CLINICAL PRACTICE GUIDELINES
Clinical Practice Guidelines for the Treatment of
Rectal Prolapse
Liliana Bordeianou, M.D., M.P.H. • Ian Paquette, M.D. • Eric Johnson, M.D.
Stefan D. Holubar, M.D. • Wolfgang Gaertner, M.D. • Daniel L. Feingold, M.D.
Scott R. Steele, M.D.
Prepared by the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons
STATEMENT OF THE PROBLEM Although rectal prolapse is a benign condition, it can
be debilitating because of the discomfort of prolapsing
Rectal prolapse is a disorder characterized by a full-thickness tissue both internally and externally, associated drainage
intussusception of the rectal wall, which protrudes externally of mucus or blood, and the common occurrence of con-
through the anus. It is associated with a spectrum of coexist- comitant symptoms of fecal incontinence, constipation, or
ing anatomic abnormalities, such as diastasis of the levator both.8 Approximately 50% to 75% of patients with rectal
ani, an abnormally deep cul-de-sac, a redundant sigmoid prolapse report fecal incontinence, and 25% to 50% of
colon, a patulous anal sphincter, and loss or attenuation of patients report constipation.9–13 Incontinence in the set-
the rectal sacral attachments. Some have hypothesized that ting of rectal prolapse may be explained by the presence
the condition is associated with (and preceded by) internal of a direct conduit (ie, the prolapse), which disturbs the
rectal intussusception or a traumatic solitary rectal ulcer, al- sphincter mechanism, the chronic traumatic stretch of
though these associations have never been clearly proven.1–3 the sphincter caused by the prolapse itself, and continu-
Rectal prolapse is rare and is estimated to occur in ous stimulation of the rectoanal inhibitory reflex by the
≈0.5% of the general population overall, although the fre- prolapsing tissue.14 Up to one half of patients with pro-
quency is higher in females and the elderly, and women lapse demonstrate pudendal neuropathy,15 which may be
aged ≥50 years are 6 times more likely as men to pro- responsible for denervation-related atrophy of the exter-
lapse.4–6 Although it is commonly thought that rectal pro- nal sphincter musculature.16 Constipation associated with
lapse is a consequence of multiparity, approximately one prolapse may result from intussuscepting bowel in the rec-
third of female patients with rectal prolapse are nullipa- tum, creating a blockage that is exacerbated with straining,
rous. The peak age of incidence is the seventh decade in pelvic floor dyssynergia, and colonic dysmotility, although
women. Interestingly, although fewer men have the condi- causality versus correlation remains highly debated.11,12
tion, the age of incidence for these men is generally ≤40 The goals of surgery to correct rectal prolapse are 3-fold:
years. A striking characteristic of younger patients, both 1) to eliminate the prolapse through either resection or resto-
male and female, is an increased tendency to have autism, ration of normal anatomy, 2) to correct associated functional
syndromes associated with developmental delay, or psy- abnormalities of constipation or incontinence, and 3) to
chiatric comorbidities requiring multiple medications.7 avoid the creation of de novo bowel dysfunction. Multiple op-
erations have been developed to achieve this complex 3-fold
Supplemental digital content is available for this article. Direct URL goal, each with various strengths and weaknesses underscor-
citations appear in the printed text, and links to the digital files are pro- ing the importance of careful patient selection and thorough
vided in the HTML and PDF versions of this article on the journal’s Web patient counseling when choosing a surgical approach.
site (www.dcrjournal.com).
Financial Disclosure: The funding body (ASCRS) did not influence the METHODOLOGY
content of this work and no other specific funding was received.
These guidelines were built based on the last set of The
Correspondence: Scott R. Steele, M.D., 9500 Euclid Ave/A30, Cleveland American Society of Colon and Rectal Surgeons (ASCRS)
Clinic, Cleveland OH, 44915. E-mail: Steeles3@ccf.org
practice parameters for treatment of rectal prolapse pub-
Dis Colon Rectum 2017; 60: 1121–1131
lished in 2011.17 An organized search of Medline, PubMed,
DOI: 10.1097/DCR.0000000000000889 Embase, and the Cochrane Database of Collected Reviews
© The ASCRS 2017 was performed from October 2011 through December
DISEASES OF THE COLON & RECTUM VOLUME 60: 11 (2017) 1121
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
, 1122 BORDEIANOU ET AL: TREATMENT OF RECTAL PROLAPSE
2016. Retrieved publications were limited to the English to final publication. After initial completion of the article,
language and human participants. The search strategies the entire committee reviewed and edited it. Final recom-
were based on the concepts of rectal prolapse and internal mendations were approved by the ASCRS Chairman and
intussusception as primary search terms. Searches were Vice Chairman of the Clinical Practice Guidelines Com-
also performed based on various treatments for rectal mittee and then ultimately the Executive Council.
prolapse, including rectopexy, suture rectopexy, resection
rectopexy, ventral rectopexy, D’Hoore rectopexy, Delorme Evaluation of Rectal Prolapse
procedure, and Altemeier procedure. An initial search
identified 781 unique citations. These were ultimately 1. The initial evaluation of a patient with rectal prolapse
categorized into subsets (see Table, Supplemental Digital should include a complete history and physical examina-
Content 1, http://links.lww.com/DCR/A390). Directed tion with focus on the prolapse, on anal sphincter struc-
ture and function, and on concomitant symptoms and
searches of the embedded references from the primary ar-
underlying conditions. Recommendation: strong recom-
ticles were also performed in certain circumstances. Pro-
mendation based on low-quality evidence, 1C.
spective, randomized controlled trials and meta-analyses
were given preference in developing these guidelines. Ul- A careful history and physical examination should be per-
timately, 172 articles were carefully reviewed, and articles formed before considering any operative intervention. If a
with poor control subjects or unclear study end points patient’s history suggests the diagnosis but no prolapse is
were excluded. The final guideline was created using 110 detected on physical examination, the patient can be asked
unique citations listed in the references below. The fi- to reproduce the prolapse by straining while on a toilet
nal grade of recommendation was performed using the with or without the use of an enema or a rectal balloon.
Grades of Recommendation, Assessment, Development, The perineum can then be inspected with the patient in
and Evaluation system (Table 1).18 A panel of members the sitting or squatting position. One should be careful,
of the ASCRS Clinical Practice Guidelines Committee however, to avoid confusing rectal prolapse with pro-
worked in production of these guidelines from inception lapsing internal hemorrhoids or rectal mucosal prolapse.
TABLE 1. The GRADE system: grading recommendations
Benefit versus Methodologic quality
Description risk and burdens of supporting evidence Implications
1A Strong recommendation, Benefits clearly outweigh risks RCTs without important Strong recommendation, can
high-quality evidence and burdens or vice versa limitations or overwhelming apply to most patients in
evidence from observational most circumstances without
studies reservation
1B Strong recommendation, Benefits clearly outweigh risks RCTs with important limitations Strong recommendation, can
moderate-quality and burdens or vice versa (inconsistent results, apply to most patients in
evidence methodologic flaws, indirect most circumstances without
or imprecise) or exceptionally reservation
strong evidence from
observational studies
1C Strong recommendation, Benefits clearly outweigh risks Observational studies or case Strong recommendation but
low- or very low-quality and burdens or vice versa series may change when higher-
evidence quality evidence becomes
available
2A Weak recommendation, Benefits closely balanced with RCTs without important Weak recommendation, best
high-quality evidence risks and burdens limitations or overwhelming action may differ depending
evidence from observational on circumstances or patient
studies or societal values
2B Weak recommendation, Benefits closely balanced with RCTs with important limitations Weak recommendation, best
moderate-quality risks and burdens (inconsistent results, action may differ depending
evidence methodologic flaws, indirect on circumstances or patient
or imprecise) or exceptionally or societal values
strong evidence from
observational studies
2C Weak recommendation, Uncertainty in the estimates of Observational studies or case Very weak recommendations;
low- or very low-quality benefits, risks and burdens; series other alternatives may be
evidence benefits, risks, and burdens equally reasonable
may be closely balanced
Adapted with permission from Chest. 2006;129:174–181.18
GRADE = Grades of Recommendation, Assessment, Development, and Evaluation; RCT = randomized controlled trial.
Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited.
