Rectal prolapse

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shaghayegh Habibi, M.D.[2]

Rectal prolapse is when the tissue that lines the rectum falls down into or sticks through the anal opening. It starts from rectal intussusception, followed by external mucosal prolapse, and eventually a full protrusion of all layers of the rectum. Rectal prolapse occurs more frequently in the elderly and women and most common symptoms include pain, fullness or a lump inside rectum, fecal incontinence, constipation and bloody and/or mucous rectal discharge. Common causes of rectal prolapse include rectal denervation, perineal nerve injury, kinking of the redundant loop of sigmoid colon and altered colonic motility. Rectal prolapse must be differentiated from hemorrhoids, anal fissure and perianal abscess, anal cancer and condylomata acuminata. Rectal prolapse cannot be corrected nonoperatively. It has two different surgery approaches: abdominal surgery (lower recurrence rate and better functional outcomes) or perineal surgery (in elderly patients, significant comorbidities, high risk patients for general anesthesia, previous pelvic surgery or radiation).

In medieval times, scientists suggested that rectal prolapse could be prevented by using a scar (through burning the anus) or by using a stick. In the 20th century, rectal prolapse was studied scientifically and Nowadays there are various surgical methods for rectal prolapse treatment.

Rectal prolapse may be classified into complete and incomplete subtypes based on disease extension or be classified into pediatric and adult subtypes based on age of presentation. Also, it may be classified by disease grading.

Rectal prolapse starts from rectal intussusception, followed by external mucosal prolapse, and eventually a full protrusion of all layers of the rectum. Rectal prolapse is associated with several coexisting anatomic abnormalities including diastasis of the levator ani, abnormally deep cul-de-sac and redundant sigmoid colon.

Common causes of rectal prolapse include rectal denervation, perineal nerve injury, kinking of the redundant loop of sigmoid colon, loss of rectal compliance and altered colonic motility.

Rectal prolapse must be differentiated from other diseases that cause anal discomfort such as hemorrhoids, anal fissure and perianal abscess, anal cancer and condylomata acuminata.

The prevalence of rectal prolapse is relatively low. It occurs more frequently in the elderly and women.

Common risk factors in the development of rectal prolapse include advanced age, female gender, obstetric history, hormonal status and long term increased intra-abdominal pressure.

Hemorrhage occurs frequently if the prolapsed rectum is left unreduced. If rectal prolapse is persistent for a long time, urological impairments may be associated.

Common complications of rectal prolapse include fecal incontinence, constipation and rectal incarceration or even strangulation.

All women with prolapse can be treated and their symptoms improved, even if not completely resolved.

Most common symptoms of rectal prolapse include pain, fullness or a lump inside rectum, fecal incontinence, constipation and bloody and/or mucous rectal discharge.

Patients with rectal prolapse usually have rectal mass, skin excoriation or irritation of anus in physical examination.

There are no diagnostic lab findings associated with rectal prolapse.

• Based on the radiological characteristics, rectal prolapse may be graded as internal rectal prolapse (recto-rectal intussusception and recto-anal intussusception) or external rectal prolapse (exteriorized rectal prolapse).
• Dynamic pelvic MRI can evaluate pelvic floor anatomy, dynamic motion and rectal evacuation.
• Demonstration of anal sphincter defect by 3D-endoanal ultrasonography is helpful for sphincter reconstruction.

In rectal prolapse, fluoroscopic defecography, MRI defecography, or balloon expulsion testing may be helpful for diagnosis. Pre-operatively, all patients should undergo anoscopy and colonoscopy.

Rectal prolapse cannot be corrected nonoperatively, although some of the symptoms associated with this condition can be reduced medically. Nonoperative treatments of rectal prolapse such as medications reducing edema, correction of constipation, exercises straining the perineum are helpful.

Rectal prolapse surgery has two different approaches: Abdominal surgery (lower recurrence rate and better functional outcomes) or perineal surgery (in elderly patients, significant comorbidities, high risk patients for general anesthesia, previous pelvic surgery or radiation).

• Primary prevention: Constipation is one of the most common cause of rectal prolapse. Sufficient fiber intake and pharmacological treatment of constipation (laxatives) can prevent developing rectal prolapse
• Secondary prevention: Ultimate goal of treatment is to prevent progression of prolapse to incarceration or strangulation and to restore defecation function.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shaghayegh Habibi, M.D.[2]

In medieval times, scientists suggested that rectal prolapse could be prevented by using a scar (through burning the anus) or by using a stick. In the 20th century, rectal prolapse was studied scientifically and Nowadays there are various surgical methods for rectal prolapse treatment.

• Historically, rectal prolapse was described on papyrus in 1500 BC.
• In 1912, Moschowitz described the anatomical basis for a rectal prolapse (the anterior rectovaginal pouch is abnormally deep). They suggested that in rectal prolpase anterior rectal wall is herniated to the defect of the pelvic fascia.
• In 1968, Broden and Snallmann suggested that rectal intussusception is the cause of rectal prolapse.
• In 1970, Theuerkauf et al. confirmed this theory that intussusception cause rectal prolapse by using radiographs.
• In 1977, they confirmed perineal nerve injury in patients with rectal prolapse by performed biopsies of the pelvic floor in patients undergoing posterior repair.^[1][2]

Hippocrates suggested a treatment for rectal prolapse; the patients could be treated by hanging them to a tree upside down, applying sodium hydroxide to the mucosa, and fixing for 3 days. In medieval times, scientists suggested that rectal prolapse could be prevented by using a scar (through burning the anus) or by using a stick. In the 20th century, rectal prolapse was studied scientifically and nowadays there are various surgical methods for rectal prolapse treatment.^[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shaghayegh Habibi, M.D.[2]

Rectal prolapse may be classified into complete and incomplete subtypes based on disease extension or be classified into pediatric and adult subtypes based on age of presentation. Also it may be classified by disease grading.

Rectal prolapse is graded into four types: ^[1]

• Grade 1: up to anal verge
• Grade 2: prolapse outside the anus but reduces spontaneously
• Grade 3: prolapses outside the anus but can be manually reduced
• Grade 4: prolapse can not be reduced manually

Rectal prolapse is classified by disease extension into two subtypes:^[2]

• Complete prolapse: a protrusion of the entire layer of the rectum to the outside of the anus.

• Incomplete prolapse: the protruding rectal wall is limited to the inside of the anal canal. Mucosal prolapse is not a protrusion of the whole layer of the rectal wall, but only the anal mucosa.

Rectal prolapse may be classified by age of presentation into two subtypes:^[3]

• Pediatric type: which usually presents with mucosal prolapse only

• Adult type: showing full-thickness protrusion

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shaghayegh Habibi, M.D.[2]

Rectal prolapse starts from rectal intussusception, followed by external mucosal prolapse, and eventually a full protrusion of all layers of the rectum. Rectal prolapse is associated with several coexisting anatomic abnormalities including diastasis of the levator ani, abnormally deep cul-de-sac and redundant sigmoid colon.

The evolution of rectal prolapse starts from excessive straining over time that leads to the weakness of pelvic floor muscles and connective tissue injury (including nerve injury and neuropathy of the pelvic floor). These lead to rectal intussusception initially, followed by external mucosal prolapse, and eventually a full protrusion of all layers of the rectal wall through the anus.^[1]

The shearing forces exerted by the passage of flatus or fecal matter push and pull the obstructing mucosal folds, thereby gradually involving and progressively traumatizing the deeper layers of the rectal wall and initiating a vicious circle of obstruction and prolapse formation.^[2]

Rectal prolapse is associated with several coexisting anatomic abnormalities:^[3][4]

• Diastasis of the levator ani
• Abnormally deep cul-de-sac of Douglas
• Redundant sigmoid colon
• Patulous anal sphincter
• Loss or attenuation of the rectal sacral attachments

The gross pathology of rectal prolapse includes:

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shaghayegh Habibi, M.D.[2]

More common causes of rectal prolapse include rectal denervation, perineal nerve injury, kinking of the redundant loop of sigmoid colon, altered colonic motility and less common causes include relaxation of lateral ligament and pelvic floor muscles and loss of rectal compliance.

More common causes of rectal prolapse include:^[1][2]

• Rectal denervation
• Perineal nerve injury (due to descent of the pelvic floor, viginal delivery and excessive straining during defection)
• Kinking of the redundant loop of sigmoid colon at the junction between the sigmoid colon and the rectum
• Altered colonic motility
• Anismus (paradoxical contractions of the pelvic floor)^[3][4]

Less common causes of rectal prolapse include:^[1][2]

• Relaxation of the lateral ligaments
• Relaxation of the pelvic floor muscles
• Loss of rectal compliance as a result of mesh placement

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Rectal prolapse must be differentiated from other diseases that cause anal discomfort such as hemorrhoids, anal fissure and perianal abscess, anal cancer and condylomata acuminata.

Recatal prolapse must be differentiated from other diseases that cause anal discomfort and pain with defecation such as hemorrhoids, anal fissure and perianal abscess.

Disease	History	Physical exam findings	Sample image
Hemorrhoids	External hemorrhoids External hemorrhoids are painful as the skin below the punctate line is sensitive to pain.[1] Blood clots may form in external hemorrhoids. Thrombosed external hemorrhoids cause bleeding, painful swelling, or a hard lump around the anus. When the blood clot dissolves, extra skin is left behind. This skin can become irritated or itch. Excessive straining, rubbing, or cleaning around the anus may make symptoms, such as itching and irritation, worse. Internal hemorrhoids The most common symptom of internal hemorrhoids is bright red blood on stool, on toilet paper, or in the toilet bowl after a bowel movement. Internal hemorrhoids that are not prolapsed are usually not painful. Prolapsed hemorrhoids often cause pain, discomfort, and anal itching	Skin examination Inspection of the anal verge may show scratch marks and skin tags. Inspection also may reveal external hemorrhoids or prolapsed internal hemorrhoids. Digital rectal examination Digital rectal examination reveals the size and location of hemorrhoids. Thrombosed hemorrhoids are tender to palpation. Internal hemorrhoids are not palpable by digital rectal examination and the use of anoscope is mandatory.
Anal fissure	Anal fissure usually presents with tearing pain with every bowel movement.[1] Pain usually lasts for minutes to hours after every bowel movement. Patient is typically afraid of going to the bathroom to avoid the pain, which leads to a viscious cycle. The fissure worsens the constipation and the constipation (hard stool) aggravates the fissure. About two-thirds of the patients present with bright red blood streaks on toilet papers or on the surface of stools. May be accompanied by pruritis and discharge.	Most fissures occur in the posterior midline of the anal canal.[2] Skin tags in the perianal area may accompany chronic anal fissures.
Rectal prolapse	Rectal prolapse most commonly occurs in multiparous females over 40 years old.[3] Appears as a progressive mass protrusion from the anus. The protrusion first appears with straining and defecation, then progresses to the degree when it is no longer replaced back. It presents with abdominal discomfort and incomplete defecation. Fecal incontinence and anal discharge. Pain is not usually present.	Mass protruding from the anus.[4] Concentric mucosal rings are characteristic of rectal prolapse.
Perianal abscess	Perianal abscess presents with severe, continuous, dull, aching pain in the perianal area.[5] Pain is exacerbated with bowel movements, but is not exclusive to it. Constipation due to fear of bowel movements. Fever, headache, and chills may accompany the pain. If the abscess starts to drain, discharge of purulent or bloody fluid may be noticed.	Flatulent, erythematous, and tender area of skin overlying the abscess. If abscess is deep, tenderness is elicited with digital rectal examination.
Anal cancer	Rectal bleeding is the most common presentation.[6] Mass sensation in the anus. Mucoid discharge may occur. Patient may give a history of anal condyloma (especially homosexual men).[7] Fecal incontinence.	On digital rectal examination, solid hemorrhagic mass that is firmly fixed to the surrounding structures is noted. Femoral and inguinal lymph nodes may show lymphadenopathy secondary to spread of cancer.
Condylomata acuminata	Patient may give a history of unprotected anal sex with an infected partner. Having multiple sexual partners is a risk factor and should be investigated.[8] Condyloma acuminata presents with painless warts that vary in size, shape, and color. Pruritis and discharge may accompany the warts.	Anal condyloma acuminata may be accompanied by cervical, vaginal, or even ororpharyngeal warts, so the patient should be examined thoroughly.[9]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shaghayegh Habibi, M.D.[2]

The prevalence of rectal prolapse is relatively low. It occurs more frequently in the elderly and women.

Rectal prolapse is estimated to occur in ≈0.5% of the general population.^[1]

• Rectal prolapse can occur in all ages but commonly affects elderly women in the seventh to eighth decade of life. ^[2]

• There is no racial predilection to rectal prolapse.

• Females are more commonly affected by rectal prolapse than male. The female to male ratio is approximately 9 to 1.^[3]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shaghayegh Habibi, M.D.[2]

More common risk factors in the development of rectal prolapse include advanced age, female gender, obstetric history and long term increased intra-abdominal pressure. Less common causes are change in hormonal status and systemic connective tissue disease.

Common risk factors in the development of internal rectal prolapse include:^[1][2]

• Advanced age
• Female gender
• Obstetrical history (vaginal delivery, previous obstetrical trauma)
• Increase intra-abdominal pressure such as straining, constipation or chronic coughing

Less common risk factors in the development of rectal prolapse include:^[1][2]

• Hormonal status (onset of menopause)
• Systemic connective tissue diseases (dysfunction of the elastic fibers of the rectal wall)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shaghayegh Habibi, M.D.[2]

There is insufficient evidence to recommend routine screening for rectal prolapse.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shaghayegh Habibi, M.D.[2]

• Hemorrhage occurs frequently if the prolapsed rectum is left unreduced. If rectal prolapse is persistent for a long time, urological impairments may be associated.
• Common complications of rectal prolapse include fecal incontinence, constipation and rectal incarceration or even strangulation.
• All women with prolapse can be treated and their symptoms improved, even if not completely resolved.

Allowing rectal prolapse to continue untreated beyond 4 years may lead to higher rates of subsequent rectal prolapse recurrence, secondary to a weakened pelvic floor. ^[1] In addition, Hemorrhage occurs frequently if the prolapsed rectum is left unreduced. If rectal prolapse is persistent for a long time, urological impairments (bladder stones or urethral stricture) may be associated.^[2]

Common complications of rectal prolapse include:^[1][3][4]

• Fecal incontinence (50-75%)
• Constipation (25-50%)
• Rectal incarceration or even strangulation

All women with prolapse can be treated and their symptoms improved, even if not completely resolved.^[5]

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