STARR procedure for prolapse

At a glance

The STARR procedure (Stapled TransAnal Rectal Resection) is a surgical technique designed to treat internal rectal prolapse and the obstructed defecation it causes. It works by removing a circumferential section of the lower rectal wall using a circular stapling device, all performed through the anus without external incisions.

This guide covers how the procedure works, who it is designed for, and what the recovery process involves.

How the procedure works

The problem it addresses

Internal rectal prolapse (intussusception) occurs when the rectal wall folds inward during straining. This folding creates a blockage that makes it difficult to fully empty the bowel. People describe:

• Feeling that stool is stuck despite the urge to go
• Excessive straining with poor results
• Needing to use fingers to assist bowel movements
• A sense of incomplete emptying after every visit

The technique

The STARR procedure addresses this by removing the redundant rectal tissue that causes the folding:

1. Performed under general or spinal anaesthesia
2. Access through the anus — no external incisions
3. A circular stapling device is inserted through the anus
4. A full-thickness section of the lower rectal wall is captured and removed
5. The stapler simultaneously cuts and seals — removing the tissue and joining the edges in one step
6. The result is a tighter, shorter rectal wall that is less prone to folding

The procedure typically takes 30 to 60 minutes.

Who it is suitable for

Good candidates

• People with internal rectal prolapse (intussusception) confirmed on imaging
• Obstructed defecation that has not responded to conservative measures
• Failed biofeedback or pelvic floor rehabilitation — STARR is usually considered after non-surgical approaches
• People with a specific anatomical pattern confirmed by defecography (imaging of the bowel during defecation)

Less suitable for

• Full external rectal prolapse — different surgical approaches are typically more appropriate
• Functional bowel disorders without anatomical prolapse
• People with existing faecal incontinence — the procedure may worsen it
• Irritable bowel syndrome as the primary diagnosis

Careful patient selection is one of the most important factors in STARR outcomes. The procedure works best when there is a clear anatomical problem (the prolapse) causing a specific functional issue (the obstruction).

Recovery

Hospital stay

Most people stay in hospital for one to three days. During this time:

• Pain management is established
• Bowel function is monitored
• Any early complications are watched for

First two weeks

• Mild to moderate discomfort, typically manageable with standard pain relief
• Bowel function may be irregular — looser stools, increased frequency, urgency
• Limited heavy lifting or straining
• Light activities and walking are encouraged
• Stool softeners to avoid straining

Weeks 2 to 6

• Bowel function gradually normalises for most people
• The initial urgency typically settles
• Return to normal activities including work
• Follow-up appointments to assess progress

Longer term

• Improvement in obstructed defecation symptoms develops over weeks to months
• Some people notice immediate improvement; others describe a gradual change
• Bowel frequency typically settles to a new normal within three to six months

Potential complications

Like any surgical procedure, STARR carries risks that should be discussed with your surgeon:

• Urgency and frequency — increased in the early weeks, usually temporary
• Bleeding — from the staple line, usually minor
• Staple line problems — rare but can include narrowing or breakdown
• Faecal incontinence — uncommon but reported in some cases
• Ongoing obstructed defecation — the procedure does not help everyone
• Recurrence — the prolapse can recur in some cases over time

The decision-making process

STARR is typically considered after conservative measures have been tried:

1. Dietary and behavioural changes — fibre, hydration, toilet posture, not straining
2. Pelvic floor rehabilitation — biofeedback and physiotherapy
3. Diagnostic imaging — to confirm the anatomical problem
4. Surgical discussion — weighing STARR against other options

The conversation with your surgeon should cover expected outcomes, risks specific to your situation, and what to expect during recovery.