Surgical outcomes on health-related quality of life in rectal prolapse: A systematic review and meta-analysis

Abstract

Objectives

Rectal prolapse is a serious but not life-threatening condition. It can involve many complications, including quality-of-life changes. Surgical intervention is the standard medical treatment for these patients. In this article, we aim to investigate the quality-of-life outcomes in patients undergoing rectal prolapse surgery, compare different surgical methods, and assess different quality-of-life questionnaires to study these patients.

Data Sources

We conducted a systematic literature search on PubMed, Scopus, ScienceDirect, and Embase.

Study Selection

A total of 4916 studies were screened, resulting in a final 34 included studies, and 20 were included in the meta-analysis.

Interventions

Data were extracted from studies comparing the quality of life in rectal prolapse patients before and after surgery.

Main outcome measures

Except for one, all included studies reported improved quality-of-life scores. Different instruments were used to examine these patients' quality of life, but SF-36 was implemented most frequently. It comprises eight different domains, and these domains were reported in six different studies.

Results

All eight domains showed better outcomes after surgery. The final analysis was based on the surgical approach (perineal or abdominal) and showed no statistically significant superiority of any of the approaches.

Limitations

The high heterogeneity of the included studies.

Conclusion

Surgical intervention can improve the quality of life of rectal prolapse patients. However, there is no consensus on which surgical approach achieves the best outcomes. Different instruments are used to evaluate the quality of life in these patients, but there is no specific questionnaire to assess this.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-025-03198-0.

Introduction

Rectal prolapse is described as the rectum’s full-thickness protrusion through the anus. It progresses from an internal intussusception, only visible on defecography, to an external mucosal prolapse and eventually a full-thickness rectal prolapse. Complete rectal prolapse and internal intussusception can develop independently or can be associated with the descent and dysfunction of other pelvic organs, such as rectoceles, uterine or vaginal vault prolapse, cystocele, or enterocele [1]. Risk factors for developing rectal prolapse include chronic constipation, diarrhea, multiparity, vaginal delivery, previous pelvic surgery, and pelvic floor dysfunction, as well as advancing age, dementia, and stroke [2]. Rectal prolapse occurs in individuals at both ends of the age spectrum. In the pediatric population, the condition is usually diagnosed by 3 years of age, with an equal gender distribution. In adults, rectal prolapse affects women more frequently than men, accounting for 80% to 90% of patients with rectal prolapse, with a peak incidence after the 5th decade [3].

There are two management methods for rectal prolapse: nonoperative and operative. Rectal prolapse cannot be treated nonoperatively; however, some of the related symptoms, such as fecal incontinence, pain, and constipation, can be managed conservatively [4]. Conservative treatment consists of a high-fiber diet, increased fluid consumption, pelvic floor exercises, biofeedback, and, in constipated patients, aperients and rectal enemas [2]. Although none of these conservative treatments treat the prolapse, they may help improve the patient’s condition and quality of life [4]. For patients with rectal prolapse, opting for long-term medical treatment instead of surgery will ultimately lead to permanent fecal incontinence. In addition, postponing surgical intervention beyond 4 years may heighten the risk of the prolapse recurring, presumably secondary to a secondarily weakened pelvic floor [4]. Also, without surgery, prolapse is likely to reoccur with gradual weakness of anal sphincters and fecal incontinence, with a risk of strangulation [2].

Rectal prolapse is mainly treated with surgery [4]. For patients with rectal prolapse, opting for long-term medical treatment instead of surgery will ultimately lead to permanent fecal incontinence. In addition, postponing surgical intervention beyond 4 years may increase the risk of prolapse recurrence presumably secondary to a secondarily weakened pelvic floor. Surgical techniques for rectal prolapse have been traditionally classified as abdominal or perineal approaches [2].

Although many experts continue to recommend transabdominal procedures, when possible, the choice between abdominal and perineal techniques remains debatable. Multiple retrospective studies have shown that the recurrence rates following abdominal surgery for rectal prolapse are approximately one-fourth of those following perineal surgery, with the abdominal approach leading to improved functional outcomes. However, the data supporting the decreased recurrence rates have been recently questioned. For instance, in a randomized controlled trial conducted in 2013 with 293 patients, known as the Prolapse Surgery Perineal or Rectopexy trial and organized by the Association of Coloproctology of Great Britain and Ireland, similar rates of rectal prolapse recurrences were found regardless of the surgical method used. However, critics have pointed out flaws in the study’s methodology and noted that it may have been underpowered [4].

According to the WHO, the definition of health-related quality of life (HRQoL) is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. HRQoL is described as a subjective, dynamic, and multifaceted tool that encompasses physical, psychological, social, and spiritual dimensions [5, 6].

Some questionnaires evaluate the quality of life for gastrointestinal diseases, such as the Inflammatory Bowel Disease Questionnaire (IBDQ) [7].

The quality of life after prolapse surgery is an important issue that should be considered. Some questionnaires evaluate the postoperative quality of life, such as SF6, PAC-QOL, GIQLI, EQ-5D-5L, FI-QOL, etc. However, there are no specific questionnaires for postoperative quality of life after prolapse surgery.

Materials and methods

This is a systematic review and meta-analysis of the health-related quality of life in rectal prolapse patients undergoing surgical intervention compared with preoperative values. This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO), with a CRD42024500124 identification code.

Study outcomes

The primary outcome of this study was to assess the health-related quality of life scores in patients undergoing surgical intervention for the treatment of rectal prolapse, before and after surgery. All studies evaluating quality-of-life scores before and after surgery in rectal prolapse patients were included in our literature review.

Inclusion criteria

• Studies concerning rectal prolapse patients diagnosed and confirmed by colorectal surgeons.

• Studies with pediatric, adult, or elderly populations.

• Studies evaluating health-related quality of life as a functional outcome in rectal prolapse patients.

• Randomized controlled trials, cohorts with either prospective or retrospective design, and cross-sectional studies.

• Studies that applied surgical intervention in rectal prolapse patients

• Studies comparing the quality of life pre- and postoperatively with any valid approved instrument

• Peer-reviewed papers

Exclusion criteria

• Interventional study with a non-surgical intervention

• Any study focused on psychological disorders affecting the quality of life in rectal prolapse patients (including anxiety, depression, distress,etc.)

• Studies with incomplete data

• Any type of review and opinion papers

• Case reports, case series, and qualitative research

• Studies with non-valid quality-of-life scales

• Congress abstracts

• Animal studies

Study endpoints

The primary outcome was the health-related quality-of-life scoring, measured by a valid, approved questionnaire both before and after rectal prolapse surgery to compare this functional outcome change after the surgical intervention.

The secondary endpoint was the quality-of-life scoring based on the eight domains of the SF-36 questionnaire. Studies that met the criteria of having a complete record of eight domains both pre- and postoperatively were selected for inclusion in this analysis.

An additional outcome considered in a separate analysis was the effect of the surgical approach (perineal or abdominal) on the patients’ quality of life and applied all the studies including quality-of-life scorings for both approaches.

Search methodology

Sources

A systematic literature search was performed, and studies from 1927 to 2024 were identified using PubMed, SCOPUS, ScienceDirect, and Embase. Three authors performed the literature review completely independently.

Search strategy

Search strategies were developed by an expert medical librarian who considered the following concepts: (rectal prolapse or anus prolapse), (colorectal surgery or rectal surgery or rectal prolapse surgical methods), and quality of life. An appropriate search strategy was first developed for PubMed by combining all MeSH terms and keywords and then adjusted for three other databases. There were no search limitations regarding time, language, or publication type. Search results from all four databases were then exported to EndNote software version 20, and duplicates were excluded manually. Deduplicated search results were then imported to Rayyan software web service for screening.

Data collection

This systematic review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines [8]. In the first phase, two reviewers (HY-K and YR) independently screened the deduplicated search results based on the titles and abstracts to determine whether they were appropriate according to the prespecified inclusion and exclusion criteria. Conflicts were then resolved by a third reviewer.

In the second phase, a complete full-text screening of phase 1 selected studies was done by two independent reviewers (HY-K and DN) to determine whether they included the data to answer the main questions of the review. For instance, whether the studies presented the total score for quality of life in rectal prolapse patients before and after a surgical intervention was checked. If the study applied the SF-36 questionnaire, we checked whether it included the complete scoring profile of each of the eight quality-of-life domains, used both surgical approaches, and included a comparison between these two approaches.

Data extraction

Two reviewers (YR and FF) independently extracted the following data from each included study: authors, year of publication, country, study design and setting, participant number and characteristics, quality-of-life questionnaire, quality-of-life total score before and after the surgery, SF-36 domain scores, type of surgical intervention, and time interval.

Data synthesis

This is a narrative synthesis of the findings of the included studies to assess quality-of-life scoring systems used in rectal prolapse patients who have undergone surgical treatments. Moreover, meta-analyses and statistical operations were conducted to address the three main questions of our review. Studies addressing the total score of quality of life for the participants were included in the main analysis. Studies including domain scoring for SF-36 were included in the second analysis, and studies addressing both abdominal and perineal approaches were identified to be included in the third analysis comparing the two surgical approaches.

Data required for each study to be included in the meta-analysis were number of participants, mean value, and standard deviation. Among the included studies, some did not present the required statistics to be included in the meta-analysis; in these cases, standard formulas [9] were administered to extract the standard deviation and mean of the values from any other statistics like P value, test statistics, confidence interval, and median.

When all the included data were in the required format, a random-effect meta-analysis was undertaken to pool the data of all studies. A random effect model was administered, using the method of DerSimonian and Laird [9], because studies implemented different surgical interventions to treat rectal prolapse patients. Since each study administered a different instrument to assess the quality of life of its participants, standardized mean differences (SMDs) were reported in the meta-analysis. The standardized mean difference is a commonly reported measure in meta-analyses, and the intervention effect is reported in a standard format rather than the original units of each study.

Risk of bias assessment

Two reviewers (HY-K and DN) independently assessed the risk of bias in included studies using the risk of bias in non-randomized studies of interventions (ROBINS-I) tool. Seven domains of bias throughout the entire course of intervention were evaluated with this tool: (1) bias due to confounding, (2) bias in the selection of study participants, (3) bias in the classification of interventions, (4) bias due to deviations from intended intervention, (5) bias due to missing data, (6) bias in the measurement of outcomes, and (7) bias in the selection of the reported result. An overall bias assessment was made based on the domain scores for each study. Each study’s overall risk of bias has been reported as low, moderate, serious, and critical. Conflicts were resolved by consensus.

Results

Literature search and study characteristics

A total of 4916 studies were identified in our database searches. Of these, 2202 were excluded as duplicates. Of the remaining 2714 studies, 2609 were excluded through title and abstract screening. The remaining 103 studies were included for full-text review. After the full-text screening, 34 studies were assessed as eligible for inclusion. Among these 34 studies, 19 were qualified as eligible for inclusion in our meta-analysis of quality-of-life total scores. Regarding domain-based analysis of quality of life, six studies were identified as eligible for inclusion in the meta-analysis (Fig. 1) (Table 1).

Fig. 1.

PRISMA flowchart of included studies

Table 1.

Study characteristics

	Study	Year of publication	Study design	Study population disease severity	Sex (F) %	Number of participants	QoL assessment tool	Surgical method	Recurrence rate (%)
Included in the meta-analyses	Badrek-Al Amoudi et al.	2013	Cohort	RP	90	50	BBSQ-22	Abdominal	16
	Boccasanta et al.	2021	Retrospective cohort	CRP	91.54	130	SF-36	Perineal	20.7
	Cunin et al.	2013	Cohort	RP	91.76	85	GIQLI	Abdominal	7
	Elagili et al.	2015	Retrospective cohort	RP	93.33	75	FI-QOL CGQL	Perineal	14.6
	Gosselink et al.	2013	Cohort	IRP	94.7	151	PAC-QOL & GIQOL	Abdominal	-
	Gosselink et al.	2015	Retrospective cohort	ERP / HIRP	94.51	91	GIQOL	Abdominal	3.3
	Grossi et al.	2022	RCT	IRP	100	28	PAC-QOL & EQ-VAS	Abdominal	0
	Hu et al.	2022	Retrospective cohort	ERP	100	51	EQ-5D-5L	Abdominal and perineal	23.5
	Hyun et al.	2018	Cohort	Full-thickness RP	55.56	63	FIQL	Abdominal	0
	Kim et al.	2012	Cohort	Full-thickness ERP	83.93	18	PAC-QOL & EQ-VAS & EQ-5D-5L	Abdominal and perineal	16.6
	Kim et al.	2013	Cohort	Full-thickness ERP	88.68	53	PAC-QOL & EQ-VAS & EQ-5D-5L	Perineal	9.4
	Madbouly et al.	2018	Retrospective cohort	CRP	81.08	74	GIQOL	Abdominal	2.7
	Maggiori et al.	2013	Prospective cohort	Full-thickness ERP and/or rectocele	87.88	33	GIQOL	Abdominal	6
	Owais et al.	2014	Retrospective cohort	ERP / IRP	0	68	BBSQ-22	Abdominal	4.4
	Sayed et al.	2022	Prospective cohort	RP	68.18	44	GIQOL	Abdominal	9
	Senapati et al.	2013	RCT	RP	86.25	293	EQ-5D	Abdominal and perineal	23.2
	Smedberg et al.	2022	RCT	RP	94.26	134	SF-36	Abdominal and perineal	34.3
	Tsunoda et al.	2016	prospective cohort	ERP and/or RAI	93.18	59	FI-QOL SF-36 PAC-QOL	Abdominal	1.6
	Tsunoda et al.	2021	Cohort	PCP	89.47	114	SF-36 FI-QOL	Abdominal	-
	Tsunoda et al.	2021	Retrospective cohort	RAI and/or rectocele	94.12	51	FI-QOL SF-36 PAC-QOL	Abdominal	-
	Auguste et al.	2006	Cohort	CRP	87	54	Visick score	Abdominal	7.4
	Degasperi et al.	2019	RCT	ODS and IRP	100	50	SF-36	Abdominal	0
	Foppa et al.	2014	Retrospective cohort	Full thickness RP	97.2	179	FIQOL	Abdominal	5.5
	Hidaka et al.	2019	RCT	RP	90	75	PAC-QOL	Abdominal	13.3
	Johnson et al.	2012	Cohort	Internal Rectal Intussusception	91.6	48	SF-36	Abdominal	4.1
	Laitakari et al.	2021	Cohort	Recurrent ERP or symptomatic IRP	95.3	43	QOL-VAS	Abdominal	4.5
	Laitakari et al.	2022	Retrospective cohort	ERP or symptomatic IRP	100	401	QOL-VAS	Abdominal	1.2
	Otto et al.	2018	Retrospective cohort	Resection rectopexy for RP	90	40	SF-36 & FI-QOL	Abdominal	-
	Randall et al.	2014	Cohort	ERP	87.3	190	BBSQ-22	Abdominal	2.1
	Reichert et al.	2016	Prospective cohort	RP and cul-de-sac syndrome	100	26	SF-36	Abdominal	0
	Sezai et al.	2005	Cohort	CRP	5	40	FI-QOL	Abdominal and perineal	7.5
	Solari et al.	2022	Retrospective cohort	RP and/or obstructed defecation	98.3	61	PAC-QOL	Abdominal	8.1
	Tsunoda et al.	2020	Retrospective cohort	ERP	89.6	58	FI-QOL SF-36	Abdominal	1.7
	Yang et al.	2017	Retrospective cohort	Full-thickness RR	100	69	FI-QOL	Abdominal	4.3

RCT randomized controlled trial, IRP internal rectal prolapse, ERP external rectal prolapse, RP rectal prolapse, CRP complete rectal prolapse, RAI rectoanal intussusception, ODS obstructed defecation syndrome, BBSQ-22 Birmingham Bowel and Urinary Symptoms Questionnaire 2022; GIQLI Gastrointestinal Quality of Life Index, FI-QOL Fecal Incontinence Quality of Life, CGQL Cleveland Global Quality of Life, PAC-QOL Patient Assessment of Constipation Quality of Life questionnaire.

Quality-of-life total score

There were a total of 20 studies comparing the total QoL scores pre- and postoperatively (Table 1). All 20 studies reported improved QoL outcomes after surgery, except one study [10] that reported lower QoL total scores postoperatively with an SMD of – 0.06 (Fig. 2). That study included 75 patients who were randomized between two perineal approaches (Altemeier and Delorme surgery); pooling these two groups, there was a 0.3 decrease in total QoL score based on the FI-QOL questionnaire [10]. Considering all 20 studies, there were 1576 patients with preoperative scores and 1424 with follow-up scores. The pooled estimate for QoL total scores was 1.65 (95% confidence interval [CI]: 1.05; 2.24). However, a high I² value of 97% suggested high heterogeneity among the studies.

Fig. 2.

Health-related quality of life, total score

There were 14 studies, other than the 20 studies that were not eligible for inclusion in this meta-analysis. Of these 14 studies, 6 did not report any QoL total scores [11–16], 4 did not provide any preoperative data [17–20], and 4 did not document any statistical index, only providing a qualitative report of their findings [21–24].

Quality-of-life domains

SF-36 was the most frequently used questionnaire in all 34 studies. It is a generic, self-reporting, quality-of-life questionnaire, comprising 36 questions, and is widely used in different research settings. Its scoring system comprises eight different domains that can be summarized first as physical and emotional sections and second as a total score utilized in the previous analysis.

Regarding this eight-domain scoring system, we included six studies that reported SF-36 domain scores in our second analysis [11–13, 16, 25, 26]. The 36-Item Short Form Health Survey questionnaire (SF-36) is a commonly used tool for assessing Health-Related Quality of Life. The SF-36 evaluates eight dimensions: physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH). Component investigations revealed that the SF-36 measures two distinct concepts: a physical dimension, represented by the Physical Component Summary (PCS), and a mental dimension, represented by the Mental Component Summary (MCS) [27].

In this analysis, we evaluated the QoL scores pre- and postoperatively based on the eight domains of the SF-36 instrument: physical functioning, physical role, bodily pain, general health, vitality, social role, emotional role, and mental health. There were 394 patients with preoperative data and 359 with postoperative QoL scores.

Physical functioning

The first domain is physical functioning, which aims to investigate the limitations in usual physical activities caused by patients’ disease. The pooled estimate for the physical functioning domain was 1.00 (95% confidence interval [CI]: 0.23; 1.77) (Fig. 3). It is the highest pooled estimate value among all domains. All studies reported QoL score improvement in this domain. There was a high heterogeneity among the studies as the I² value equaled 94%.

Fig. 3.

SF-36, Physical functioning

Physical role

This domain targets the limitations in role activities caused by physical health problems. There was a 0.77 pooled estimate for this domain (95% CI: − 0.17; 1.71) (Fig. 4). Tsunoda et al. captured no differences before and after surgery in this specific domain [12]. All other studies reported higher scores after the surgery. There was a 91% I² value, showing high heterogeneity among the studies.

Fig. 4.

Forest plot demonstrating pooled analysis of physical activity quality of life

Bodily pain

The third domain represents the bodily pain caused by the health problem. The pooled estimate was 0.59 (95% CI: – 0.55; 1.74) (Fig. 5), the lowest value among all other domains. This surgical intervention had the least effect on this QoL domain. Considering the forest plot (Fig. 5), Reichert et al. reported a high SMD value of 3.35[16], although Boccasanta et al. reported a negative SMD value of – 1.18[26]. This makes sense regarding the high I² value.

Fig. 5.

Forest plot demonstrating pooled analysis of bodily pain domain of the SF-36 Quality of Life Questionnaire

General health

The fourth domain investigates the patient's general health perception. There was a pooled estimate of 0.79 (95% CI: − 0.76; 2.34) (Fig. 6) in six studies. Two studies reported negative SMD values [13, 26], and one reported a low SMD value of 0.03, which is equivalent to no effect [25]. Comparing these low values with the high SMD reported by Reichert et al. [16] makes it challenging to judge the real effect of surgery on this domain. The final I² value was 95%, which is considered high.

Fig. 6.

Forest plot demonstrating pooled analysis of studies’ general health scores of SF-36 Quality of Life Questionnaire

Vitality

The vitality domain, interpreted as energy and fatigue, had a pooled estimate of 0.97 (95% CI: − 0.36; 2.30) (Fig. 7). All studies showed higher scores after the surgery except one study that reported no difference before and after surgery [13]. The heterogeneity among the studies was high as the I² value was 93%.

Fig. 7.

Forest plot demonstrating pooled analysis of studies’ SF-36 Quality of Life Questionnaire vitality scores

Social role

This domain evaluates limitations in social roles and activities caused by the disease. The pooled estimate for this domain was 0.85(95% CI: 0.31; 1.39) (Fig. 8). All studies mentioned higher scores after surgery in this domain. Here, the data were more homogeneous, and an I² value of 0.87% was calculated, which was lower than in the previous domains.

Fig. 8.

Forest plot demonstrating pooled analysis of studies’ scores evaluating social role performance on the SF-36 Quality of Life Questionnaire

Emotional role

The seventh domain, which scores the limitations in role activities after the disease, had a pooled estimate of 0.93(95% CI: 0.05; 1.80) (Fig. 9). Higher postoperative values were documented in all six studies. The I² value for heterogeneity was 91%, which is high.

Fig. 9.

Forest plot demonstrating pooled analysis of studies’ scores evaluating emotional role performance on the SF-36 Quality of Life Questionnaire

Mental health

The last domain had a pooled estimate of 0.61 (95% CI: − 0.77; 1.99) (Fig. 10). Boccasanta et al. reported a highly negative SMD value of − 1.47 [26], which contrasts with the high value reported by Reichert et al. [16]. Like for the vitality domain, Degasperi et al. documented an SMD value of 0, suggesting that the surgery did not affect the mental health of the patients with prolapse [13]. The 97% I² value in this domain shows high heterogeneity among the studies.

Fig. 10.

Forest plot demonstrating pooled analysis of the mental health domain on the SF-36 Quality of Life Questionnaire

Surgical approach comparison

Our last analysis assessed the value of which surgical approach is applied and whether it affects patients' postoperative QoL score. There are many surgical methods to manage rectal prolapse, but they can be summarized as perineal and abdominal approaches. We applied a subgroup to the 20 included studies and identified two subgroups: those that applied the abdominal approach and those that used a perineal surgical method (Fig. 11). Among the 20 included studies, 13 utilized an abdominal approach [28–40], 3 were focused on perineal approaches [10, 41, 42]. The remaining four studies used both the perineal and abdominal approaches [25, 43–45]. In these four studies, patients who underwent abdominal surgery were analyzed in the first group, and patients who were treated with a perineal approach were analyzed in the second group.

Fig. 11.

Subgroup analysis of the surgical methods and QoL score

A total of 998 patients had preoperative data for the abdominal approach, 948 of whom had follow-up data. As most of the studies used an abdominal approach, the number of patients who underwent a perineal approach was smaller. For the perineal approach, there were data for 578 and 483 patients before and after the surgery, respectively. The pooled estimate for the abdominal group was 1.70 (95% CI: 1.03; 2.38), whereas in the perineal group, there was a pooled estimate of 1.26 (95% CI: 0.46; 2.05), leading us to conclude that abdominal approaches had a better effect on the health-related quality-of-life outcomes in the management of rectal prolapse patients. All the included studies in the abdominal and perineal subgroups demonstrated a positive effect of surgery on the QoL scores, except for that of Elagili et al., who reported a negative SMD value of – 0.06 for perineal surgery (Fig. 10). For the heterogeneity test, the abdominal group had an I² value of 96%, whereas the perineal group had an I² of 95%, which both demonstrate high heterogeneity among the studies.

Meta-regression showed that female proportion (> 90% of the study population) and age had significant effects on the overall QoL score results before and after surgery. However, study design (RCT or non-RCT) and follow-up duration did not have any significant effects of the overall QoL score results before and after surgery (Table 2).

Table 2.

Univariate random effects meta-regression of variables potentially associated with total QoL scores before and after surgery

Covariate	Effect size	SE	P value	$R^2$ %
Sex (female > 90%)	1.2431	0.5523	0.0244	18.08
Age (> 60)	1.2263	0.5670	0.0306	16.47
Study design (RCT)	0.9052	0.8426	0.2827	0.64
Follow-up (> 12 m)	0.2084	0.6502	0.7486	0.00

Effect size: The total difference between the two groups

SE standard error of the effect size, $R^2$ Score The proportion of total heterogeneity accounted for by the covariate

Recurrence

Here, we calculated the pooled estimate for the recurrence rate among studies reported. The heterogeneity of studies regarding recurrence was acceptable (46%) among the abdominal group with a pooled estimate of 0.05 (95% CI: 0.02 – 0.08). The pooled estimate of recurrence rate among all included studies was 0.08 (95% CI: 0.04 – 0.13) (Fig. 12).

Fig. 12.

Forest plot demonstrating pooled analysis of the recurrence rate

Quality appraisal

As part of our systematic review and meta-analysis on the quality of life in rectal prolapse, we assessed the risk of bias in the 34 included studies. Thirty non-randomized studies were assessed using the ROBINS-I tool, and the remaining 4 randomized controlled studies were assessed using RoB2 [46, 47]. The majority demonstrated a moderate risk of bias in multiple domains. Below is a summary of our findings (Table 3) (Fig. 13).

Table 3.

Traffic light table for risk of bias assessment of the included studies. A Non-randomized studies assessed by ROBINS-I. B Randomized controlled studies assessed by RoB 2

Fig. 13.

Summary plot of risk of bias assessment of included studies. A Non-randomized studies assessed by ROBINS-I. B Randomized controlled studies assessed by RoB 2

The majority of the included studies’ quality appraisals revealed a moderate risk of bias, mostly as a result of confounding and participant selection problems. When analyzing the meta-analysis results, these biases must be considered. The results provide insightful information about the quality of life in rectal prolapse but should be interpreted cautiously because of the moderate risk of bias. By assuring a representative sample, reducing confounding variables, and managing missing data openly, future research should strive to reduce these biases.

Discussion

This systematic review and meta-analysis was conducted to review the different quality-of-life (QoL) measurement tools and their implications in clinical practice. Although benign, rectal prolapse can cause serious problems for patients regarding routine daily activities. Therefore, its management should be thoughtful, improving patients’ quality of life. The treatment decisions for these patients are based on physical examinations and functional assessments. Patients will be candidates for either conservative management or surgery [48]. Surgical methods consist of two major approaches: perineal and abdominal. Although current treatments for rectal prolapse have promising results, some patients continue with remaining symptoms and do not have ideal QoL scores. This raises two questions: (1) which surgical method should be chosen for which patients? (2) Are available QoL assessment tools effective in clinical practice?

Quality-of-life tools have been increasingly developed for specific diseases over the years [49–52]. Only one has been developed to assess patients with benign colorectal conditions [50]. Here, we aimed to assess the effectiveness of disease-specific tools for patients with rectal prolapse so we could propose a useful tool for assessing these patients.

To achieve this goal, we included all studies assessing quality of life with at least one standard tool.

The included studies used either general or specific QoL questionnaires. This resulted in great heterogeneity of our included studies.

We collected data on QoL scores for patients before and after surgery. We grouped our included studies into those assessing QoL with general questionnaires and those using disease-specific questionnaires. We aimed to determine which surgery yields the most improvement and to evaluate the efficacy of the existing disease-related QoL questionnaires.

However, regarding the total score, most studies reported definite successful results with improved QoL scores. The pooled analysis of total QoL scores of studies showed a statistically significantly better postoperative quality-of-life score (pooled SMD: 1.65, 95% CI [1.05–2.24]).

Practical implications

Improving therapeutic strategies requires a specified target domain of interest. Therefore, we went further with subgroup analysis to address the potential target domain. The results of domain subgroup analyses were inconclusive. Considering the total number of participants (n = 2999), these results suggest that although current QoL assessment tools can demonstrate an overall improvement in patients’ QoL, they cannot guide us through developing better treatment strategies to improve patients’ other symptoms.

The efficacy of different surgical methods has been a subject of debate [25]. It has been proposed that perineal surgery results in fewer complications and, therefore, the abdominal approach must be reserved for cases where perineal surgery cannot be performed [53]. We compared the total scores of QoL improvement between patients who underwent abdominal versus perineal approaches as a comparison scale. Our analysis showed no statistically significant difference between these two groups based on patients’ QoL score improvement. Therefore, decisions on the surgical method are made according to the physician’s judgment and expertise, along with the patient’s preferences.

Research implications

The results of this study indicate the need for developing more specific QoL assessment tools to investigate treatments of benign colorectal diseases. These conditions, although impacting patients’ QoL, are, to some extent, being overlooked. We suggest developing standard disease-specific QoL assessment tools for these conditions, especially rectal prolapse, given its high prevalence.

Limitations

We believe the major limitation of our study is the high heterogeneity of the included studies. The heterogeneity in the QoL assessment tools used in studies results from different patient populations and different data collecting methods. We combined both RCT and non-RCT studies in our analyses because of the limitation due to the scarcity of high-quality RCTs and their short follow-up periods to conduct a comprehensive analysis of the data.

Conclusion

The QoL domains of interest for therapeutic planning can be unclear for practitioners using current validated QoL assessment tools. Here, we show the need to develop a prolapse-specific QoL assessment tool to better address patients’ remaining problems after treatment. Furthermore, a validated prolapse-specific QoL questionnaire could help resolve existing conflicts in choosing surgical treatment approaches.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Authors’ contributions: HY-K: data gathering, writing the original draft, review and editing, supervision. YR: data gathering, analyzing the data, writing the original draft. DN: data gathering, writing the original draft. FF: data gathering, writing the original draft. MS: review and editing. AK: review and editing. MRK: review and editing. AK: review and editing. MSF: review and editing. BB: review and editing. SMA-T: conceptualization, supervision, review and editing.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability

The data supporting this study’s findings will be available upon request from the corresponding author.

Declarations

Conflict of interest

The authors declare that there is no conflict of interest.

Ethical approval

This study was conducted in full accordance with the ethical principles outlined in the Declaration of Helsinki. It was approved by the Ethics Committee of the Tehran University of Medical Sciences, Tehran, Iran, under approval number IR.TUMS.MEDICINE.REC.1403.451.

Informed consent

For this type of study, formal consent is not required.