Strategy for Selection of Type of

Operation for Rectal Prolapse Based on

Clinical Criteria
A. J. Brown, M.B., Ch.B., J. H. Anderson, M.D., R. F. McKee, M.D.,
I. G. Finlay, M.B., Ch.B.
Department of Coloproctology, Glasgow Royal Infirmary, Glasgow, United Kingdom

PURPOSE: Reports of outcome after surgery for rectal pro-
lapse predominantly relate to single operative procedures.
A single surgical operation is not appropriate for all patients
with rectal prolapse. We describe a selective policy based
on clinical criteria. METHODS: Patients were offered sur-
gery according to the following broad clinical protocol.
Those who were unfit for abdominal surgery had a perineal
operation. The remainder had a suture abdominal recto-
pexy. A sigmoid resection was added for patients in whom
incontinence was not a predominant symptom. RESULTS:
Surgery was performed in 159 patients. Of these, 57 had a
perineal operation, 65 had fixation rectopexy, and 37 had
resection rectopexy. There were no in-hospital deaths, and
major complications occurred in five patients (3.5 percent).
Minimum follow-up was 3 years. Of the 143 patients with
long-term follow-up, recurrence occurred in 7 (5 percent).
Constipation increased from 41 to 43 percent (59–61/143)
and incontinence decreased from 43 to 19 percent (61 to
27/143). CONCLUSIONS: A selective policy has improved
outcome compared with reports of a single operation. Fu-
ture studies might consider an objective method of select-
ing the type of operation for rectal prolapse. [Key words:
Rectal prolapse; Rectopexy; Perineal procedures]
neal,4–6 according to the route of access. Abdominal
operations involve dissection and fixation of the rec-
tum and may include sigmoid/colonic resection. Per-
ineal operations may include repair of the pelvic
floor/anal sphincters with or without bowel resection.
Although there are proponents for each approach,
there have been few comparative trials, and to date
there are no guidelines as to which operation should
be used in any given clinical situation.
During the period of this study, we selected the
operation for patients with rectal prolapse based on
simple clinical criteria. Elderly or frail patients are of-
fered a perineal procedure: fit patients have an ab-
dominal operation irrespective of age. Of the latter
group, those in whom the principal symptom is fecal
incontinence are treated by rectopexy without colonic
resection; those with no incontinence are treated by
resection rectopexy. We report the outcome using
these criteria.

M ore than 100 different operative procedures

have been described for rectal prolapse.1–6
Broadly, these are classified as abdominal1–3 or peri- PATIENTS AND METHODS
Presented at the meetings of the Scottish Society of Coloproctol-
ogy, Stirling, Scotland, March 20, 1998, the Association of Surgeons Consecutive patients in the Department of Colo-
of Great Britain and Ireland, Edinburgh, Scotland, May 13 to 15,
1998, and the Association of Coloproctology of Great Britain and proctology who had surgery for rectal prolapse from
Ireland, Jersey, Channel Islands, United Kingdom, June 29 to July 1, 1988 to 1998 were reviewed by using case notes and
1998.
other departmental records. Functional outcome was
Correspondence to: A. J. Brown, M.B., Ch.B., Department of
Coloproctology, Glasgow Royal Infirmary, 16 Alexandra Parade,
obtained by outpatient review, telephone consulta-
Glasgow, G31 2ER, United Kingdom, e-mail: alistair.brown4@ tion, and/or written questionnaire. Outcome data was
btopenworld.com obtained from the case records for those patients who
Dis Colon Rectum 2004; 47: 103–107
DOI: 10.1007/s10350-003-0013-x
died during the review period.
© The American Society of Colon and Rectal Surgeons Treatment protocol was as follows. Patients who
103
104 BROWN ET AL
were frail, usually elderly, and considered unfit for an
abdominal operation were offered a perineal proce-
dure. This decision was based on the clinician’s judg-
ment. In practice, all patients considered fit for lapa-
rotomy were offered an abdominal procedure
irrespective of chronological age. This was a suture
rectopexy without the use of foreign-fixation material.
The rectum was fully mobilized both anteriorly and
posteriorly to the level of the pelvic floor, but the
lateral “stalks” were preserved to maintain the para-
sympathetic nerve supply. A utero-suspension was
usually performed if the patient had not had a hyster-
ectomy. Sigmoid resection was used in continent pa-
tients if the predominant presenting symptom was
constipation but was strictly avoided in incontinent
patients. If sigmoid resection was performed, the in-
ferior mesenteric vessels were preserved to maintain
both the vascular and sympathetic nerve supply of the
rectum.
Almost all the perineal operations were modified
perineal rectosigmiodectomies,4 which included pli-
cation of the levator/anal sphincter muscles. The re-
maining patients had a Delorme procedure.
In assessing functional outcome, incontinence was
graded according to the St. Mark’s scoring system.7 A
patient was considered to suffer from preoperative or
postoperative constipation if they had taken regular
laxatives for at least three months before surgery or
before the most recent postoperative review. In addi-
tion, patients were required to consider the constipa-
tion to be a “major” clinical problem. Major postop-
erative complications were defined as those
prolonging hospital stay. The prolapse was consid-
ered to be recurrent when visible to patient or clini-
cian.
The outcome between patients in each operative
group was analyzed using Fischer’s exact test or chi-
squared test as appropriate. The age difference be-
tween operative groups was analyzed using the
Mann-Whitney U test. P < 0.05 was considered statis-
tically significant, and all tests were two-tailed.
RESULTS
Rectal prolapse surgery was undertaken in 159 pa-
tients (15 males). Median age was 64 (range, 10–90)
years, and minimum follow-up was 3 (range, 3–9)
years. There were 57 patients in the perineal group
(49 patients underwent perineal rectosigmoidectomy
and 8 had a Delorme’s operation), 65 fixation recto-
pexies, and 37 resection rectopexies.
Dis Colon Rectum, January 2004
Figure 1. Recurrence rate expressed as rate of recur-
rence per year since surgery.
There were no in-hospital deaths within 28 days of
surgery. Major surgical complications occurred in five
patients (3.5 percent).
Patients undergoing perineal operations were sig-
nificantly older than those who had an abdominal
procedure (aged 60 vs. 75 years; P < 0.001); however,
major complications were similar in both groups (ab-
dominal, 4 percent; perineal, 2 percent; P = not sig-
nificant (NS)). Prolapse recurrence during follow-up
was significantly higher in the perineal group com-
pared with the abdominal group (15 vs. 1 percent; P <
0.001). Recurrence rate as expressed as rate of recur-
rence per year since surgery (Kaplan-Meier curve) is
shown in Figure 1.
Before surgery, 43 of 102 patients (42 percent) in
the abdominal group had severe constipation. After
surgery, 52 of these patients (51 percent) had severe
constipation (P = NS). Incontinence was the principal
symptom before surgery in 46 patients (45 percent)
who had an abdominal procedure compared with 19
patients (19 percent) after surgery (P < 0.0001).
Functional outcome could not be obtained for 16
patients; all had perineal operations. The functional
outcome for the remaining patients who had perineal
surgery improved with regard to constipation and in-
continence. Constipation decreased from 39 percent
presurgery to 22 percent postsurgery (P = NS) and
incontinence from 37 to 20 percent (P = NS).
The functional outcome according to type of surgi-
cal procedure performed is shown in Table 1. Consti-
pation deteriorated after fixation rectopexy but im-
proved in patients having resection rectopexy or
perineal operation. Incontinence improved after all
procedures.
During follow-up, 20 patients died from natural
causes (perineal group, 11; fixation rectopexy group,
5; resection rectopexy group, 4). Overall, of 143 pa-
Vol. 47, No. 1 SELECTING RECTAL PROLAPSE OPERATIONS
Table 1.
Functional Outcome According to Type of Surgical Procedure
Fixation Rectopexy
(n = 65)
Median age (yr) 61 (31–88)
Preoperative constipation 26 (40)
Postoperative constipation 38 (58)
Preoperative incontinence 33 (51)
Postoperative incontinence 15 (23)
Data are numbers with ranges in parentheses or numbers with percentages in parentheses.
tients in whom outcome was established, recurrence
occurred in 5 percent (7/143), constipation increased
from 41 percent (59/143) preoperatively to 43 percent
(61/143) postoperatively, and incontinence decreased
from 43 percent (61/143) to 19 percent (27/143) post-
operatively.
DISCUSSION
The literature with regard to the surgery of rectal
prolapse predominantly reports outcomes after a
single, operative approach, making the assumption
that one operation is suitable for all patients with the
condition. We have developed a selective policy for
the selection of type of operation for patients with
rectal prolapse.
Historically, the most widely used operation for
rectal prolapse in the United Kingdom has been rec-
topexy,8 which involves dissection of the rectum to
the pelvic floor with fixation using foreign material,
such as ivalon8 or, more recently, marlex.9,10 The op-
eration is highly effective in removing the prolapse
and preventing recurrence (0–4 percent)9,11 but pro-
duces the complication of severe constipation, which
is difficult to treat in up to 50 percent of patients.12
Several putative explanations for this have been pro-
posed, including denervation of the rectum after dis-
section and division of the lateral ligaments,13 loss of
compliance of the rectum caused by foreign-fixation
material,14 creation of a redundant sigmoid loop pro-
ducing partial obstruction,15 or an underlying hindgut
neuropathy.16 In an attempt to reduce the risk of post-
operative constipation, resection of the redundant sig-
moid colon has been advocated1 and has been shown
in two small, prospective, randomized trials2,3 to be
safe and to reduce postoperative constipation but per-
haps with an increased risk of incontinence. It also
has been shown that it is unnecessary to use foreign
material to fix the rectum, thereby reducing the risk of
infection and altered rectal compliance.14,17 Based on
105
Resection Rectopexy Perineal Procedure
(n = 37) (n = 41)
59 (14–83) 75 (10–91)
17 (46) 16 (39)
14 (38) 9 (22)
13 (35) 15 (37)
4 (11) 8 (20)
this evidence, we developed our strategy for the se-
lection of an abdominal operation for patients with
rectal prolapse. All patients had a suture rectopexy
without the use of fixation material. Those patients in
whom the predominant symptom was constipation
had a sigmoid resection, but this was avoided in pa-
tients with incontinence. Despite these broad guide-
lines, there were patients who were not treated ac-
cording to the protocol. This may have been because
patients frequently have both constipation and incon-
tinence. It also may reflect the variability in clinical
decision making despite a broad protocol.
Perineal operations for rectal prolapse have the ad-
vantage that they are less invasive for unfit patients
but have a high recurrence rate.18 This is unfortunate
because the postoperative functional results, particu-
larly with regard to constipation, are better than those
reported after abdominal rectopexy.19,20 Our manage-
ment strategy limited perineal operations to those
who were unfit for an abdominal approach.
In the present study, the use of this selective policy
was safe and effective. There were no in-hospital
deaths and few complications. The overall recurrence
rate was 5 percent but was significantly higher in the
perineal group. This may limit the use of perineal
operations as the initial surgical treatment for rectal
prolapse to those patients who are unsuitable for an
abdominal operation. Advocates for the perineal ap-
proach would counter with the view that the opera-
tion can be easily reperformed in the event of recur-
rence.5 Furthermore, it is possible in this series that
patients who had a perineal procedure may have had
a more severe prolapse than the younger patients
who had an abdominal procedure. The availability of
minimally invasive laparoscopic operations, which
were not used in this series, may further extend the
indications for the abdominal approach.
The introduction of our selective policy was pre-
dominantly designed to improve postoperative func-
tion. Constipation increased by only 2 percent com-
106 BROWN ET AL
pared with the large increases reported after fixation
rectopexy12,17 and is probably attributable to the se-
lective use of sigmoid colon resection, avoidance of
foreign-fixation material, and preservation of the lat-
eral ligaments. Incontinence was markedly reduced in
the present series from 24 to 19 percent. This may be
explained in part by the avoidance of sigmoid resec-
tion in patients who had incontinence before surgery
and plication of the anal sphincter at the perineal op-
erations. Other explanations include increased anal
sphincter pressure,21 improved rectal and anal canal
sensation,21 and restoration of the rectoanal inhibitory
reflex22 as a consequence of relief of the pressure and
stretch of the rectal prolapse.
Although many patients had other investigations,
including anorectal physiology, pudendal nerve mo-
tor terminal latency, and colonic transit studies, these
were not used in the strategy for the selection of the
operative procedure. Future studies may attempt to
develop a selection strategy based on one or more of
these investigations.
CONCLUSIONS
Overall, the results of the present study show an
improvement over reports of a single technique. Re-
currence rates are better than those reported for single
series of perineal operations.5,6 Constipation rates are
better than those reported for fixation rectopexy.12,17
Incontinence rates are better than those reported after
the use of resection rectopexy.23 Patients with rectal
prolapse show considerable variability with regard to
extent of prolapse, degree of anal sphincter and pel-
vic floor neuropathy, degree of hindgut neuropathy,
and delay in colonic transit. Consequently, there is
probably no single operation that is suitable for all
patients and no operation that will produce complete
resolution of all symptoms. We have proposed a com-
promise based on simple clinical criteria that seem to
have improved overall outcome compared with series
of individual operations. Further study, ideally by ran-
domized, controlled trials, is required to determine
whether selection can be based on more objective
criteria.
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