Rectal prolapse - surgical repair

A rectal prolapse occurs when the rectum turns itself inside out and comes out through the anus. A rectocele is the protrusion of the rectum into the vagina. In both cases, known risk factors include chronic constipation and straining on the toilet to pass bowel motions. Vaginal childbirth is a risk factor for rectocele. Treatment depends on many individual factors, such as the age of the patient, the severity of the prolapse, and whether or not other pelvic abnormalities are present (such as prolapsed bladder).

Common problems
Some of the problems associated with rectal prolapse and rectocele include:

• Pain and discomfort
• Constipation
• Difficulties passing a bowel motion
• The feeling that the bowel isn’t completely emptied after passing a motion
• Faecal incontinence, which means an inability to control the bowels.

• Laparotomy (open abdominal surgery) - the surgeon uses a single, large incision (cut) in the abdomen. Once the incision is made, the overlying organs are carefully moved aside. To stop the rectum prolapsing, it is lifted, pulled straight and stitched directly to the inner surface of the sacrum (central bone of the pelvis). Sometimes, a short length of bowel may be removed.
• Laparoscopy (keyhole abdominal surgery) - laparoscopy may be possible in some cases. This involves inserting slender instruments through a number of small incisions in the abdomen. Recovery time following laparoscopy is usually quicker than open surgery.
• Anal surgery - under anaesthesia, the prolapsed bowel is gently pulled out through the anus. The prolapsed section of bowel is usually removed and the structural damage repaired. The bowel is rejoined and returned back through the anus to restore bowel function and appearance to normal.

• One or more incisions are made along the back wall of the vagina to expose the underlying structures.
• Weakened pelvic floor muscles around the vagina and rectum are strengthened with absorbable stitches.
• The wall is repaired using absorbable stitches.
• Sometimes, the perineum (area between the vagina and anus) needs to be repaired at the same time with deep stitches into the muscle.
• If the vagina has been stretched (from childbirth, for example), the excess tissue may be removed.
• The vaginal incisions are stitched closed.
• The vagina is packed with gauze.
• A urinary catheter is inserted to allow urine to drain from the bladder.

• Your temperature, pulse, breathing and blood pressure are observed and noted.
• An intravenous fluid line is in your arm to replace fluids in your body.
• You are given pain-killing drugs. Tell your nurse if you need more pain relief.
• You may have a catheter to drain off urine for the next day or so, or until you can empty your bladder by yourself.
• If you have a vaginal pack, this will be taken out later the same day or the day after surgery.
• You may be in hospital for three to six days following surgery.
• You will need to make follow-up appointments with your doctor.

• Allergic reaction to the anaesthetic
• Haemorrhage
• Infection
• Injury to nearby nerves or blood vessels
• Damage to other pelvic organs, such as the bladder or rectum
• Death (necrosis) of the rectal wall
• Recurrence of the rectal prolapse.

• Rest as much as you can.
• Avoid heavy lifting or straining for a few weeks.
• Don’t strain on the toilet.
• Take measures to prevent constipation, such as eating high fibre foods and drinking plenty of water.
• If you had rectocele surgery, expect bloody vaginal discharge for about four weeks or so.
• Contact your doctor if you experience any unusual symptoms, such as difficulties with urination, heavy bleeding, fever, or signs of infection around the wound sites.
• You can expect to return to work in around six weeks after surgery.
• Attend follow-up appointments with your surgeon.

• Lifestyle changes - including high fibre diet, drinking plenty of water and getting regular exercise.
• Change to toileting habits - such as no longer straining when trying to pass a bowel motion. This may require using fibre supplements or laxatives.
• Pessary - a special ring-like device, which is worn high in the vagina and helps to support the pelvic organs. This is only used for rectocele.

• Your doctor
• Colorectal or general surgeon (for rectal prolapse)
• Gynaecologist (for rectocele)

• Surgery options for rectal prolapse include open abdominal surgery (laparotomy), keyhole surgery (laparoscopy) and anal surgery.
• Surgery for rectocele aims to repair the rectovaginal septum, the tissue that supports and separates the vagina and rectum.
• Surgery gives good results in most cases, but some patients may find that symptoms such as constipation or the inability to completely empty the bowels continue.

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