A rectopexy is a surgical procedure that repositions and secures the rectum back into its normal place inside the pelvis. It’s the primary treatment for rectal prolapse, a condition where the full thickness of the rectal wall slides downward and protrudes through the anus. The surgery aims to eliminate the prolapse, improve symptoms like fecal incontinence or constipation, and prevent new problems from developing.
Why Rectopexy Is Performed
Rectal prolapse happens when the rectum loses the structural support that holds it in position. The entire rectal wall telescopes downward and eventually pushes out through the anal opening. This is often accompanied by other pelvic floor problems, including weakened muscles, bulging of the rectal wall into the vagina (rectocele), or abnormal descent of the perineum.
Living with rectal prolapse typically means dealing with mucus or bloody discharge, difficulty emptying the bowels, and leaking stool. These symptoms tend to worsen over time because the prolapsing tissue progressively stretches the anal sphincter muscles. Rectopexy addresses the root cause by physically anchoring the rectum so it can no longer slide out of position. Over time, scar tissue forms around the repair site, adding long-term stability.
How the Diagnosis Is Confirmed
In many cases, a surgeon can diagnose rectal prolapse during a physical exam alone, sometimes by asking you to bear down or sit on a commode to reproduce the prolapse. But several additional tests help guide surgical planning.
Defecography is the most informative imaging study. Contrast paste with a consistency similar to stool is placed into the rectum, and you’re asked to defecate while X-ray or MRI images are captured in real time. This shows the rectum actively prolapsing and reveals other pelvic floor abnormalities that may need to be corrected during the same operation. A colonoscopy is standard to rule out other colorectal conditions. If you have severe constipation, a transit study (where you swallow small markers and track how quickly they move through your colon) can determine whether slow-transit constipation should also be addressed surgically. Anal manometry, which measures pressure and nerve function in the sphincter, doesn’t usually change the surgical plan but can help predict how well incontinence will improve after surgery.
Types of Rectopexy
There are several ways to perform a rectopexy, and the differences come down to how the rectum is accessed, where it’s secured, and whether mesh is used.
Ventral Mesh Rectopexy
This is currently the most widely studied technique. The surgeon frees only the front surface of the rectum, places a piece of mesh along the lowest point of the anterior rectal wall, and then suspends and anchors the mesh to the bony prominence at the base of the spine (the sacral promontory). By working only on the front of the rectum, the approach avoids the nerves running along the back and sides of the pelvis, which reduces the risk of sexual dysfunction and new bowel problems.
Posterior Sutured Rectopexy
Instead of using mesh, the surgeon mobilizes the back of the rectum and stitches it directly to the tissue overlying the sacrum. A randomized trial comparing the two approaches in 75 patients found no significant difference in how well they relieved obstructed defecation symptoms. Complication rates were also similar, at about 3% for each technique. The sutured approach had a slightly higher early recurrence rate (5% within the first year versus none in the mesh group), though this difference wasn’t statistically significant.
Abdominal Rectopexy With Bowel Resection
In some cases, particularly when slow-transit constipation is a major concern, the surgeon will also remove a segment of the sigmoid colon during the same operation. This shortens the colon and can help with chronic constipation that wouldn’t improve from repositioning the rectum alone.
Open, Laparoscopic, or Robotic Surgery
The same rectopexy techniques can be performed through different surgical approaches. Open surgery requires a larger abdominal incision. Laparoscopic surgery uses several small incisions with a camera and thin instruments. Robotic-assisted surgery is similar to laparoscopic but gives the surgeon enhanced precision through a robotic platform.
Minimally invasive approaches (laparoscopic and robotic) generally mean less pain, shorter hospital stays, and faster recovery. However, one case-control study found that recurrence rates were notably higher after minimally invasive procedures: 27% for laparoscopic and 20% for robotic, compared to just 2% for open surgery. This is an important tradeoff to discuss with your surgeon, as the best approach depends on the severity of the prolapse, your overall health, and surgeon experience.
Perineal Approaches for Higher-Risk Patients
Not every patient is a candidate for abdominal surgery. For older adults or those with significant medical conditions, surgeons may opt for a perineal approach, which accesses the rectum through the anus and avoids abdominal incisions entirely.
The Altemeier procedure involves pulling the prolapsed rectum and part of the sigmoid colon through the anus, removing the excess tissue, and reattaching the remaining rectum to the large intestine. The pelvic floor muscles can be tightened at the same time. The Delorme procedure is used for smaller prolapses: the inner lining of the prolapsed rectum is stripped away, and the exposed muscular layer is folded and stitched to create a thicker, more stable rectal wall. Both procedures can be done under regional anesthesia, making them safer options for patients who can’t tolerate general anesthesia well.
Recovery After Rectopexy
Recovery depends heavily on whether you had open or minimally invasive surgery. Laparoscopic rectopexy patients typically spend one to three days in the hospital, while open surgery may require a longer stay. Most people can return to light daily activities within two to four weeks, though heavy lifting is usually restricted for six weeks or more to protect the repair.
Bowel function takes time to normalize. You can expect some irregularity in the first few weeks. A high-fiber diet and adequate fluid intake help keep stools soft, which is important because straining puts stress on the surgical repair. Some surgeons recommend stool softeners during early recovery for the same reason. Pelvic floor physical therapy is sometimes prescribed to retrain the muscles that coordinate bowel movements, especially if incontinence was a major symptom before surgery.
Long-Term Outcomes and Recurrence
Most people experience meaningful improvement after rectopexy. In one large study, fecal incontinence scores dropped significantly after surgery, with 36% of patients reporting clear improvement in their leaking. The average scores for both incontinence severity and daily life impact improved substantially across the entire study group.
Patient satisfaction tends to be high. In a 10-year follow-up study of 161 patients who underwent ventral rectopexy, 81% said they would have the operation again, and 91% would recommend it to family or friends. Even among patients who experienced a recurrence, most still said they would choose surgery again.
Recurrence is the main long-term concern. That same 10-year study found a recurrence rate of 10.5% overall and 7.5% among patients who were having their first prolapse repair. The median time to recurrence was about six and a half years, meaning some recurrences show up many years after an initially successful surgery. Patients who had prior prolapse surgery before their rectopexy, and those with evidence of nerve damage to the pelvic floor, appear to be at higher risk.
Possible Complications
Rectopexy is generally safe, with serious surgical complications occurring in roughly 3% of cases in randomized trials. These can include infection, bleeding, or, rarely, injury to nearby structures like the ureter.
The more common issue is functional. Even when the anatomy looks perfect after surgery, bowel symptoms don’t always improve, and they can sometimes get worse. New-onset constipation develops in about 5 to 10% of patients after ventral mesh rectopexy, and some studies report constipation of any kind (new or persistent) in over a third of patients postoperatively. Fecal incontinence improves for many, but a small number of patients develop new leaking they didn’t have before surgery. When mesh is used, there is a rare but recognized risk of mesh erosion into the rectum or vagina, which may require additional surgery. Techniques that avoid extensive dissection around the back and sides of the rectum, like ventral rectopexy, were specifically designed to minimize nerve-related complications such as worsened constipation and sexual dysfunction.