muscle training and biofeedback) also aim to support the patient and optimise sphincter function. Advice on the use of absorbent pads or anal plugs may also be given. Whereas these meas- ures are effective in many patients, a proportion remains with persistent severe incontinence that requires more intensive treatment.

Sacral Nerve Stimulation

Sacral nerve stimulation may be considered at this stage and has the advantages of having a peripheral nerve evaluation phase to evaluate whether a permanent implant is likely to be successful. It is also a minimally invasive procedure and may be carried out under local anaesthetic. Four female patients with persisting faecal incontinence following full-thickness rectal prolapse repair have shown improvement in incontinent episodes from 14 to two per week [52].

Two other papers [53, 54] studying sacral nerve stimulation in a more general population included three patients with ongoing resistant faecal incontinence Table 2.Large studies (>50 patients) involving perineal repair of full-thickness rectal prolapse

Lechaux et al. [38] 85 Delorme’s 69 13.5

Watts and Thompson [39] 113 Delorme’s 40 26.5

Watkins et al. [40] 52 Delorme’s 83 10

Williams et al. [41] 114 Altemeier 46 10

Ramanujam et al. [42] 72 Altemeier 67 5.5

Kim et al. [37] 183 Altemeier 53 15.8

Kimmins et al. [43] 63 Altemeier 50 6.4

Table 3.Large studies (>50 patients) involving laparoscopic abdominal repair of full-thickness rectal prolapse

Auguste et al. [44] 54 Laparoscopic 72.4 7.4

D’Hoore et al. [45] 42 Laparoscopic 90 5

Lechaux et al. [46] 48 Laparoscopic 31 4

Kariv et al. [47] 111 Laparoscopic 48 9.3

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following rectal prolapse surgery. All three were reported as showing improvement. It appears to be an effective therapy in this subgroup of patients, although numbers reported remain small.

Injectable Bulking Agents

Another minimally invasive procedure involves the injection of sphincter bulking biomaterials. Some benefit has been noted, but studies again remain small and follow-up short [55, 56].

Postanal Repair, Dynamic Graciloplasty, Artifical Bowel Sphincter, Stoma

More invasive surgery includes postanal repair, which has been tried with limited success, and most series have been small, especially with regard to faecal incontinence following prolapse repair [57]. The dynamic graciloplasty procedure and artificial bowel sphincter implants may also be attempted, but both are major operations that have a high morbidity and failure rate [58, 59]. Permanent stoma placement is another surgical option.

Discussion

The majority of patients with full-thickness rectal prolapse experience faecal incontinence [4, 5, 60].

Once the prolapse has been dealt with surgically, approximately one third of these patients continue to suffer from faecal incontinence [4–7]. Treatment is largely conservative in what is often an elderly group of patients. Minimally invasive procedures, such as sacral nerve stimulation, and other more invasive procedures, including stoma formation, should be reserved for the carefully selected minority or patients with ongoing symptoms significantly affect- ing their quality of life.

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