Surgery beats sclerotherapy for rectal prolapse in children ages 5 and older

Dr. Belinda Dickie and Dr. Erin McNamara in the operating room
Overall, when used as an initial management approach, surgery had a significantly higher success rate for rectal prolapse than sclerotherapy. (Photo: Michael Goderre/Boston Children's)

Rectal prolapse — the protrusion of the lining of a child’s rectum through the anal sphincter — can occur for many reasons. In the pediatric population, it most commonly occurs in children under 4 years old but can affect older children as well. Children with colorectal and pelvic malformations tend to be at increased risk for rectal prolapse, as are those with chronic constipation or diarrhea and neurological conditions such as tethered cord or spinal cord injury.

Rectal prolapse often resolves spontaneously and can be treated medically. However, children with severe or recurrent rectal prolapse require further treatment, typically in the form of sclerotherapy or surgical correction.

“Sclerotherapy is an outpatient procedure with low rates of complications, which makes it appealing as an initial treatment option,” says Prathima Nandivada, MD, a surgeon in Boston Children’s Colorectal and Pelvic Malformation Center. “But some patients undergo multiple sessions of sclerotherapy without improvement before surgical correction is pursued. This can delay resolution of symptoms and cause distress for families.”

Surgical success for rectal prolapse

To learn more about the effectiveness of both approaches, Nandivada and her colleagues reviewed medical records from 67 children who were referred for treatment for rectal prolapse at the Colorectal and Pelvic Malformation Center.

After comparing medical management, sclerotherapy, and surgical correction (rectopexy or transanal resection) as initial treatment strategies, the team found that only 33 percent of patients resolved with sclerotherapy alone, compared to 79 percent who underwent surgery as initial management. Overall, when used as an initial management approach, surgery had a significantly higher success rate than sclerotherapy, even after controlling for severity of disease, psychiatric diagnosis, age, and other factors.

Takeaways for your practice

The results — published in the Journal of Pediatric Gastroenterology and Nutritionhave helped inform the center’s approach to rectal prolapse, says Nandivada. Medical therapy and pelvic floor physiotherapy remain the first-line therapies for most children with rectal prolapse, especially under age 5 years. However, for older children, especially adolescents, with persistent prolapse despite lifestyle modification, pelvic floor therapy, and constipation management:

  • Offer sclerotherapy as a first-line treatment due to the low complication risk.
  • Counsel families that rates of resolution with sclerotherapy are low (50-60 percent).
  • If sclerotherapy doesn’t result in significant resolution after one injection, discuss surgical correction rather than continuing with multiple sclerotherapy sessions.

“We believe this treatment algorithm for rectal prolapse can help minimize time to resolution and avoid unnecessary procedures,” she explains.

Learn more about the Colorectal and Pelvic Malformation Center.

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