Discussion
Rectal prolapse has an incidence of 0.5% and is more commonly seen in
the elderly3. Risk factors include female gender, age
over 40, multiparity, vaginal delivery, prior pelvic surgery, chronic
straining, chronic diarrhoea or constipation, cystic fibrosis, dementia
or stroke, pelvic floor dysfunction and anatomical defects such as
anterior or posterior vaginal wall prolapse1.
Patients present with abdominal discomfort, incomplete bowel evacuation
and mucus and/or stool discharge, altered bowel habits, faecal
incontinence and a prolapsing mass through the anus that may reduce
spontaneously or require manual reduction1,3.
It is associated with a number of anatomical anomalies including
diastasis of the levator ani, a deep cul-de-sac, a redundant sigmoid
colon, a patulous anal sphincter, and a loss of rectal sacral
attachments3.
Initial assessment should include a complete history and physical
examination3. The clinician should review the
patient’s diet, fiber intake, fluid intake, and use of medication that
may contribute to constipation, symptoms of concomitant uterine or
vaginal prolapse and urinary incontinence1, and
underlying conditions3.
On examination, the concentric rings of the rectum protruding through
the anus are the hallmark of rectal prolapse1. Digital
rectal examination may find a patulous anus, poor sphincter tone,
mass and concomitant pelvic floor pathology1.
Defecography with fluoroscopy or MRI is helpful if the prolapse is
unable to be reproduced on examination and may reveal concomitant pelvic
floor prolapse1. Those with pelvic floor prolapse may
benefit from urodynamics3. A colonoscopy should be
considered to look for an underlying neoplasm3. Anal
physiologic testing may identify associated functional disorders such as
constipation or fecal incontinence3.
The general consensus in the literature is that rectal prolapse cannot
be corrected non-surgically with medical therapy
alone3. Medical therapy to date is limited to adequate
fluid and fibres, stool softeners to treat constipation and skin care to
avoid maceration1,3; the use of anal plugs have been
described4. These are considered palliative
interventions that do not address the prolapse itself but may improve
the patient’s quality of life3.
Surgical repair of rectal prolapse is the treatment of
choice1, either transabdominal or perineal. There is
no consensus on the optimal surgical approach in terms of recurrence
rate or bowel function1. Choice of surgery depends on
the patient’s status, age, baseline bowel function, surgeon’s experience
and preference1.
Abdominal procedures have higher mortality and morbidity rates compared
to perineal procedures2. The mortality rates for
abdominal procedures is 0 to 7 percent and morbidity rates is 0 to 52
percent2. The most common major complications include
pelvic infection, hematomas, fistulas, stenosis and obstructed
defecation2. As such, patients with poorer
medico-surgical co-morbidities may be more suitable for perineal
repairs2.
Although abdominal procedures have lower recurrence rates, perineal
procedures have fewer risks and complications than abdominal procedures
with reported mortality 0 to 4 percent and morbidity rates less than 20
percent2. Complications after a perineal repair
include bleeding, pelvic infection and faecal
leakage2.
After surgery, symptoms of faecal incontinence generally improve;
symptoms of constipation generally improve with perineal procedures but
may improve or worsen with abdominal procedures2.
Patients undergoing perineal repair procedures show an improvement in
constipation ranging from 13 to 100 percent2.
Vaginal pessaries are commonly used in gynaecological practice as a
non-surgical option for the treatment of vaginal pelvic organ prolapse
(POP) and stress urinary incontinence5.
There are reports of intravaginal devices for faecal incontinence
treatment8. This ‘vaginal bowel-control system’ is
described as a vaginal silicone-coated stainless steel base with a
posterior balloon that is pressure-regulated pump8.
The pump is deflated for a bowel movement and inflated to prevent
incontinence; this acts on the distal rectum to allow the patient to
control her bowel motions8. Similar to the vaginal
pessary for prolapse, not all women could be successfully fit as a
result of discomfort, vaginal dimensions or exclusion
criteria8.
Vaginal pessaries are generally made of medical grade silicone that come
in a range of shapes and sizes to support the pelvic organs, with the
space occupying type being more suitable for a larger
prolapse5. There is no robust evidence for the use of
one type of pessary over another, so similar to the pessary fitting for
POP, choice of vaginal pessary for rectal prolapse requires some trial
and error5. When choosing an initial pessary size, a
pelvic examination is required to assess the length of the vagina from
the posterior fornix to the pubic symphysis, and to assess the vaginal
width by spreading the index and middle fingers horizontally at the
level of cervix or vaginal vault5. Support pessaries
lie along the vaginal axis; the posterior component sits in the
posterior vaginal fornix and the anterior component sits under the
symphysis pubis5,6. An appropriate size is achieved
when the patient’s symptoms are relieved, they are able to void and
defecate, the pessary remains in situ with activities of daily living,
is comfortable for the patient and allows the patient the preservation
of sexual intercourse should this be their wish5.
Figure 2 shows a rectocele and intussusception before and after a
vaginal pessary is placed in situ, with a reduction of the rectal
prolapse possibly by elevating and supporting the previous Delormes
“doughnut”.
When counselling of patients on use of the vaginal pessary for rectal
prolapse, potential complications need to be
discussed5. Side effects include vaginal discharge,
ulcerations, bleeding, pain, vaginal and urinary tract infections,
urinary retention, faecal impaction, interference with sexual
intercourse, de novo (occult) SUI and pessary
expulsion5,6. A forgotten pessary can result in
erosion into the bowel, bladder or vaginal wall and fistula
formation5.
Once the pessary is inserted, the woman is asked to strain and cough,
ambulate and void and strain while sitting on a
toilet6. This determines that the pessary will not be
expelled and that the patient can void when she returns
home5,6. Vaginal estrogen should be prescribed for
postmenopausal women to reduce the risk of vaginal
erosion5. There is a need for regular follow-up every
3-6 months to change the pessary, assess for side effects and examine
the vagina for erosion5.
The success rate, that is the continued use of the pessary in women for
POP, is around 80% at 2-3 months and 60% at 6-12
months5,6. 50 to 60% of women who trial a pessary for
POP continue to use them for a further one to two
years6,7. Long term data on success rate of the use of
the pessary for rectal procidentia requires larger trials.