Rectal Prolapse: Clinical Guidelines

List of Abbreviations

ACR — Association of Coloproctologists of Russia

BFB — biofeedback

AR — anal sphincter apparatus

GI — gastrointestinal tract

RP — radiopharmaceutical medicinal product

PPS — pelvic floor descent syndrome

ODS – obstructed defecation syndrome

TRUS — transrectal ultrasonography

FDD — functional defecation disorder

Terms and Definitions

Pelvic floor descent syndrome (PFDS) – a set of disorders arising due to descent or prolapse of pelvic organs. These diseases can exist as separate nosological entities (rectocele, rectal prolapse, enterocele).

Obstructed defecation syndrome (ODS) – impaired rectal evacuation caused by anatomical changes in the posterior pelvic floor, such as rectocele, internal intussusception and rectal prolapse, enterocele, and sigmocele in combination with dyscoordination and/or atrophy of the pelvic floor muscles.

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Rectal prolapse – protrusion or exit of all layers of the rectum outward through the anal opening [1-3,73].

Synonym: rectal prolapse.

Internal rectal prolapse – intussusception of the wall of the rectum and/or sigmoid colon without exiting outward, i.e., the rectal wall prolapses into its lumen but does not drop out through the anus [1,4-6,26].

Synonym: internal (intrarectal) intussusception of the rectum.

Anal canal prolapse – prolapse of the anal canal walls through the anal opening [1-3,12].

Synonym: prolapse of the anus.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

External and internal rectal prolapse and anal canal prolapse develop due to weakness of the ligamentous and muscular apparatus of the pelvic organs. These conditions are generally considered nosological forms of perineal descent syndrome, which occurs more frequently in women. Accordingly, rectal and anal canal prolapse is more often observed in female patients. However, men exposed to characteristic risk factors throughout their lives can also develop pelvic floor descent with prolapse or internal intussusception of the rectum [1-3,8-12,18,21].

The risk of developing the disease in women increases with complicated pregnancy and childbirth, including obstetric surgical interventions, precipitous labor, perineal tears, and macrosomia [8].

Rectal prolapse may develop as a result of heavy physical exertion or intense sports, not only those involving heavy lifting. The underlying mechanism of these factors involves an increase in intra-abdominal pressure, as well as sharp vertical loads leading to the displacement of pelvic organs in the sagittal plane [10].

Another risk factor provoking pelvic organ prolapse followed by rectal and anal canal prolapse is chronic bowel and pulmonary diseases. Chronic constipation, which triggers frequent and intense straining, and persistent cough lead to a multiple sharp increase in intra-abdominal pressure and, consequently, overstretching of the musculo-fascial structures of the pelvic floor that ensure the normal position of the organs.

Constitutional body features and structural characteristics of the rectum that may contribute to the development of rectal prolapse include a deep rectouterine pouch in women and rectovesical pouch in men, diastasis of the levator ani portions, inadequate fixation of the rectum to the sacrum, and weakness of the anal sphincter [10-12].

Among the pathogenetic mechanisms of rectal prolapse, three main theories are distinguished. The first, the so-called "hernia" theory, describes a mechanism whereby, with an increase in intra-abdominal pressure, loops of the small intestine are displaced into the pouch of Douglas, pushing apart the portions of the levator ani and exerting a direct impact on the pelvic peritoneum and the rectum. Under this pressure, the anterior wall of the rectum gradually begins to displace downward, resembling a sliding perineal hernia, eventually reaching the anus and, over time, protruding beyond it [12]. The second theory is the intussusception theory. Primary importance in the genesis of prolapse is attributed to rectal intussusception resulting from weakness of the ligamentous-muscular apparatus, while all other changes ("relaxation of the sphincter, cicatricial degeneration of the rectal wall") are considered secondary [13,14]. According to the third, neurogenic, theory of the genesis of rectal prolapse, the underlying cause is a primary lesion of the pudendal nerve, which leads to pelvic floor descent and rectal prolapse [15,16]. In clinical practice, one sometimes encounters a combination of various mechanisms of rectal prolapse, and the above theories cannot explain the entire diversity of cases. Therefore, A. Altmeier et al. suggested that the sliding hernia theory and the intussusception theory do not exclude, but rather complement each other and make a combined contribution to the pathogenesis of the disease [17].

1.3 Epidemiology of the Disease or Condition

Rectal and anal canal prolapse accounts for an average of 9% of all coloproctological diseases or from 0.3% to 5.2% among patients in general surgical inpatient departments [19, 31, 91].

Women over 50 years of age suffer from rectal and anal canal prolapse 6 times more often than men [8, 9, 18, 19, 20]. Traditionally, rectal prolapse is considered a consequence of difficult, repeated childbirth, but about 1/3 of female patients with this condition are nulliparous [2]. The peak incidence occurs in the seventh decade in women, whereas in men this problem can develop at the age of 40 or earlier. Rectal prolapse occurring at a young age is most often diagnosed against the background of autism, psychomotor retardation, and various mental illnesses requiring long-term use of neuroleptics [21]. In 31% of patients, the disease develops against the background of heavy physical labor [22].

1.4 Features of Coding the Disease or Condition

Diseases of the digestive system (XI)

Other diseases of the intestine (K62)

K62.2 Prolapse of anus.

K62.3 Rectal prolapse.

K63.3 Ulcer of anus and rectum.

1.5 Classification of the disease or condition

Oxford radiological classification [23]:

1. High recto-rectal intussusception (prolapse remains above the puborectalis line).

2. Low recto-rectal intussusception (prolapse at the level of the puborectalis line).

3. High recto-anal intussusception (prolapse reaches the anal canal).

4. Low recto-anal intussusception (prolapse in the anal canal, but does not extend beyond the anal verge).

5. External rectal prolapse.

Classification of the State Research Center of Coloproctology named after A.N. Ryzhikh [1,24,63]:

Stages of rectal prolapse:

Phases of compensation of pelvic floor muscle function [1,24]:

· compensation phase - the prolapsed rectum is reduced due to the contraction of the pelvic floor muscles;

· decompensation phase - the reduction of the rectum is carried out only manually.

Grades of anal sphincter insufficiency [24,25]:

Notes on formulating the diagnosis

The formulation of the diagnosis should reflect the presence of an external and/or internal component, indicate the stage of prolapse in complete prolapse, the phase of compensation of pelvic floor muscle function, as well as the grade of anal sphincter insufficiency.

Examples of diagnostic formulations:

1. "Internal rectal prolapse. Perineal descent in the phase of compensation of pelvic floor muscle function."

2. "Rectal prolapse stage 1 in the phase of compensation of pelvic floor muscle function, anal sphincter insufficiency stage 2."

1.6 Clinical presentation of the disease or condition

The main clinical symptom is the presence of prolapse or eversion of the rectum through the anus during defecation, followed by spontaneous or manual reduction, and mucus discharge from the anus. Patients with internal intussusception generally complain of a feeling of incomplete emptying, difficulty in evacuating intestinal contents, and a sensation of obstruction at the outlet of the rectum, which together constitute obstructive defecation syndrome [5,26]. Also, in 50-75% of patients with rectal prolapse, fecal incontinence (flatus, liquid stool) is noted [23,27,28].

2. Diagnostics, medical indications and contraindications for diagnostic methods

The necessary and sufficient criteria for establishing the diagnosis of "rectal prolapse" are clinical examination data, namely physical examination findings that reveal full-thickness circular prolapse or eversion of the rectum through the anus during straining or defecation. If rectal prolapse is not confirmed during clinical examination, the diagnosis is established based on objective data from instrumental examination methods, primarily proctography (defecography) [1,13,32,39,40].

• All patients with suspected rectal prolapse are recommended an outpatient visit (examination, consultation) with a coloproctologist or surgeon in order to establish a diagnosis and select the tactics for diagnosis and treatment [1,25].

GCR CLEL 4Level of recommendation evidence - C (level of evidence validity — 4)

2.1 Complaints and Anamnesis

In external rectal prolapse, patients complain of the rectum everting through the anus during defecation, physical exertion, or upon transitioning to an upright position. The prolapsed rectum reduces spontaneously or requires manual assistance. The prolapsed part of the rectum can vary in shape, size, and length [29]

In internal rectal prolapse, the following complaints are noted:

· difficulty emptying the rectum;

· sensation of incomplete emptying;

· need to apply manual pressure to the perineum or insert a finger into the rectal lumen for evacuation;

· discharge of blood during defecation (in the presence of a solitary ulcer or damage to the rectal mucosa) [1,2,26,30].

All these symptoms are grouped into obstructive defecation syndrome.

Approximately 50-75% of patients with rectal prolapse complain of fecal incontinence, and 25-50% of constipation [28-31].

When taking the medical history, attention should be paid to the number of deliveries, the character of labor (precipitous labor, instrumental assistance), occupational hazards (heavy physical exertion), presence of constipation or chronic pulmonary diseases, i.e., identifying factors contributing to the development of rectal prolapse [22,32-34].

It is also extremely important not only to find out how the clinical picture of the disease developed, but also to identify the main factors that could contribute to the development of the disease, to assess their current severity and the possibility of their correction.

Main (precipitating) factors contributing to the development of prolapse [1-3,8-12,22]:

· severe physical exertion with increased intra-abdominal pressure;

· constipation and prolonged straining during defecation;

· degree of anal incontinence;

· heredity;

· irregular stool consistency;

· pregnancy and childbirth;

· chronic obstructive pulmonary disease.

Thorough consideration of all anamnestic factors is extremely important when choosing the method of surgical treatment.

2.2 Physical Examination

Comment: examining the patient in a gynecological chair makes it possible to detect rectal prolapse when straining causes protrusion of all layers of the intestinal wall beyond the anal canal. The prolapsed segment of the intestine can have a cylindrical or spherical shape of various lengths and widths. At the same time, during its palpation, in addition to the mucosal layer, the muscular layer of the intestinal wall is determined. If rectal prolapse does not occur during the examination in the chair, it is necessary to perform an examination with straining in a squatting position. As a rule, rectal prolapse develops in patients with an asthenic body type; in addition, there are data on the development of this condition in patients with psychoneurotic disorders. In internal rectal prolapse, transrectal digital examination reveals excessive folding of the intestinal wall. It is also possible to detect a spastic puborectal muscle that does not relax upon straining, induration, and an ulcerous defect of the rectal wall in a solitary ulcer.

2.3 Laboratory Diagnostics

There is no specific laboratory diagnostic test for rectal prolapse. Laboratory diagnostic tests should be performed in patients during the preparation and planning of surgical intervention to rule out comorbid diseases and conditions, as well as when differential diagnosis is necessary.

2.4 Instrumental Diagnostics

Instrumental examination using endoscopic, radiological, and physiological methods makes it possible to determine the severity of perineal descent syndrome, against the background of which rectal prolapse occurs, as well as the presence of concomitant signs of perineal descent syndrome (rectocele, sigmocele, pelvic floor dyssynergia) and the functional state of the colon, and to rule out other coloproctological diseases [37-39,44,45]

Comment: during anoscopy and rectosigmoidoscopy, one can detect excessive mobility of folds invaginating into the rectoscope tube upon straining—a characteristic endoscopic symptom of internal intussusception. In addition, manifestations of solitary rectal ulcer syndrome and various changes in the rectal mucosa can be detected. They may appear as small areas of infiltration and hyperemia, ulcerative defects 0.5–3 cm in diameter, predominantly localized along the anterior semi-circumference of the rectum 5–10 cm from the anus, as well as polypoid formations sometimes circularly encompassing the intestinal wall. Polypoid growths on the rectal mucosa as manifestations of a solitary ulcer occur in 25% of cases. In 18% of patients, areas of mucosal hyperemia are detected, and in 57 % of cases, there are multiple mixed changes in the rectal wall.

Comment: during defecography, the position of the rectum relative to the pubococcygeal line is determined at rest, during voluntary contraction, along with its emptying time and residual volume. Defecography data make it possible to draw a conclusion about the degree of perineal descent syndrome, detect internal rectal intussusception and associated changes such as rectocele, sigmocele, and pelvic floor muscle dyssynergia (Table 1).

Table 1. Normal parameters of defecography [39].

Comment: the study of gastrointestinal passage is of great importance for detecting slow-transit constipation, which can be one of the triggering mechanisms for the development of rectal prolapse. At the same time, after oral administration of a contrast agent, daily radiological monitoring of its movement through the gastrointestinal tract is carried out. The study is performed against the background of the patient's usual diet, and attention is paid to the presence or absence of a stool during the diagnostic procedure. Normally, the intestine is completely emptied of the contrast suspension within 48-72 hours. A transit time of over 72 hours indicates impaired bowel function. In functionally compromised sections, contrast stasis may exceed 96 hours. The interpretation of colonic passage data must be performed taking into account proctography (defecography) indicators. This makes it possible to determine the functional characteristics of the colon—the predominance of slow-transit constipation or evacuation disorders [39,40].

Comment: comprehensive sphincterometry is performed to assess the neuroreflex activity of the anal sphincter and determine the degree of anal incontinence. The study is performed using a calibrated manometric probe inserted into the rectum to a depth of 3.5-4.0 cm, with a fatigue test of the external anal sphincter and pelvic floor muscles, as well as a straining test to rule out functional bowel disorders. Normal values of comprehensive sphincterometry are given in Table 2.

Table 2. Normal values of comprehensive sphincterometry [56].

Electromyography of the pelvic floor muscles (stimulation EMG) is performed to assess the somatic innervation of the pelvic floor muscles. It is performed by stimulating the distal branches of the pudendal nerves with a special electrode at their entry point into the ischioanal fossa at the ischial spines. The impulse conduction time is evaluated as pudendal nerve latency. Normally, it is 2.0±0.2 ms. Patients with increased pudendal nerve latency may have a greater degree of fecal incontinence after surgical correction of prolapse, although no direct correlation between these conditions has been found [46,47,55].

2.5 Other Procedures

none

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 Conservative Treatment

• Conservative treatment is recommended for all patients with rectal and anal prolapse to eliminate constipation [48-50].

GCR ALEL 1Grade of Recommendation — A (Level of Evidence — 1)

Comment: the specialized literature contains no data on the cure of rectal and anal prolapse in adults by conservative methods. Conservative treatment is exclusively symptomatic in nature and aims to normalize the motor-evacuation function of the colon, eliminate or reduce the intensity of pain syndrome, reduce the severity of inflammatory changes in the rectal wall, and alleviate anal incontinence. In patients with severe concomitant diseases, when the risk of surgical treatment exceeds the expected effect of the operation, a number of techniques can be used to reduce the negative consequences of rectal and anal prolapse—manual assistance during defecation and exercises aimed at increasing pelvic floor muscle tone.

• In patients with internal rectal prolapse and functional bowel disorders, biofeedback therapy is recommended [45, 51-53].

GIB CLOE 4Grade of Recommendation – C (Level of Evidence – 4)

Comment: the goal of therapy is to train the pelvic floor muscle function required for effective defecation. The method is based on biofeedback, which involves providing the patient with audiovisual information about the state and changes in certain physiological processes. In practice, this is implemented by placing sensors in the anal canal, on the perineal skin, or on the abdominal wall, and displaying data on muscle activity on a screen in front of the patient. Based on the received signals, the patient can consciously modify muscle contractions and improve pelvic floor muscle function. Exercises are performed 15–30 times. The course consists of 10–15 sessions. According to various sources, the effect of biofeedback therapy is observed in 70% of patients with functional defecation disorders, while in 50% the effect persists in the long term [45, 51-53].

3.2 Surgical Treatment

Surgery is the mainstay of treatment for rectal prolapse. There are numerous methods for correcting rectal prolapse. Depending on the surgical approach, they are divided into perineal and transabdominal procedures. The choice of surgery depends on the patient's age, presence of severe comorbidities, bowel motor-evacuation function, and the surgeon's preference and experience. Transabdominal procedures are preferred in patients without significant comorbidities and with a low anesthetic risk, whereas perineal procedures are usually performed in elderly and senile patients with severe comorbidities and conditions [59-62, 64-82].

3.2.1. Transabdominal surgeries

• For patients with rectal prolapse and a low anesthetic risk, it is recommended to perform surgical treatment via a transabdominal approach (rectopexy, including video-endoscopic techniques):

— suture rectopexy – Zerenin-Kümmell procedure;

— posterior sling rectopexy (Wells procedure);

— rectopexy (colpopexy) with mesh [60-62, 94].

GCR ALEL 1Grade of Recommendation — A (Level of Evidence — 1)

Comment: transabdominal procedures provide better functional outcomes and a lower recurrence rate (6%-15%) compared to transperineal procedures, making them the procedures of choice in the treatment of rectal prolapse [59]. Practically all transabdominal operations can be performed both via open and laparoscopic approaches.

Suture rectopexy – Zerenin-Kümmell procedure

The pelvic peritoneum is opened to the right of the rectum at the level of the sacral promontory. The incision is extended downward to the bottom of the pouch of Douglas, encircling the rectum anteriorly. Mobilization of the rectum is performed along the posterior and right lateral semicircles down to the levator ani muscles. Then, starting from the sacral promontory in the distal direction, 3-4 non-absorbable sutures (polyamide) are placed, capturing the longitudinal ligament of the sacrum. Using the same sutures, starting from the lower one, the anterior wall of the rectum is plicated. When the sutures are tied, the rectum is rotated by 180° and fixed to the sacrum. The pelvic peritoneum is sutured over the rectum, creating a duplication to eliminate the deep pouch of Douglas [63]. According to literature data, the recurrence rate after suture rectopexy ranges from 3% to 14% [24, 63]. This technique may cause constipation or worsen existing transit disorders in the long-term postoperative period in 50% of operated patients [24].

Posterior sling rectopexy (Wells procedure)

The pelvic peritoneum is incised on both sides of the rectum, exposing the sacral promontory. The rectum is mobilized along the posterior and lateral semicircles down to the level of the levator ani muscles. A polypropylene surgical mesh (8x3 cm) is sutured to the sacrum in a direction transverse to the axis of the sacrum using two non-absorbable sutures (polyamide). The mobilized rectum is placed on the patch without excessive tension, and the free edges of the mesh are fixed with non-absorbable material (polyamide) to the lateral walls of the rectum (2 sutures on each side). The pelvic peritoneum is sutured over the mesh. The recurrence rate after posterior sling rectopexy is 6%-15%, and improvement in continence in the postoperative period occurs in 3-40% of patients [68-70]. The probability of constipation ranges from 19% to 45% [71].

Rectopexy (colpopexy) with mesh

After incising the pelvic peritoneum to the right of the rectum, it is mobilized along the anterior and right lateral semicircles down to the lateral ligament. In men, the rectum is mobilized along the anterior semicircle to the border of the middle and lower ampullary segments. In women with concomitant rectocele, the surgery is performed with dissection of the rectovaginal septum and mobilization of the anterior wall of the rectum down to the anal sphincter. A polypropylene surgical mesh (10x3 cm) is sutured with three to four non-absorbable sutures (polyamide) to the entire surface of the mobilized anterior wall of the rectum. In women, two additional sutures fix the posterior vaginal fornix to the mesh. Then, the free end of the mesh is secured to the periosteum of the 1st sacral vertebra with two non-absorbable sutures (polyamide), and the operation is completed by suturing the pelvic peritoneum over the mesh. The recurrence rate after rectopexy (colpopexy) with mesh is 3% - 15%, and the average rate of postoperative complications is 23%. The onset or increased severity of postoperative constipation was noted in only 14.4% of patients [64-67].

3.2.2. Perineal surgeries

• For elderly and senile patients with rectal prolapse and severe comorbidities and conditions, it is recommended to perform surgery via a perineal approach – Restoring the rectum. Perineal proctoplasty (Delorme procedure).

— In case of incarceration of the prolapsed rectum – Perineal proctectomy (Altemeier procedure).

— In patients with internal prolapse – Transanal mucosectomy of the lower ampullary rectum (Longo procedure) [25, 74-83].

GIB CLOE 4Grade of Recommendation – C (Level of Evidence – 4)

Comment:

Delorme procedure

Transanally, 2 cm proximal to the dentate line, a circular incision of the rectal mucosa is made. The mucosa is sharply separated from the muscular layer of the prolapsed bowel segment and excised. 4-5 vertical mattress sutures are placed on the muscular wall of the rectum to create a muscle roll, and then the integrity of the mucous membrane is restored. A positive aspect of this intervention is its low invasiveness. However, the probability of prolapse recurrence after this method is higher than after transabdominal operations, amounting to 4%-38% [75-76]. Inflammatory complications, urinary retention, bleeding, and constipation occur in the postoperative period in 4-12% of cases [74, 77].

Perineal proctectomy (Altemeier procedure)

A circular incision of the full thickness of the bowel wall is made 2 cm above the dentate line. The rectum and distal sigmoid colon are transanally mobilized with ligation of blood vessels as close as possible to the bowel wall up to the level where further bowel prolapse is impossible. After transecting the colon and removing the specimen, an anastomosis is formed using hand-sewn sutures or a stapler.

Despite the low invasiveness of this surgical intervention, the complication rate reaches 10-12%, including bleeding from the suture line, pelvic abscesses, and anastomotic leakage [78]. The recurrence rate ranges from 16% to 30% [2, 20, 79, 80]. A number of surgeons additionally perform levatorplasty alongside rectosigmoidectomy. There are reports in the literature that the use of levatorplasty reduces the recurrence rate to 7% [81, 82].

Transanal proctoplasty (Longo procedure)

The surgery is performed in patients with internal rectal prolapse not complicated by a solitary ulcer.

This operation utilizes two special circular staplers. An anoscope is inserted into the anal canal, and the intussuscepted rectal wall is identified. Then, two muco-muscular semi-purse-string sutures are placed on the anterior semicircle of the rectum (Vicryl on a 5/8 needle), capturing the intussusceptum. The distance between the sutures is 1-2 cm depending on the severity of the prolapse. After inserting the stapler head into the rectum, the placed sutures are tied over it, and excess tissues are resected using the circular stapler. The same procedure is performed on the posterior wall.

The complication rate after the Longo procedure ranges from 15% to 37% [83-87]. The most common is fecal urgency (40%), but after one year it persists in only 10% of patients [88].

According to literature data, good functional treatment outcomes in the first months after surgery reach 90%, but after 18 months, the return of symptoms is noted in 52% of patients [89, 90].

4. Medical Rehabilitation and Sanatorium-Resort Treatment

4.1 Rehabilitation

• All patients who have undergone surgery for rectal prolapse are recommended rehabilitation measures [25, 91].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

Comment.

General principles of rehabilitation after surgical treatment of rectal prolapse:

1. Comprehensive assessment of the patient's baseline status and formulation of a rehabilitation program;

2. Drawing up a plan for diagnostic and therapeutic measures required for rehabilitation;

3. Multidisciplinary approach to the organization of rehabilitation care;

4. Monitoring the effectiveness of therapy during restorative treatment and upon completion of the rehabilitation course.

Stages of patient rehabilitation after surgical treatment:

Stage 1 – early rehabilitation, from day 2 to day 7 after surgery. During this period, the patient is hospitalized for 3–5 days; this stage involves monitoring hemostasis, the wound process (including infectious and inflammatory complications), and relief of postoperative pain syndrome using the visual analogue scale for its assessment (Appendix G3).

Stage 2: for 21 days in an outpatient setting, subject to a therapeutic and health-promoting regimen. Monitoring physical activity is essential, as it helps accelerate reparative processes and heal postoperative wounds. Medical nutrition is a key component of early postoperative rehabilitation and helps normalize gastrointestinal function, eliminate constipation, and achieve normal stool consistency. To this end, patients are prescribed an adequate intake of fluids and dietary fiber with a high water-holding capacity, which softens stool consistency and restores full defecation without the need for straining to empty the rectum.

Phase 3, from 30 to 45 days postoperatively, is conducted by a multidisciplinary team including a coloproctologist, a gastroenterologist, and a functional diagnostics physician. The core of the rehabilitation process at this stage is the dynamic monitoring of the patient's general somatic and psycho-emotional status. A set of diagnostic and therapeutic measures is carried out aimed at correcting anal sphincter insufficiency using the Wexner anal continence grading scale (Appendix G1), addressing colonic motor-evacuation disorders, and monitoring physical activity. This stage focuses on regulating function and strengthening pelvic floor muscles (Kegel exercises), as well as continuing adequate fluid and dietary fiber intake. Biofeedback (BFB) therapy is performed in patients with dyssynergic pelvic floor muscle contraction. If the treatment is insufficiently effective, the course is repeated in 3 months. Repeat courses of BFB therapy and tibial neurostimulation are also prescribed in the presence of anal incontinence symptoms. Follow-up examinations are conducted at 1, 3, and 6 months after surgical treatment. Results are evaluated using quality of life questionnaires (SF-36, Appendix G2). In addition, instrumental examination is required at 6, 12, 24, and 36 months postoperatively to objectively assess the anatomical and functional state of the pelvic organs.

5. Prevention and Dispensary Observation

5.1 Prevention

Prevention of rectal prolapse consists of eliminating risk factors for the disease: increased intra-abdominal pressure during heavy physical exertion, constipation, chronic lung diseases, effective treatment of postpartum complications, and adequate obstetric and gynecological care.

• As primary prevention of disease recurrence, in the presence of signs of functional colon disorders (constipation) before surgical treatment, it is recommended to use conservative therapy aimed at selecting a diet incorporating high-fiber foods and a large amount of fluid. In cases where bowel function cannot be improved through diet, bulk-forming laxatives (ATX code A06AC) or macrogol (ATX code A06AD15) should be used [1,25].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

Comments: In addition, an assessment of the functional state of the pelvic floor muscles and anal continence is carried out – investigation of the function of the sphincter apparatus of the rectum (sphincterometry), and electromyography of the pelvic floor muscles.

5.2 Dispensary Follow-up

• Patients who have undergone surgical treatment for rectal prolapse are recommended dynamic follow-up by a coloproctologist [1,25].

GCP CLEL 5Grade of Recommendation – C (Level of Evidence – 5)

Comment. All patients who have undergone surgical treatment for rectal prolapse require dynamic follow-up by a coloproctologist during the first year (dispensary appointment (examination, consultation) by a coloproctologist once every 6 months). Subsequently, this category of patients requires follow-up examinations once a year to monitor the condition of the pelvic floor muscles and pelvic organ function [1,25].

6. Organization of Medical Care

Medical care, with the exception of medical care within the framework of clinical trials, in accordance with Federal Law No. 323-FZ dated November 21, 2011 (as amended on December 28, 2022) "On the Fundamentals of Protecting the Health of Citizens in the Russian Federation", and Government Decree of the Russian Federation No. 1968 dated November 17, 2021, "On Approval of the Rules for the Phased Transition of Medical Organizations to the Provision of Medical Care Based on Clinical Guidelines Developed and Approved in Accordance with Parts 3, 4, 6–9, and 11 of Article 37 of the Federal Law 'On the Fundamentals of Protecting the Health of Citizens in the Russian Federation'", is organized and provided:

1) in accordance with the regulations on the organization of medical care by types of medical care, approved by the authorized federal executive body;

2) in accordance with the care standards for the profile "coloproctology", which are mandatory for implementation throughout the Russian Federation by all medical organizations;

3) based on these clinical guidelines;

4) taking into account the standards of medical care approved by the authorized federal executive body.

Hospitalization of patients with rectal prolapse is carried out in a planned manner for the purpose of surgical intervention. Treatment of this category of patients is carried out in a specialized coloproctological hospital. Medical care for patients with rectal prolapse is provided by coloproctologists.

Indication for hospitalization:

• confirmed diagnosis of rectal prolapse and/or anal canal prolapse and/or internal rectal intussusception.

Indications for patient discharge:

• in case of steady improvement, when the patient can continue treatment on an outpatient basis under the supervision of a coloproctologist without prejudice to health

• in the absence of indications for further inpatient treatment

• if the patient needs to be transferred to another medical institution

• at the request of the patient or their legal representative

• in cases of non-compliance by the patient with prescriptions or the internal regulations of the hospital, provided this does not threaten the patient's life or the health of others.

7. Additional Information

Negative factors affecting treatment outcomes include:

1. Development of infectious complications.

2. Stool disorders (diarrhea or constipation).

3. Patient non-compliance with restrictions on motor activity and physical exertion.

Criteria for Evaluating the Quality of Medical Care

Criteria for evaluating the quality of primary health care for adults with external and internal rectal prolapse and anal canal prolapse

Criteria for evaluating the quality of specialized medical care for adults with external and internal rectal prolapse and anal canal prolapse

References

Appendix A1. Working Group Composition

All members of the working group are members of the Association of Coloproctologists of Russia.

There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of the clinical guidelines:

1. Coloproctologist;

2. Surgeon;

3. Gastroenterologist;

4. General practitioner (internist);

5. General practitioner (family physician)

6. Endoscopist;

7. Mid-level medical professionals;

8. Healthcare organizers;

9. Medical insurance experts (including conducting medical and economic expertise)

10. Medical students, residents, postgraduate students.

Table 1. Levels of evidence (LoE) grading scale (LoE) for diagnostic methods (diagnostic interventions)

Table 2. Scale for assessing levels of reliable evidence (LRE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, rehabilitation interventions)

Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)

Procedure for updating clinical guidelines.

The clinical guideline revision mechanism provides for their systematic updating—at least once every three years, as well as upon the emergence of new evidence from the perspective of evidence-based medicine regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.

Appendix A3. Reference Materials

No data.

Appendix B. Physician Action Algorithms

Appendix C. Patient Information

Disease Information. External rectal prolapse is the protrusion or eversion of all layers of the rectum outward through the anal opening. Internal rectal prolapse is the intrarectal intussusception of the rectum and/or sigmoid colon without external eversion, i.e., the rectal wall prolapses into its lumen but does not protrude through the anus.

In such situations, depending on the severity of symptoms, conservative treatment under medical supervision may be required, and in cases of complete prolapse, hospitalization for surgical treatment. In patients with internal rectal intussusception when pelvic floor muscle dyssynergia is detected, a course of biofeedback (BFB) therapy is recommended as a first step. If treatment is ineffective and symptoms of obstructed defecation syndrome (ODS) persist, surgical intervention is considered. The choice of surgical method depends on the severity of the defect and the patient's physical condition. The final scope of surgery is chosen individually, taking into account the entire complex of anatomical and functional disorders in each specific case. Depending on the type of proposed intervention, the expected level of pain, as well as the degree and duration of disability, may vary significantly.

Information needed in the postoperative period. In the postoperative period, during the first 1-3 months after surgery, it is important to follow a work-rest schedule with limited physical exertion and to regulate the frequency and consistency of stools. It is necessary to achieve regular, soft stools and avoid excessive straining.

Treatment of constipation, unless caused by conditions requiring surgical intervention, should begin with a diet containing sufficient plant fiber, fermented dairy products, and vegetable oil. Smoked foods, salted foods, marinades, cocoa, and chocolate are excluded from the diet; fried foods, sausage products, and rye bread are partially restricted. One should eat less bread and bakery products made from premium wheat flour, pasta, and semolina dishes. Foods with a high content of dietary fiber and ballast substances (found in plant-based foods, primarily grains) are recommended. Foods that help normalize bowel movements include fresh kefir, sour milk, and acidophilus. Water-soaked prunes, figs, infusions made from them, plum juice, boiled beets, and dried fruit purees have a positive effect. Among first courses, soups, borscht, and cabbage soup made from strong vegetable broths are beneficial.

Nutritionists recommend carrot, prune, and apple puddings with added lemon, beet puree, and vinaigrette with vegetable oil. In the mornings on an empty stomach, drinking a glass of mineral water, fruit juice (plum, peach, apricot), or a hot lemon drink is recommended. A laxative effect is produced by eating grated carrots, a raw apple, sour milk, and 5-7 prunes washed and soaked in boiling water overnight on an empty stomach. In addition, when the general condition is satisfactory, walks and light physical exercise are indicated. Morning gymnastics and brisk walking are recommended.

Pharmacotherapy for constipation should be carried out with great caution, in short courses, under medical supervision.

Several additional recommendations for constipation:

1. Consult a physician to determine which of the above recommendations apply to you;

2. Drink 4-8 glasses of fluid per day;

3. Your diet should include foods that promote bowel motility (peristalsis). We recommend whole-grain bread, bran crispbreads, porridges – buckwheat, oatmeal, wheat, pearl barley with milk or vegetable oil, and grain dishes. Include fiber-rich foods in your diet (nutritionists recommend adding raw vegetables and fruits, nuts, and sprouted wheat to milkshakes). Try oatmeal cookies and cornflakes;

4. Apples, figs, dates, and tea with lemon help some patients well;

5. Prune decoction is beneficial in the mornings and at night;

6. Be sure to add bran to your food, starting with one teaspoon per day. Then this amount should be increased to 4-6 spoons per day. Increasing the dose too quickly can cause loose stools and flatulence. Try adding bran to porridges, rice or potato casseroles, and dairy products;

7. During chemotherapy, take laxatives only as a last resort.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Wexner Anal Incontinence Score

Russian title: Wexner Anal Incontinence Score

Original title (if any): Continence Grading Scale

Source (official developer website, validation

validation): Wexner, S. D. Etiology and management of fecal incontinence / S.D. Wexner, J. M. Jorge // Dis. Colon Rectum. – 1993. – № 36 (1). – р. 77-97.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify)____________________________________________

Purpose: The questionnaire is used for the patient's subjective assessment of the severity of anal incontinence symptoms, as well as the impact of fecal incontinence on quality of life.

Key (interpretation): score interpretation after summing the points:

"0" points – complete continence, "20" points – complete anal incontinence.

Notes: advantages – simplicity and practicality, easy to use and interpret.

Disadvantages – the system is based only on the assessment of subjective data, lack of objective parameters; it does not take into account the patient's psychological state.

Appendix G2. SF-36 Quality of Life Questionnaire

Russian title: SF-36 Quality of Life Questionnaire

Original title (if any): "SF-36 Health Status Survey"

Source (official developer website, publication with validation): Ware J.E., Snow K.K., Kosinski M., Gandek B. SF-36 Health Survey. Manual and interpretation guide // The Health Institute, New England Medical Center. Boston, Mass. - 1993.

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify)____________________________________________

Purpose: SF-36 is a generic quality of life questionnaire. Translation into Russian and testing of the methodology was carried out by the "Institute of Clinical Pharmacology Research".

Content (template): The 36 items of the questionnaire are grouped into eight scales: physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health. Each scale score ranges between 0 and 100, where 100 represents full health; all scales form two summary measures: mental and physical well-being.

SF-36 QUESTIONNAIRE.

Full name

Date of completion________________

1. In general, would you say your health is

(circle one number)

Excellent.................................................. 1

Very good........................................ 2

Good................................................... 3

Fair....................................................... 4

Poor...................................................... 5

2. Compared to one year ago, how would you rate your health in general now?

(circle one number)

Much better now than one year ago...... 1

Somewhat better now than one year ago......... 2

About the same as one year ago......... 3

Somewhat worse now than one year ago........... 4

Much worse now than one year ago.............. .5

3. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (circle one number on each line)

4. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? (circle one number on each line)

5. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your emotional state: (circle one number on each line)

6. During the past 4 weeks, to what extent has your physical health or emotional state interfered with your normal social activities with family, friends, neighbors, or groups?

(circle one number)

Not at all........................................... 1

Slightly........................................... 2

Moderately......................................... 3

Quite a bit.............................................. 4

Extremely................................... 5

7. How much bodily pain have you had during the past 4 weeks? (circle one number)

None............................................... 1

Very mild.................................. 2

Mild........................................... 3

Moderate...................................... 4

Severe.......................................... 5

Very severe……………………6

8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? (circle one number)

Not at all............................................ 1

A little bit............................................ 2

Moderately......................................... 3

Quite a bit.............................................. 4

Extremely.................................... 5

9. The following questions are about how you have been feeling and how your mood has been during the past 4 weeks. Please give one answer for each question that best corresponds to your feelings. (circle one number)

10. During the past 4 weeks, how much of the time has your physical health or emotional state interfered with your social activities (like visiting friends, relatives, etc.)? (circle one number)

All of the time........................................ 1

Most of the time................................ 2

Some of the time................................... 3

A little of the time………………………………4

None of the time................................... 5

• How TRUE or FALSE is each of the following statements for you? (circle one number on each line)

The questionnaire includes the following scales:

· Physical Functioning (PF).

· Role-Physical Functioning (RP).

· Bodily Pain (BP).

· General Health (GH).

· Vitality (VT).

· Social Functioning (SF).

· Role-Emotional Functioning (RE).

· Mental Health (MH).

All scales of the questionnaire are grouped into 2 summary measures: the physical health component (scales 1–4) and the mental health component (scales 5–8).

Methodology for calculating the main SF-36 questionnaire scores.

For items 6, 9a, 9d, 9g, 9h, 10, 11, values are reverse-scored.

Formula for calculating values: [(actual score) – (minimum possible score)] : (possible range of values) * 100.

Requirements for presenting results:

1. Indication of the number of observations for each variable;

2. Descriptive statistics – M ± SD, Me (LQ; UQ), % (n/N);

3. Precision of results (estimates, p-value); CI (for primary study outcomes) and p-value;

4. Indication of statistical methods used (parametric and non-parametric) and statistical software packages.

Key (interpretation): Results are presented as scores across 8 scales, constructed such that a higher score indicates a higher level of quality of life.

Appendix G3. Visual analogue scale for pain assessment

Russian title: Visual analog scale for pain assessment.

Original title (if available): Visual Analog Scale for Pain (VAS Pain).

Source (official developer website, validation publication): Hawker G.A., Mian S., Kendzerska T., French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res (Hoboken) 2011; 63(Suppl 11): S240 - 52

Type (underline):

- assessment scale

- score

- questionnaire

- other (specify)____________________________________________

Purpose: Designed for quantitative assessment of pain intensity considering the patient's subjective sensations and selection of analgesic therapy.

Content (template):

"Rate the severity of pain on the scale, where 0 is no pain and 10 is the worst imaginable severe pain."

Instructions: the patient is asked to mark the severity of pain on a 10-centimeter line using a scale from 0 to 10.

Key (interpretation): 1 - 3 points - mild pain; 4 - 7 points - moderate pain; 8 points and more - severe pain.