Which conservative management strategies are recommended for patients with rectal prolapse who are not surgical candidates?

For patients with rectal prolapse who are not suitable candidates for surgery, conservative management strategies include lifestyle modifications such as weight loss if BMI is above 30 kg/m2, minimising heavy lifting, and preventing or treating constipation to reduce strain on the pelvic floor. Pelvic floor muscle training, ideally supervised and lasting at least 16 weeks, is recommended to strengthen pelvic support and improve symptoms. The use of vaginal pessaries may be considered to provide mechanical support for prolapse, with appropriate follow-up and care to prevent complications. Additionally, topical vaginal oestrogen or oestrogen-releasing rings can be considered for women with genitourinary symptoms associated with menopause, especially if physical or cognitive impairments limit the use of other forms of oestrogen therapy. These conservative options should be discussed with the patient, taking into account their preferences, comorbidities, and lifestyle factors.

For faecal incontinence associated with rectal prolapse, conservative measures include the use of faecal collection devices in certain settings and consideration of non-surgical interventions such as sacral nerve stimulation trials in specialist centres if surgery is inappropriate. Stoma formation is reserved for severe cases only after all non-surgical and surgical options have been considered.

Overall, conservative management aims to improve symptoms and quality of life while avoiding surgical risks in unsuitable candidates.

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