Rectal descent is a physical, mechanical problem. If medical treatment fails, it can be corrected with surgery. However, having rectal descent is not like having a cancer. People don't die from rectal descent; therefore, they don't need to have surgery unless they want it.
The requirements for considering surgery for rectal descent are:
- The person has symptoms of rectal descent.
- Signs of rectal descent are seen on defecography (x-ray).
- Difficult rectal emptying interferes with the ability to enjoy life and to work productively.
- The person wishes to have surgery.
- Other medical problems (such as heart or lung disease) do not make the risk of surgery so high that the risks outweigh the possible benefits.
The surgery for rectal descent has three parts. The colon is shortened by removing the sigmoid colon (sigmoid resection). The sides of the rectum are lifted up and sewn with suspender stitches to the lower backbone (rectopexy). The space between the rectum and vagina is closed to support the rectum and to prevent the intestines from filling this space. Finally we may also add a piece of Goretex (like they use to make gloves), to support the weight of the rectum and vagina.
Removing the sigmoid colon involves cutting out about 8-12 inches of colon just above the rectum. This is called the sigmoid colon because it is shaped like an "S." In people with rectal descent, the sigmoid colon has a tendency to fall down in the pelvis. Taking it out (and hooking the ends together) straightens the left side of the colon. This makes it easier for stool to pass. Since the sigmoid colon is removed, it cannot flop over the rectopexy stitches causing a kink in the rectum.
Lateral stalks of fibrous tissue support the rectum on either side. A soft strong suture of Goretex is used to pass a stitch through the lateral stalk on one side of the rectum. Then it is passed through the surface of the sacrum (lower backbone). This is repeated three times. When these sutures are tied they pull the rectum up and attach it firmly again to the top of the sacrum. This is the rectopexy.
If there is a deep space between the rectum and the vagina that allows the intestines to fall down into or through the pelvic floor (enterocele) then we close this space by putting three rows of sutures in the front wall of the rectum and the back wall of the vagina. With each suture, several running stitches are made. When all three rows of stitches are in place, they are tied gently and not too tightly, so that they pull the front of the rectum together with the back of the vagina.
Finally, a piece of Goretex is sewn to the rectopexy stitches and then to the top of the vagina. When the knots on the Goretex patch are tied the weight of the front of the rectum and the vagina rests on the backbone. It no longer rests on the muscles of the pelvic floor. In lifting up the vagina we are also attempting to straighten out the front of the rectum so that it no longer bulges forward.
The post-operative recovery is very similar to that after colon resection for colonic inertia (slow colon). The risks and possible complications are about the same.
Flap valve rectal prolapse. The front of the rectum falls down over the top of the anal canal and is pushed into it as the person tries to move her bowels. The harder they push the harder the front of the rectal wall gets pushed down into the anal canal. This blocks the rectum and will not let it empty.