Rectal prolapse

2025-10-16T20:40:03Z

2600:100C:B29C:5A4C:0:10:1888:BD01:

{{short description|Protrusion of the walls of the rectum outside the body}}
{{Infobox medical condition (new)
| name = Rectal prolapse
| synonyms = Complete rectal prolapse, external rectal prolapse
| image = Full thickness rectal prolapse & mucosal prolapse..jpg
| caption = '''A'''. full thickness external rectal prolapse, and '''B'''. [[mucosal prolapse]]. Note circumferential arrangement of folds in full thickness prolapse compared to radial folds in mucosal prolapse.<ref>{{cite journal | vauthors = Hammond K, Beck DE, Margolin DA, Whitlow CB, Timmcke AE, Hicks TC | title = Rectal prolapse: a 10-year experience | journal = The Ochsner Journal | volume = 7 | issue = 1 | pages = 24–32 | date = Spring 2007 | pmid = 21603476 | pmc = 3096348 }}</ref>
| field = [[General surgery]]
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A '''rectal prolapse''' occurs when walls of the [[rectum]] have [[wikt:prolapse|prolapsed]] to such a degree that they protrude out of the [[anus]] and are visible outside the body.<ref>{{Cite book|title=Rectal Prolapse: Diagnosis and Clinical Management | vauthors = Altomare DF, Pucciani F |publisher=Springer |year=2007 |page=12 |isbn=978-88-470-0683-6}}</ref> However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.<ref name="ASCRS: Prolapse and Intussusception">{{cite web|vauthors=Kim DG|title=ASCRS core subjects: Prolapse andIntussusception|url=http://www.fascrs.org/physicians/education/core_subject/2000/prolapse_and_intussusception/|publisher=ASCRS|access-date=14 October 2012|archive-date=27 February 2021|archive-url=https://web.archive.org/web/20210227041506/https://fascrs.org/physicians/education/core_subject/2000/prolapse_and_intussusception/}}</ref><ref name="Contemporary surgery online">{{cite web|vauthors=Kiran RP|title=How stapled resection can treat rectal prolapse|url=http://www.contemporarysurgery.com/inside.asp?ArtID=6287|publisher=Contemporary surgery online|access-date=14 October 2012|archive-date=7 May 2013|archive-url=https://web.archive.org/web/20130507105202/http://www.contemporarysurgery.com/inside.asp?ArtID=6287}}</ref>

Rectal prolapse may occur without any symptoms, but depending upon the nature of the prolapse there may be [[rectal discharge|mucous discharge]] (mucus coming from the anus), [[rectal bleeding]], degrees of [[fecal incontinence]], and [[obstructed defecation]] symptoms.<ref name="ASCRS Prolapse, Intussusception, SRUS" />

Rectal prolapse is generally diagnosed more commonly in elderly women, although it may occur at any age and any sex. It is very rarely life-threatening, but the symptoms can be debilitating if left untreated.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> Most external prolapse cases can be treated successfully, often with a surgical procedure. Internal prolapses are traditionally harder to treat and surgery may not be suitable for many patients.
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==Classification==
[[File:Internalrectalintussusceptionexternalrectalprolapse.JPG|424px|thumbnail| '''A'''. Internal rectal intussusception. '''B'''. External (complete) rectal prolapse]]
The different kinds of rectal prolapse can be difficult to grasp, as different definitions are used and some recognize certain subtypes and not others do not. Essentially, rectal prolapses may be:
* '''full thickness''' (complete), where all the layers of the rectal wall prolapse, or involve the '''mucosal''' layer only (partial)
* '''external''' if they protrude from the anus and are visible externally, or '''internal''' if they do not
* '''circumferential''', where the whole circumference of the rectal wall prolapses, or '''segmental''' if only parts of the circumference of the rectal wall prolapse
* present at rest, or occurring during straining.

'''External (complete) rectal prolapse''' (rectal procidentia, full thickness rectal prolapse, overt rectal prolapse<ref name="Gouvas2015">{{cite journal |last1=Gouvas |first1=N |last2=Georgiou |first2=PA |last3=Agalianos |first3=C |last4=Tan |first4=E |last5=Tekkis |first5=P |last6=Dervenis |first6=C |last7=Xynos |first7=E |title=Ventral colporectopexy for overt rectal prolapse and obstructed defaecation syndrome: a systematic review. |journal=Colorectal Disease |date=February 2015 |volume=17 |issue=2 |pages=O34-46 |doi=10.1111/codi.12751 |pmid=25186920}}</ref>) is
a full thickness, circumferential, true intussusception of the rectal wall which protrudes from the anus and is visible externally.<ref name=Samson2015>{{cite journal | vauthors = Tou S, Brown SR, Nelson RL | title = Surgery for complete (full-thickness) rectal prolapse in adults | journal = The Cochrane Database of Systematic Reviews | issue = 11 | article-number = CD001758 | date = November 2015 | volume = 2015 | pmid = 26599079 | pmc = 7073406 | doi = 10.1002/14651858.CD001758.pub3 }}</ref><ref>Altomare, Pucciani (2007) p.14</ref>

'''[[Internal rectal intussusception]]''' (occult rectal prolapse, internal procidentia) can be defined as a funnel shaped infolding of the upper rectal (or lower [[sigmoid colon|sigmoid]]) wall that can occur during [[defecation]].<ref name="Coloproctology">{{cite book| vauthors = Zbar AP, Wexner SD |title=Coloproctology |url= https://archive.org/details/coloproctology00zbar|url-access=limited|year=2010|publisher=Springer|location=New York|isbn=978-1-84882-755-4|page=[https://archive.org/details/coloproctology00zbar/page/n149 143]}}</ref> This infolding is perhaps best visualised as folding a sock inside out,<ref name="ASCRS textbook" /> creating "a tube within a tube".<ref name="Obstructed defecation web">{{cite web| vauthors = Marzouk D |title=Internal Rectal Intussusception [Internal Rectal Prolapse]|url=http://www.obstructed-defaecation.com/Internal%20rectal%20intussusception.html|access-date=8 July 2012}}</ref> Another definition is "where the rectum collapses but does not exit the anus".<ref>{{cite book|title=Advanced therapy in gastroenterology and liver disease | vauthors = Bayless TM, Diehl A | publisher=PMPH-USA |year=2005 |page=521 |isbn=978-1-55009-248-6}}</ref> Many sources differentiate between internal rectal intussusception and mucosal prolapse, implying that the former is a full thickness prolapse of rectal wall. However, a publication by the [[American Society of Colon and Rectal Surgeons]] stated that internal rectal intussusception involved the [[mucosa]]l and [[submucosa]]l layers separating from the underlying [[muscularis mucosa]] layer attachments, resulting in the separated portion of rectal lining "sliding" down.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> This may signify that authors use the terms internal rectal prolapse and internal mucosal prolapse to describe the same phenomena.

'''Mucosal prolapse''' (partial rectal mucosal prolapse)<ref name="Gupta 2006">{{cite journal | vauthors = Gupta PJ | title = Treatment of rectal mucosal prolapse with radiofrequency coagulation and plication--a new surgical technique | journal = Scandinavian Journal of Surgery | volume = 95 | issue = 3 | pages = 166–171 | year = 2006 | pmid = 17066611 | doi = 10.1177/145749690609500307 | s2cid = 23227666 }}</ref> refers to prolapse of the loosening of the submucosal attachments to the muscularis propria of the distal rectummucosal layer of the rectal wall. Most sources define mucosal prolapse as an external, segmental prolapse which is easily confused with prolapsed (3rd or 4th degree) [[hemorrhoid]]s (piles).<ref name="ASCRS textbook">{{cite book| vauthors = Wolff BG, Fleshman JW, Beck DE, Pemberton JH, Wexner SD, Church JM, Garcia-Aguilar J, Roberts PL, Saclarides TJ, Stamos MJ |title=The ASCRS textbook of colon and rectal surgery|year=2007|publisher=Springer|location=New York|isbn=978-0-387-24846-2|page=674}}</ref> However, both internal mucosal prolapse (see below) and circumferential mucosal prolapse are described by some.<ref name="Gupta 2006" /> Others do not consider mucosal prolapse a true form of rectal prolapse.<ref name="Pittsburgh Colorectal Surgeons">{{cite web|title=Rectal Prolapse on Pittsburgh Colorectal Surgeons|url=http://colorectalsurgerypittsburgh.com/conditions/prolapse.html|publisher=West Penn Allegheny Health System|access-date=15 October 2012|archive-date=28 October 2013|archive-url=https://web.archive.org/web/20131028163444/http://colorectalsurgerypittsburgh.com/conditions/prolapse.html}}</ref>

'''Internal mucosal prolapse''' (rectal internal mucosal prolapse, RIMP) refers to prolapse of the mucosal layer of the rectal wall which does not protrude externally. There is some controversy surrounding this condition as to its relationship with hemorrhoidal disease, or whether it is a separate entity.<ref name="Gaj 2005">{{cite journal | vauthors = Gaj F, Trecca A | title = Hemorrhoids and rectal internal mucosal prolapse: one or two conditions? A national survey | journal = Techniques in Coloproctology | volume = 9 | issue = 2 | pages = 163–165 | date = July 2005 | pmid = 16007353 | doi = 10.1007/s10151-005-0219-0 | hdl = 11573/576276 | s2cid = 19519510 }}</ref> The term "mucosal hemorrhoidal prolapse" is also used.<ref name="Guanziroli 2011">{{cite journal | vauthors = Guanziroli E, Veraldi S, Guttadauro A, Rizzitelli G, Frassani S | title = Persistent perianal dermatitis associated with mucosal hemorrhoidal prolapse | journal = Dermatitis | volume = 22 | issue = 4 | pages = 227–229 | date = Aug 1, 2011 | doi = 10.2310/6620.2011.11017 | pmid = 21781642 | hdl = 10281/62853 | hdl-access = free }}</ref>

'''Solitary rectal ulcer syndrome''' (SRUS, solitary rectal ulcer, SRU) occurs with internal rectal intussusception and is part of the spectrum of rectal prolapse conditions.<ref name="ASCRS Prolapse, Intussusception, SRUS">{{cite web| vauthors = Madhulika G, Varma MD |title=Prolapse, Intussusception, & SRUS|url=http://www.fascrs.org/physicians/education/core_subjects/2008/prolapse_intussusception_srus/|publisher=ASCRS|access-date=13 October 2012 |archive-url=https://web.archive.org/web/20131214030448/http://www.fascrs.org/physicians/education/core_subjects/2008/prolapse_intussusception_srus/|archive-date=14 December 2013}}</ref> It describes [[ulceration]] of the rectal lining caused by repeated frictional damage as the internal intussusception is forced into the anal canal during straining. SRUS can be considered a consequence of internal intussusception, which can be demonstrated in 94% of cases.

'''Mucosal prolapse syndrome''' (MPS) is recognized by some. It includes solitary rectal ulcer syndrome, rectal prolapse, proctitis cystica profunda, and inflammatory polyps.<ref name=nonaka>{{cite journal | vauthors = Nonaka T, Inamori M, Kessoku T, Ogawa Y, Yanagisawa S, Shiba T, Sakaguchi T, Gotoh E, Maeda S, Nakajima A, Atsukawa K, Takahasi H, Akasaka Y | display-authors = 6 | title = A case of rectal cancer arising from long-standing prolapsed mucosa of the rectum | journal = Internal Medicine | volume = 50 | issue = 21 | pages = 2569–2573 | year = 2011 | pmid = 22041358 | doi = 10.2169/internalmedicine.50.5924 | doi-access = free }}</ref><ref name=abid>{{cite journal | vauthors = Abid S, Khawaja A, Bhimani SA, Ahmad Z, Hamid S, Jafri W | title = The clinical, endoscopic and histological spectrum of the solitary rectal ulcer syndrome: a single-center experience of 116 cases | journal = BMC Gastroenterology | volume = 12 | issue = 1 | page = 72 | date = June 2012 | pmid = 22697798 | pmc = 3444426 | doi = 10.1186/1471-230X-12-72 | doi-access = free }}</ref> It is classified as a chronic benign inflammatory disorder.

Rectal prolapse and internal rectal intussusception has been classified according to the size of the prolapsed section of rectum, a function of rectal mobility from the sacrum and infolding of the rectum. This classification also takes into account sphincter relaxation:<ref name="Fleshman 1989">{{cite journal | vauthors = Fleshman JW, Kodner IJ, Fry RD | title = Internal intussusception of the rectum: a changing perspective | journal = The Netherlands Journal of Surgery | volume = 41 | issue = 6 | pages = 145–148 | date = December 1989 | pmid = 2694021 }}</ref>
* Grade I: nonrelaxation of the sphincter mechanism ([[anismus]])
* Grade II: mild intussusception
* Grade III: moderate intussusception
* Grade IV: severe intussusception
* Grade V: rectal prolapse

Rectal internal mucosal prolapse has been graded according to the level of descent of the intussusceptum, which was predictive of symptom severity:<ref name="Pescatori 1999">{{cite journal | vauthors = Pescatori M, Quondamcarlo C | title = A new grading of rectal internal mucosal prolapse and its correlation with diagnosis and treatment | journal = International Journal of Colorectal Disease | volume = 14 | issue = 4–5 | pages = 245–249 | date = November 1999 | pmid = 10647634 | doi = 10.1007/s003840050218 | s2cid = 21170092 }}</ref>
* first degree prolapse is detectable below the anorectal ring on straining
* second degree when it reached the dentate line
* third degree when it reached the anal verge

[[File:Internal rectal intussusception.jpg|framed|right|A. Normal anatomy: (r) rectum, (a) anal canal <br /> B. Recto-rectal intussusception <br /> C. Recto-anal intussusception]]
The most widely used classification of internal rectal prolapse is according to the height on the rectal/sigmoid wall from which they originate and by whether the intussusceptum remains within the rectum or extends into the [[anal canal]]. The height of intussusception from the anal canal is usually estimated by [[defecography]].<ref name="Obstructed defecation web" />

'''Recto-rectal (high) intussusception''' (intra-rectal intussusception) is where the intussusception starts in the rectum, does not protrude into the anal canal, but stays within the rectum. (i.e. the intussusceptum originates in the rectum and does not extend into the anal canal. The intussuscipiens includes rectal lumen distal to the intussusceptum only). These are usually intussusceptions that originate in the upper rectum or lower [[sigmoid colon|sigmoid]].<ref name="Obstructed defecation web" />

'''Recto-anal (low) intussusception''' (intra-anal intussusception) is where the intussusception starts in the rectum and protrudes into the anal canal (i.e. the intussusceptum originates in the rectum, and the intussuscipiens includes part of the anal canal)

An Anatomico-Functional Classification of internal rectal intussusception has been described,<ref name="Obstructed defecation web" /> with the argument that other factors apart from the height of intussusception above the anal canal appear to be important to predict symptomology. The parameters of this classification are anatomic descent, diameter of intussuscepted bowel, associated rectal hyposensitivity and associated delayed colonic transit:
* Type 1: Internal recto-rectal intussusception
** Type 1W Wide lumen
** Type 1N Narrowed lumen
* Type 2: Internal recto-anal intussusception
** Type 2W Wide Lumen
** Type 2N Narrowed lumen
** Type 2M Narrowed internal lumen with associated rectal hyposensitivity or early megarectum
* Type 3: Internal-external recto-anal intussusception

==Diagnosis==

===Medical history===

Patients may have associated gynecological conditions which may require multidisciplinary management.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> History of [[constipation]] is important because some of the operations may worsen constipation. Fecal incontinence may also influence the choice of management.

===Physical examination===
Rectal prolapse may be confused easily with prolapsing hemorrhoids.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> Mucosal prolapse also differs from prolapsing (3rd or 4th degree) hemorrhoids, where there is a segmental prolapse of the hemorrhoidal tissues at the 3, 7 and 11 o'clock positions.<ref name="Gupta 2006" /> Mucosal prolapse can be differentiated from a full thickness external rectal prolapse (a complete rectal prolapse) by the orientation of the folds (furrows) in the prolapsed section. In full thickness rectal prolapse, these folds run circumferential. In mucosal prolapse, these folds are radially.<ref name="ASCRS textbook" /> The folds in mucosal prolapse are usually associated with internal hemorrhoids. Furthermore, in rectal prolapse, there is a sulcus present between the prolapsed bowel and the anal verge, whereas in hemorrhoidal disease there is no sulcus.<ref name="ASCRS: Prolapse and Intussusception" /> Prolapsed, incarcerated hemorrhoids are extremely painful, whereas as long as a rectal prolapse is not strangulated, it gives little pain and is easy to reduce.<ref name="ASCRS Prolapse, Intussusception, SRUS" />

The prolapse may be obvious, or it may require straining and squatting to produce it.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> The anus is usually patulous, (loose, open) and has reduced resting and squeeze pressures.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> Sometimes it is necessary to observe the patient while they strain on a toilet to see the prolapse happen<ref name="Yamada GI textbook" /> (the perineum can be seen with a mirror or by placing an endoscope in the bowl of the toilet).<ref name="ASCRS textbook" /> A phosphate enema may need to be used to induce straining.<ref name="ASCRS: Prolapse and Intussusception" />

The perianal skin may be macerated (softening and whitening of skin that is kept constantly wet) and show [[excoriation]].<ref name="ASCRS textbook" />

===Proctoscopy/sigmoidoscopy/colonoscopy===
These may reveal congestion and [[edema]] (swelling) of the distal rectal mucosa,<ref name="Yamada GI textbook" /> and in 10–15% of cases there may be a solitary rectal ulcer on the anterior rectal wall.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> Localized inflammation or ulceration can be biopsied and may lead to a diagnosis of SRUS or colitis cystica profunda.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> Rarely, a [[neoplasia|neoplasm]] (tumour) may form on the leading edge of the intussusceptum. In addition, patients are frequently elderly and therefore have increased incidence of [[colorectal cancer]]. Full length colonoscopy is usually carried out in adults prior to any surgical intervention.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> These investigations may be used with contrast media ([[barium enema]]) which may show the associated mucosal abnormalities.<ref name="ASCRS textbook" />

===Videodefecography===
This investigation is used to diagnose internal intussusception, or demonstrate a suspected external prolapse that could not be produced during the examination.<ref name="ASCRS: Prolapse and Intussusception" /> It is usually not necessary with obvious external rectal prolapse.<ref name="ASCRS textbook" /> [[Defecography]] may demonstrate associated conditions like [[cystocele]], vaginal vault prolapse or [[enterocele]].<ref name="ASCRS Prolapse, Intussusception, SRUS" />

===Colonic transit studies===
[[Colonic transit studies]] may be used to rule out [[colonic inertia]] if there is a history of severe constipation.<ref name="ASCRS: Prolapse and Intussusception" /><ref name="ASCRS Prolapse, Intussusception, SRUS" /> Continent prolapse patients with slow transit constipation, and who are fit for surgery may benefit from subtotal colectomy with rectopexy.<ref name="ASCRS Prolapse, Intussusception, SRUS" />

===Anorectal manometry===
This investigation objectively documents the functional status of the sphincters. However, the clinical significance of the findings are disputed by some.<ref name="ASCRS textbook" /> It may be used to assess for pelvic floor dyssenergia,<ref name="ASCRS Prolapse, Intussusception, SRUS" /> ([[anismus]] is a contraindication for certain surgeries, e.g. [[Stapled trans-anal rectal resection]]), and these patients may benefit from post-operative [[biofeedback]] therapy. Decreased squeeze and resting pressures are usually the findings, and this may predate the development of the prolapse.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> Resting tone is usually preserved in patients with mucosal prolapse.<ref name="Yamada GI textbook" /> In patients with reduced resting pressure, levatorplasty may be combined with prolapse repair to further improve continence.<ref name="ASCRS textbook" />

===Anal electromyography/pudendal nerve testing===
It may be used to evaluate incontinence, but there is disagreement about what relevance the results may show, as rarely do they mandate a change of surgical plan.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> There may be denervation of striated musculature on the electromyogram.<ref name="Yamada GI textbook" /> Increased nerve conduction periods (nerve damage), this may be significant in predicting post-operative incontinence.<ref name="ASCRS Prolapse, Intussusception, SRUS" />

==Complete rectal prolapse==
[[File:Rectal prolaps.jpg|thumbnail|right|A severe example of complete (external) rectal prolapse. Note circumferential arrangement of mucosal folds.]]

Rectal prolapse is a "falling down" of the rectum so that it is visible externally. The appearance is of a reddened, proboscis-like object through the anal sphincters. Patients find the condition embarrassing.<ref name="ASCRS textbook" /> The symptoms can be socially debilitating without treatment,<ref name="ASCRS Prolapse, Intussusception, SRUS" /> but it is rarely life-threatening.<ref name="ASCRS textbook" />

The true incidence of rectal prolapse is unknown, but it is thought to be uncommon. As most affected people are elderly, the condition is generally under-reported.<ref>{{Cite news |title=Professional Guide to Diseases |publisher=Lippincott Williams & Wilkins |year=2008 |page=[https://archive.org/details/isbn_9780781778992/page/294 294] |isbn=978-0-7817-7899-2 |url-access=registration |url=https://archive.org/details/isbn_9780781778992/page/294 }}</ref> It may occur at any age, even in children,<ref name="pmid17194301">{{cite journal | vauthors = Saleem MM, Al-Momani H | title = Acute scrotum as a complication of Thiersch operation for rectal prolapse in a child | journal = BMC Surgery | volume = 6 | page = 19 | date = December 2006 | pmid = 17194301 | pmc = 1785387 | doi = 10.1186/1471-2482-6-19 | doi-access = free }}</ref> but there is peak onset in the fourth and seventh decades.<ref name="ASCRS: Prolapse and Intussusception" /> Women over 50 are six times more likely to develop rectal prolapse than men. It is rare in men over 45 and in women under 20.<ref name="Yamada GI textbook">{{cite book| vauthors = Yamada T, Alpers DH, Kalloo AN, Kaplowitz N, Owyang C, Powell DW |title=Textbook of gastroenterology|year=2009|publisher=Blackwell Pub.|location=Chichester, West Sussex|isbn=978-1-4051-6911-0|page=1725|edition=5th}}</ref> When males are affected, they tend to be young and report significant bowel function symptoms, especially [[obstructed defecation]],<ref name="ASCRS Prolapse, Intussusception, SRUS" /> or have a predisposing disorder (e.g., congenital [[anal atresia]]).<ref name="ASCRS textbook" /> When children are affected, they are usually under the age of 3.

35% of women with rectal prolapse have never had children,<ref name="ASCRS Prolapse, Intussusception, SRUS" /> suggesting that pregnancy and labor are not significant factors. Anatomical differences such as the wider pelvic outlet in females may explain the skewed gender distribution.<ref name="ASCRS textbook" />

Associated conditions, especially in younger patients include autism, developmental delay syndromes, and psychiatric conditions requiring several medications.<ref name="ASCRS Prolapse, Intussusception, SRUS" />

===Signs and symptoms===
Signs and symptoms include:
* history of a protruding mass.<ref name="ASCRS: Prolapse and Intussusception" />
* degrees of [[fecal incontinence]], (50–80% of patients)<ref name="ASCRS: Prolapse and Intussusception" /><ref name="ASCRS Prolapse, Intussusception, SRUS" /> which may simply present as a [[rectal discharge|mucous discharge]].<ref name="ASCRS: Prolapse and Intussusception" />
* [[constipation]]<ref name="ASCRS Prolapse, Intussusception, SRUS" /> (20–50% of patients)<ref name="ASCRS Prolapse, Intussusception, SRUS" /> also described as [[Rectal tenesmus|tenesmus]] (a sensation of incomplete evacuation of stool) and [[obstructed defecation]].<ref name="ASCRS: Prolapse and Intussusception" />
* a feeling of bearing down.<ref name="Yamada GI textbook" />
* [[rectal bleeding]]<ref name="ASCRS: Prolapse and Intussusception" />
* [[diarrhea]]<ref name="Yamada GI textbook" /> and erratic bowel habits.

Initially, the mass may protrude through the anal canal only during defecation and straining, and spontaneously return afterwards. Later, the mass may have to be pushed back in following defecation. This may progress to a chronically prolapsed and severe condition, defined as spontaneous prolapse that is difficult to keep inside, and occurs with walking, prolonged standing,<ref name="ASCRS Prolapse, Intussusception, SRUS" /> coughing or sneezing ([[Valsalva]] maneuvers).<ref name="ASCRS: Prolapse and Intussusception" /> A chronically prolapsed rectal tissue may undergo pathological changes such as thickening, ulceration and bleeding.<ref name="ASCRS Prolapse, Intussusception, SRUS" />

If the prolapse becomes trapped externally outside the anal sphincters, it may become strangulated and there is a risk of perforation.<ref name="Yamada GI textbook" /> This may require an urgent surgical operation if the prolapse cannot be manually reduced.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> Applying granulated sugar on the exposed rectal tissue can reduce the [[edema]] (swelling) and facilitate this.<ref name="Yamada GI textbook" />

===Cause===
[[File:Rectal prolapse - low mag.jpg|thumb|right|[[Micrograph]] showing a rectal wall with changes seen in rectal prolapse. There is a marked increase of fibrous tissue in the submucosa and fibrous tissue +/- smooth muscle [[hyperplasia]] in the [[lamina propria]]. [[H&E stain]]]]

The precise cause is unknown,<ref name="ASCRS: Prolapse and Intussusception" /><ref name="ASCRS textbook" /><ref name=Coloproctology /> and has been much debated.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> In 1912 Moschcowitz proposed that rectal prolapse was a sliding hernia through a pelvic [[fascia]]l defect.<ref name="ASCRS textbook" />

This theory was based on the observation that rectal prolapse patients have a mobile and unsupported pelvic floor, and a hernia sac of peritoneum from the Pouch of Douglas and rectal wall can be seen.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> Other adjacent structures can sometimes be seen in addition to the rectal prolapse.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> Although a [[pouch of Douglas]] [[hernia]], originating in the cul de sac of Douglas, may protrude from the anus (via the anterior rectal wall),<ref name="Yamada GI textbook" /> this is a different situation from rectal prolapse.

Shortly after the invention of [[defecography]], In 1968 Broden and Snellman used [[defecography|cinedefecography]] to show that rectal prolapse begins as a circumferential intussusception of the rectum,<ref name="ASCRS: Prolapse and Intussusception" /><ref name="ASCRS textbook" /> which slowly increases over time.<ref name="Yamada GI textbook" /> The leading edge of the intussusceptum may be located at 6–8 cm or at 15–18 cm from the [[anal verge]].<ref name="Yamada GI textbook" /> This proved an older theory from the 18th century by [[John Hunter (surgeon)|John Hunter]] and [[Albrecht von Haller]] that this condition is essentially a full-thickness rectal intussusception, beginning about 3 inches above the [[dentate line]] and protruding externally.<ref name="ASCRS Prolapse, Intussusception, SRUS" />

Since most patients with rectal prolapse have a long history of constipation,<ref name="ASCRS textbook" /> it is thought that prolonged, excessive and repetitive straining during defecation may predispose to rectal prolapse.<ref name="ASCRS: Prolapse and Intussusception" /><ref name=Coloproctology /><ref name="Yamada GI textbook" /><ref>{{cite journal | vauthors = Turell R | title = Sexual problems as seen by proctologist | journal = New York State Journal of Medicine | volume = 74 | issue = 4 | pages = 697–698 | date = April 1974 | pmid = 4523440 }}</ref><ref>Essential Revision Notes in Surgery for Medical Students By Irfan Halim; p139</ref><ref name="Hampton-2009">{{cite journal | vauthors = Hampton BS | title = Pelvic organ prolapse | journal = Medicine and Health, Rhode Island | volume = 92 | issue = 1 | pages = 5–9 | date = January 2009 | pmid = 19248418 }}</ref> Since rectal prolapse itself causes functional obstruction, more straining may result from a small prolapse, with increasing damage to the anatomy.<ref name=Coloproctology /> This excessive straining may be due to predisposing pelvic floor dysfunction (e.g. [[obstructed defecation]]) and anatomical factors:<ref name="ASCRS textbook" /><ref name="Yamada GI textbook" />
* Abnormally low descent of the peritoneum covering the anterior rectal wall
* poor posterior rectal fixation, resulting in loss of posterior fixation of the rectum to the sacral curve<ref name="ASCRS Prolapse, Intussusception, SRUS" />
* loss of the normal horizontal position of the rectum<ref name="ASCRS: Prolapse and Intussusception" /> with lengthening (redundant rectosigmoid)<ref name="ASCRS: Prolapse and Intussusception" /><ref name="ASCRS Prolapse, Intussusception, SRUS" /> and downward displacement of the sigmoid and rectum
* long rectal mesentery<ref name="ASCRS: Prolapse and Intussusception" />
* a deep cul-de-sac<ref name="ASCRS: Prolapse and Intussusception" /><ref name="ASCRS Prolapse, Intussusception, SRUS" />
* levator diastasis<ref name="ASCRS: Prolapse and Intussusception" /><ref name="ASCRS Prolapse, Intussusception, SRUS" />
* a patulous, weak anal sphincter<ref name="ASCRS: Prolapse and Intussusception" /><ref name="ASCRS Prolapse, Intussusception, SRUS" />

Some authors question whether these abnormalities are the cause, or secondary to the prolapse.<ref name="ASCRS: Prolapse and Intussusception" /> Other predisposing factors/associated conditions include:
* pregnancy<ref name="ASCRS: Prolapse and Intussusception" /> (although 35% of women who develop rectal prolapse are [[nulliparous]])<ref name="ASCRS: Prolapse and Intussusception" /> (have never given birth)
* previous surgery<ref name="ASCRS: Prolapse and Intussusception" /> (30–50% of females with the condition underwent previous gynecological surgery)<ref name="ASCRS: Prolapse and Intussusception" />
* pelvic neuropathies and neurological disease<ref name="Yamada GI textbook" />
* high gastrointestinal [[helminth]] loads (e.g. [[Whipworm]])<ref>{{cite web |url=http://www.parasitesinhumans.org/trichuris-trichiura-whipworm.html |title=Trichuris Trichiura |work=Whipworm |publisher=Parasites In Humans}}</ref>
* COPD<ref>{{cite journal | vauthors = Vestbo J | title=Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease | journal=American Journal of Respiratory and Critical Care Medicine | volume=187 | issue=4 | year=2013 | pages=1–7 | doi=10.1164/rccm.201204-0596PP | pmid=22878278 | url=http://ajrccm.atsjournals.org/content/187/4/347.full.pdf+html | url-access=subscription | hdl=11380/904090 | hdl-access=free }}</ref>
* cystic fibrosis <ref>{{cite web |url=https://www.lecturio.com/concepts/cystic-fibrosis/| title=Cystic Fibrosis|website=The Lecturio Medical Concept Library | date=7 August 2020|access-date= 11 July 2021}}</ref>

The association with uterine prolapse (10–25%) and cystocele (35%) may suggest that there is some underlying abnormality of the pelvic floor that affects multiple pelvic organs.<ref name="ASCRS: Prolapse and Intussusception" /> Proximal bilateral pudendal neuropathy has been demonstrated in patients with rectal prolapse who have fecal incontinence.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> This finding was shown to be absent in healthy subjects, and may be the cause of denervation-related atrophy of the external anal sphincter. Some authors suggest that [[pudendal nerve]] damage is the cause for pelvic floor and anal sphincter weakening, and may be the underlying cause of a spectrum of pelvic floor disorders.<ref name="ASCRS Prolapse, Intussusception, SRUS" />

Sphincter function in rectal prolapse is almost always reduced.<ref name="ASCRS: Prolapse and Intussusception" /> This may be the result of direct sphincter injury by chronic stretching of the prolapsing rectum. Alternatively, the intussuscepting rectum may lead to chronic stimulation of the rectoanal inhibitory reflex (RAIR – contraction of the external anal sphincter in response to stool in the rectum). The RAIR was shown to be absent or blunted. Squeeze (maximum voluntary contraction) pressures may be affected as well as the resting tone. This is most likely a denervation injury to the external anal sphincter.<ref name="ASCRS: Prolapse and Intussusception" />

The assumed mechanism of [[fecal incontinence]] in rectal prolapse is by the chronic stretch and trauma to the anal sphincters and the presence of a direct conduit (the intussusceptum) connecting rectum to the external environment which is not guarded by the sphincters.<ref name="ASCRS Prolapse, Intussusception, SRUS" />

The assumed mechanism of obstructed defecation is by disruption to the rectum and anal canal's ability to contract and fully evacuate rectal contents. The intussusceptum itself may mechanically obstruct the rectoanal [[lumen (anatomy)|lumen]], creating a blockage that straining, anismus and colonic dysmotility exacerbate.<ref name="ASCRS Prolapse, Intussusception, SRUS" />

Some believe that internal rectal intussusception represents the initial form of a progressive spectrum of disorders the extreme of which is external rectal prolapse. The intermediary stages would be gradually increasing sizes of intussusception. However, internal intussusception rarely progresses to external rectal prolapse.<ref name="Mellgren 1997">{{cite journal | vauthors = Mellgren A, Schultz I, Johansson C, Dolk A | title = Internal rectal intussusception seldom develops into total rectal prolapse | journal = Diseases of the Colon and Rectum | volume = 40 | issue = 7 | pages = 817–820 | date = July 1997 | pmid = 9221859 | doi = 10.1007/bf02055439 | s2cid = 6337533 }}</ref> The factors that result in a patient progressing from internal intussusception to a full thickness rectal prolapse remain unknown.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> Defecography studies demonstrated that degrees of internal intussusception are present in 40% of asymptomatic subjects, raising the possibility that it represents a normal variant in some, and may predispose patients to develop symptoms, or exacerbate other problems.<ref name="Shorvon 1989">{{cite journal | vauthors = Shorvon PJ, McHugh S, Diamant NE, Somers S, Stevenson GW | title = Defecography in normal volunteers: results and implications | journal = Gut | volume = 30 | issue = 12 | pages = 1737–1749 | date = December 1989 | pmid = 2612988 | pmc = 1434461 | doi = 10.1136/gut.30.12.1737 }}</ref>

===Treatment===

====Conservative====
Surgery is thought to be the only option to potentially cure a complete rectal prolapse.<ref name=Samson2015 /> For people with medical problems that make them unfit for surgery, and those who have minimal symptoms, conservative measures may be beneficial. Dietary adjustments, including increasing dietary fiber may be beneficial to reduce constipation, and thereby reduce straining.<ref name=Samson2015 /> A bulk forming agent (e.g. [[psyllium]]) or stool softener can also reduce constipation.<ref name=Samson2015 />

====Surgical====
Surgery is often required to prevent further damage to the anal sphincters. The goals of surgery are to restore the normal anatomy and to minimize symptoms. There is no globally agreed consensus as to which procedures are more effective,<ref name=Samson2015 /> and there have been over 50 different operations described.<ref name="ASCRS Prolapse, Intussusception, SRUS" />

Surgical approaches in rectal prolapse can be either perineal or abdominal. A perineal approach (or trans-perineal) refers to surgical access to the rectum and sigmoid colon via an incision around the anus and [[perineum]] (the area between the genitals and the anus).<ref name="Encyclopedia of Surgery">{{cite web| vauthors = Sherk SD |title=Rectal prolapse repair on Encyclopedia of Surgery|url=http://www.surgeryencyclopedia.com/Pa-St/Rectal-Prolapse-Repair.html#b|publisher=Encyclopedia of Surgery|access-date=16 October 2012}}</ref> Abdominal approach (trans-abdominal approach) involves the surgeon cutting into the [[abdomen]] and gaining surgical access to the [[pelvic cavity]]. Procedures for rectal prolapse may involve fixation of the bowel (rectopexy), or resection (a portion removed), or both.<ref name=Samson2015 /> Trans-anal (endo-anal) procedures are also described where access to the internal rectum is gained through the anus itself.

Abdominal procedures are associated with lower risk of postoperative recurrence of the prolapse, compared with perineal procedures (6.1% vs 16.3% in patients who are younger than 65 years of age at the time of surgery).<ref>{{cite journal | vauthors = Pellino G, Fuschillo G, Simillis C, Selvaggi L, Signoriello G, Vinci D, Kontovounisios C, Selvaggi F, Sciaudone G | display-authors = 6 | title = Abdominal versus perineal approach for external rectal prolapse: systematic review with meta-analysis | journal = BJS Open | volume = 6 | issue = 2 | article-number = zrac018 | date = March 2022 | pmid = 35390136 | pmc = 8989040 | doi = 10.1093/bjsopen/zrac018 }}</ref>

=====Abdominal procedures=====
The abdominal approach carries a small risk of impotence in males (e.g. 1–2% in abdominal rectopexy).<ref name="ASCRS textbook" /> Abdominal operations may be open or [[laparoscopic surgery|laparoscopic]] (keyhole surgery).<ref name="ASCRS: Prolapse and Intussusception" />

'''Laparoscopic procedures'''
Recovery time following laparoscopic surgery is shorter and less painful than following traditional abdominal surgery.<ref name="Encyclopedia of Surgery" /> Instead of opening the pelvic cavity with a wide incision (laparotomy), a laparoscope (a thin, lighted tube) and surgical instruments are inserted into the pelvic cavity via small incisions.<ref name="Encyclopedia of Surgery" /> Rectopexy and anterior resection have been performed laparoscopically with good results.

=====Perineal procedures=====
The perineal approach generally results in less post-operative pain and complications, and a reduced length of hospital stay. These procedures generally carry a higher recurrence rate and poorer functional outcome.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> The perineal procedures include perineal rectosigmoidectomy and Delorme repair.<ref name="ASCRS: Prolapse and Intussusception" /> Elderly, or other medically high-risk patients are usually treated by perineal procedures,<ref name="ASCRS: Prolapse and Intussusception" /> as they can be performed under a [[regional anesthesia|regional anesthetic]], or even [[local anesthetic]] with [[intravenous sedation]], thus avoid the risks of a [[general anesthetic]].<ref name="ASCRS textbook" /> Alternatively, perineal procedures may be selected to reduce risk of nerve damage, for example in young male patients for whom sexual dysfunction may be a major concern.<ref name="ASCRS Prolapse, Intussusception, SRUS" />

'''Perineal rectosigmoidectomy'''

The goal of Perineal rectosigmoidectomy is to resect or remove the redundant bowel. This is done through the perineum. The lower rectum is anchored to the sacrum through fibrosis in order to prevent future prolapse.<ref name=Samson2015 /> The full thickness of the rectal wall is incised at a level just above the dentate line. Redundant rectal and sigmoid wall is removed and the new edge of colon is reconnected (anastomosed) with the anal canal with stitches or staples.<ref name="ASCRS textbook" /> This procedure may be combined with levatorplasty, to tighten the pelvic muscles.<ref name=Samson2015 /> A combined a perineal proctosigmoidectomy with anterior levatorplasty is also called an Altemeier procedure.<ref name="ASCRS: Prolapse and Intussusception" /> Levatorplasty is performed to correct levator diastasis which is commonly associated with rectal prolapse.<ref name="ASCRS: Prolapse and Intussusception" /> Perineal rectosigmoidectomy was first introduced by Mikulicz in 1899, and it remained the preferred treatment in Europe for many years.<ref name="ASCRS: Prolapse and Intussusception" /> It was Popularized by Altemeier.<ref name="ASCRS textbook" /> The procedure is simple, safe and effective.<ref name="ASCRS: Prolapse and Intussusception" /> Continence levatorplasty may enhance restoration of continence (2/3 of patients).<ref name="ASCRS: Prolapse and Intussusception" /> Complications occur in less than 10% of cases, and include pelvic bleeding, pelvic abscess and anastomotic dehiscence (splitting apart of the stitches inside), bleeding or leak at a dehiscence<ref name="ASCRS: Prolapse and Intussusception" /> Mortality is low.<ref name="ASCRS textbook" /> Recurrence rates are higher than for abdominal repair,<ref name="ASCRS: Prolapse and Intussusception" /> 16–30%, but more recent studies give lower recurrence rates.<ref name="ASCRS: Prolapse and Intussusception" /> Additional levatorplasty can reduce recurrence rates to 7%.<ref name="ASCRS: Prolapse and Intussusception" />

'''Delorme Procedure'''

This is a modification of the perineal rectosigmoidectomy, differing in that only the mucosa and submucosa are excised from the prolapsed segment, rather than full thickness resection.<ref name="ASCRS textbook" /> The prolapse is exposed if it is not already present, and the mucosal and submucosal layers are stripped from the redundant length of bowel. The muscle layer that is left is plicated (folded) and placed as a buttress above the pelvic floor.<ref name=Samson2015 /> The edges of the mucosal are then stitched back together. "Mucosal proctectomy" was first discussed by Delorme in 1900,<ref name="ASCRS textbook" /> now it is becoming more popular again as it has low morbidity and avoids an abdominal incision, while effectively repairing the prolapse.<ref name="ASCRS: Prolapse and Intussusception" /> The procedure is ideally suited to those patients with full-thickness prolapse limited to partial circumference (e.g., anterior wall) or less-extensive prolapse (perineal rectosigmoidectomy may be difficult in this situation).<ref name="ASCRS: Prolapse and Intussusception" /><ref name="ASCRS textbook" /> Fecal incontinence is improved following surgery (40%–75% of patients).<ref name="ASCRS Prolapse, Intussusception, SRUS" /><ref name="ASCRS textbook" /> Post operatively, both mean resting and squeeze pressures were increased.<ref name="ASCRS Prolapse, Intussusception, SRUS" /> Constipation is improved in 50% of cases,<ref name="ASCRS Prolapse, Intussusception, SRUS" /> but often urgency and tenesmus are created. Complications, including infection, urinary retention, bleeding, [[anastomosis|anastomotic]] dehiscence (opening of the stitched edges inside), [[rectal stricture]] (narrowing of the gut lumen), diarrhea, and fecal impaction occur in 6–32% of cases.<ref name="ASCRS Prolapse, Intussusception, SRUS" /><ref name="ASCRS textbook" /> Mortality occurs in 0–2.5% cases.<ref name="ASCRS textbook" /> There is a higher recurrence rate than abdominal approaches (7–26% cases).<ref name="ASCRS Prolapse, Intussusception, SRUS" /><ref name="ASCRS textbook" />

'''Anal encirclement (Thirsch procedure)'''

This procedure can be carried out under [[local anaesthetic]]. After reduction of the prolapse, a subcutaneous suture (a stitch under the skin) or other material is placed encircling the anus, which is then made taut to prevent further prolapse.<ref name=Samson2015 /> Placing silver wire around the anus first described by Thiersch in 1891.<ref name="ASCRS textbook" /> Materials used include nylon, silk, silastic rods, silicone, Marlex mesh, Mersilene mesh, fascia, tendon, and Dacron.<ref name="ASCRS textbook" /> This operation does not correct the prolapse itself, it merely supplements the anal sphincter, narrowing the anal canal with the aim of preventing the prolapse from becoming external, meaning it remains in the rectum.<ref name="ASCRS textbook" /> This goal is achieved in 54–100% cases. Complications include breakage of the encirclement material, fecal impaction, sepsis, and erosion into the skin or anal canal. Recurrence rates are higher than the other perineal procedures. This procedure is most often used for people who have a severe condition or who have a high risk of adverse effects from general anesthetic,<ref name=Samson2015 /> and who may not tolerate other perineal procedures.

==Internal rectal prolapse==
{{main|Internal rectal prolapse}}
'''Internal rectal prolapse''' (internal intussusception, internal rectal intussusception, occult rectal prolapse, rectoanal intussusception) is a type of rectal prolapse where there is a telescopic, funnel-shaped infolding of the wall of the rectum that occurs during defecation.<ref name="Emile2017" /><ref name="Wijffels2010">{{cite journal |last1=Wijffels |first1=NA |last2=Collinson |first2=R |last3=Cunningham |first3=C |last4=Lindsey |first4=I |title=What is the natural history of internal rectal prolapse? |journal=Colorectal Disease|date=August 2010 |volume=12 |issue=8 |pages=822–30 |doi=10.1111/j.1463-1318.2009.01891.x |pmid=19508530}}</ref> The term internal rectal prolapse is used when the prolapsed section of rectal wall remains inside the body and is not visible outside the body.<ref name="Emile2019" /><ref>Grimes WR, Stratton M. [https://www.ncbi.nlm.nih.gov/books/NBK559246/ Pelvic Floor Dysfunction]. 2023 Jun 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID 32644672.</ref>

It may not cause any symptoms, or may cause obstructed defecation syndrome<ref name="Wijffels2010" /> and/or fecal incontinence.<ref name="vanderSchans2018">{{cite journal |last1=van der Schans |first1=EM |last2=Paulides |first2=TJC |last3=Wijffels |first3=NA |last4=Consten |first4=ECJ |title=Management of patients with rectal prolapse: the 2017 Dutch guidelines. |journal=Techniques in Coloproctology |date=August 2018 |volume=22 |issue=8 |pages=589–596 |doi=10.1007/s10151-018-1830-1 |pmid=30099626}}</ref> The causes are not clear.<ref name="Emile2017">{{cite journal |last1=Emile |first1=SH |last2=Elfeki |first2=HA |last3=Youssef |first3=M |last4=Farid |first4=M |last5=Wexner |first5=SD |title=Abdominal rectopexy for the treatment of internal rectal prolapse: a systematic review and meta-analysis. |journal=Colorectal Disease|date=January 2017 |volume=19 |issue=1 |pages=O13–O24 |doi=10.1111/codi.13574 |pmid=27943547}}</ref> It may represent the first stage of a progressive condition that eventually may result in external rectal prolapse,<ref name=weiss>{{cite journal | vauthors = Weiss EG, McLemore EC | title = Functional disorders: rectoanal intussusception | journal = Clinics in Colon and Rectal Surgery | volume = 21 | issue = 2 | pages = 122–128 | date = May 2008 | pmid = 20011408 | pmc = 2780198 | doi = 10.1055/s-2008-1075861 }}</ref><ref name="Wijffels2010" /> but this is uncommon.<ref name="Emile2019">{{cite journal |last1=Emile |first1=SH |last2=Elfeki |first2=H |last3=Shalaby |first3=M |last4=Sakr |first4=A |last5=Sileri |first5=P |last6=Wexner |first6=SD |title=Outcome of laparoscopic ventral mesh rectopexy for full-thickness external rectal prolapse: a systematic review, meta-analysis, and meta-regression analysis of the predictors for recurrence. |journal=Surgical Endoscopy |date=August 2019 |volume=33 |issue=8 |pages=2444–2455 |doi=10.1007/s00464-019-06803-0 |pmid=31041515}}</ref> It is possible that chronic straining during defecation (dyssynergic defecation / anismus), connective tissue disorders, and anatomic factors (e.g. loose connection of rectum to the sacrum, redundant sigmoid, deep pouch of Douglas) are involved.

Diagnosis is by defecography.<ref name="Emile2017" /> If internal rectal prolapse is causing symptoms, treatment is by various non surgical measures (e.g. biofeedback), or surgery. The most common surgical treatment is [[ventral rectopexy]].<ref name="Emile2019" /> Internal rectal prolapse is often associated with other conditions such as rectocele, enterocele, or solitary rectal ulcer syndrome. Internal rectal prolapse usually affects females who have given birth at least once, but it may sometimes affect females who have never given birth. About 10% of cases are in males.<ref name="Altomare2008">{{cite book |editor1-last=Altomare |editor1-first=DF |editor2-last=Pucciani |editor2-first=F |title=Rectal Prolapse: Diagnosis and Clinical Management |date=8 March 2008 |publisher=Springer Science & Business Media |isbn=978-88-470-0684-3 |language=en}}</ref> More severe forms of internal rectal prolapse are associated with older age.<ref name="Altomare2008" />

==Mucosal prolapse==
'''Rectal mucosal prolapse''' (mucosal prolapse, anal mucosal prolapse) is a sub-type of rectal prolapse, and refers to abnormal descent of the [[rectal]] [[mucosa]] through the [[anus]].<ref name="Yamada GI textbook" /> It is different to an internal intussusception (occult prolapse) or a complete rectal prolapse (external prolapse, procidentia) because these conditions involve the full thickness of the rectal wall, rather than only the mucosa (lining).<ref name="Gupta 2006" />

Mucosal prolapse is a different condition to prolapsing (3rd or 4th degree) [[hemorrhoids]],<ref name="Gupta 2006" /> although they may look similar.

Rectal mucosal prolapse can be a cause of [[obstructed defecation]] (outlet obstruction).<ref name=Coloproctology />

===Symptoms===
Symptom severity increases with the size of the prolapse, and whether it spontaneously reduces after defecation, requires manual reduction by the patient, or becomes irreducible. The symptoms are identical to advanced hemorrhoidal disease,<ref name="Gupta 2006" /> and include:
* [[Fecal leakage]] causing staining of undergarments
* [[Rectal bleeding]]
* Mucous [[rectal discharge]]
* [[Rectal pain]]
* [[Pruritus ani]]

===Cause===
The condition, along with complete rectal prolapse and [[#Internal rectal intussusception|internal rectal intussusception]], is thought to be related to chronic straining during [[defecation]] and [[constipation]].

Mucosal prolapse occurs when the results from loosening of the submucosal attachments (between the mucosal layer and the [[muscularis propria]]) of the [[Anatomical terms of location#Proximal and distal|distal]] [[rectum]].<ref name="ASCRS: Prolapse and Intussusception" /> The section of prolapsed rectal mucosa can become ulcerated, leading to bleeding.

===Diagnosis===
Mucosal prolapse can be differentiated from a full thickness external rectal prolapse (a complete rectal prolapse) by the orientation of the folds (furrows) in the prolapsed section. In full thickness rectal prolapse, these folds run circumferential. In mucosal prolapse, these folds are radially.<ref name="ASCRS textbook" /> The folds in mucosal prolapse are usually associated with internal hemorrhoids.<ref name="Yamada GI textbook" />

===Treatment===
[[List of medical abbreviations: E|EUA]] (examination under anesthesia) of anorectum and banding of the mucosa with rubber bands.

==Solitary rectal ulcer syndrome==
{{main|Solitary rectal ulcer syndrome}}
'''Solitary rectal ulcer syndrome''' (SRUS, SRU) is a chronic disorder of the rectal [[Mucous membrane|mucosa]] (the lining of the rectum).<ref name="Alejandra2019" >{{cite book |last1=Alejandra |first1=A-B |last2=José María |first2=R-T |last3=Enrique |first3=CA |title=Anorectal Disorders |date=1 January 2019 |publisher=Academic Press |isbn=978-0-12-815346-8 |pages=227–236 |chapter-url=https://www.sciencedirect.com/science/article/pii/B9780128153468000187 |language=en |chapter=18 - Solitary Rectal Ulcer Syndrome}}</ref> Symptoms are variable. There may be [[hematochezia]] (bleeding), [[obstructed defecation]], or no symptoms at all.<ref name="Sadeghi2019">{{cite journal |last1=Sadeghi |first1=A |last2=Biglari |first2=M |last3=Forootan |first3=M |last4=Adibi |first4=P |title=Solitary Rectal Ulcer Syndrome: A Narrative Review. |journal=Middle East Journal of Digestive Diseases |date=July 2019 |volume=11 |issue=3 |pages=129–134 |doi=10.15171/mejdd.2019.138 |pmid=31687110 |pmc=6819965}}</ref><ref>{{cite journal |last1=García-Armengol |first1=J |last2=Moro |first2=D |last3=Ruiz |first3=MD |last4=Alós |first4=R |last5=Solana |first5=A |last6=Roig-Vila |first6=JV |title=[Obstructive defecation. Diagnostic methods and treatment]. |journal=Cirugia Espanola |date=December 2005 |volume=78 Suppl 3 |pages=59–65 |doi=10.1016/s0009-739x(05)74645-5 |pmid=16478617}}</ref><ref name="Forootan2018" >{{cite journal |last1=Forootan |first1=M |last2=Darvishi |first2=M |title=Solitary rectal ulcer syndrome: A systematic review. |journal=Medicine |date=May 2018 |volume=97 |issue=18 |article-number=e0565 |doi=10.1097/MD.0000000000010565 |pmid=29718850 |pmc=6392642}}</ref> Very often but not always SRUS occurs in association with varying degrees of rectal prolapse.<ref name="Alejandra2019" /> The condition may be caused by different factors, such as long term constipation, straining during defecation, and dyssynergic defecation (anismus).<ref name="Sadeghi2019" /><ref name="Kuckelman2019">{{cite book |author1=Kuckelman J |author2=Johnson EK |title=Chapter in: Clinical algorithms in general surgery: a practical guide |date=2019 |publisher=Springer |location=Cham |isbn=978-3-319-98497-1 |pages=269–274 |chapter=Solitary Rectal Ulcer Syndrome}}</ref> Treatment is by normalization of bowel habits,<ref name="Alejandra2019" /> biofeedback,<ref name="Kuckelman2019" /> and other non-surgical measures. In more severe cases, various surgical procedures may be indicated.<ref name="Kuckelman2019" /><ref name="Sadeghi2019" /> The condition is relatively rare, affecting approximately 1 in 100,000 people per year.<ref name="Forootan2018" /> It affects mainly adults aged 30–50.<ref name="Forootan2018" /> Females are affected slightly more often than males.<ref name="Alejandra2019" /> The disorder can be confused clinically with [[rectal cancer]] or other conditions such as [[inflammatory bowel disease]], even when a [[biopsy]] is done.<ref name="Herold2017">{{cite book | editor-last=Herold | editor-first=Alexander | editor-last2=Lehur | editor-first2=Paul-Antoine | editor-last3=Matzel | editor-first3=Klaus E. | editor-last4=O'Connell | editor-first4=P. Ronan | title=Coloproctology | series=European Manual of Medicine | publisher=Springer | publication-place=Berlin, Heidelberg | date=2017 | isbn=978-3-662-53210-2 |edition=Second }}</ref>

==Colitis cystica profunda==
Another condition associated with internal intussusception is '''colitis cystica profunda''' (also known as CCP, or proctitis cystica profunda), which is [[cystica profunda]] in the rectum. Cystica profunda is characterized by formation of [[mucin]] [[cysts]] in the muscle layers of the gut lining, and it can occur anywhere along the gastrointestinal tract. When it occurs in the rectum, some believe to be an interchangeable diagnosis with SRUS since the [[hitsology|histologic]] features of the conditions overlap.<ref>{{cite journal | vauthors = Vora IM, Sharma J, Joshi AS | title = Solitary rectal ulcer syndrome and colitis cystica profunda--a clinico-pathological review | journal = Indian Journal of Pathology & Microbiology | volume = 35 | issue = 2 | pages = 94–102 | date = April 1992 | pmid = 1483723 }}</ref><ref name="levine">{{cite journal | vauthors = Levine DS | title = "Solitary" rectal ulcer syndrome. Are "solitary" rectal ulcer syndrome and "localized" colitis cystica profunda analogous syndromes caused by rectal prolapse? | journal = Gastroenterology | volume = 92 | issue = 1 | pages = 243–253 | date = January 1987 | pmid = 3536653 | doi = 10.1016/0016-5085(87)90868-7 }}</ref> Indeed, CCP is managed identically to SRUS.<ref>{{cite journal | vauthors = Beck DE | title = Surgical Therapy for Colitis Cystica Profunda and Solitary Rectal Ulcer Syndrome | journal = Current Treatment Options in Gastroenterology | volume = 5 | issue = 3 | pages = 231–237 | date = June 2002 | pmid = 12003718 | doi = 10.1007/s11938-002-0045-7 | s2cid = 38880216 }}</ref>

==Mucosal prolapse syndrome==
A group of conditions known as '''Mucosal prolapse syndrome''' (MPS) has now been recognized. It includes SRUS, rectal prolapse, proctitis cystica profunda, and inflammatory polyps.<ref name="nonaka" /><ref name="abid" /> It is classified as a chronic benign inflammatory disorder. The unifying feature is varying degrees of rectal prolapse, whether internal intussusception (occult prolapse) or external prolapse.

==Epidemiology==
Rectal prolapse affects less than 0.5% of the general population.<ref name=Cannon>{{cite journal | vauthors = Cannon JA | title = Evaluation, Diagnosis, and Medical Management of Rectal Prolapse | journal = Clinics in Colon and Rectal Surgery | volume = 30 | issue = 1 | pages = 16–21 | date = February 2017 | pmid = 28144208 | doi = 10.1055/s-0036-1593431 | pmc = 5179269 }}</ref> It affects women more commonly, with a female to male ratio of 9:1.<ref name=Cannon />

==History==
External rectal prolapse has been recognized since ancient times.<ref name="Wu2009">{{cite journal |last1=Wu |first1=JS |title=Rectal prolapse: a historical perspective. |journal=Current Problems in Surgery |date=August 2009 |volume=46 |issue=8 |pages=602–716 |doi=10.1067/j.cpsurg.2009.03.006 |pmid=19577675}}</ref> The first written report is in the [[Ebers Papyrus]] (1500 BC).<ref name="Tsoucalas2017">{{cite journal |last1=Tsoucalas |first1=G |last2=Papaioannou |first2=TG |last3=Papatheodoridis |first3=GV |last4=Karamanou |first4=M |title=Hippocratic views in the treatment of rectal prolapse. |journal=Acta Gastro-Enterologica Belgica |date=July 2017 |volume=80 |issue=3 |pages=411–415 |pmid=29560672 |url=https://www.ageb.be/Articles/Volume%2080%20(2017)/Fasc3/20-Karamanou.pdf}}</ref> An Egyptian mummy from 400-500 BC was discovered to have rectal prolapse.<ref name="Tsoucalas2017" /> In the [[Hippocratic Corpus]] there is a description of rectal prolapse and the following advice: ''"If there is a drop in the rectum, push it back in with a soft sponge, anoint it with snail medication, tie the person's hands and suspend him for a short time, and it will go in."''<ref name="Tsoucalas2017" />

In 1831 British surgeon Frederick Salmon wrote a treatise on rectal prolapse, "Practical Observations on Prolapsus of the Rectum".<ref name="Wu2009" /> What later became known as internal rectal prolapse was first described in 1888 in a textbook about diseases of the rectum.<ref name="Blaker2017" /> The author classified IRP as a variety of procidentia recti (i.e., rectal prolapse) with the definition "the upper part of the rectum descends through the lower part, but does not appear outside the anus."<ref name="Blaker2017" >{{cite journal |last1=Blaker |first1=K |last2=Anandam |first2=JL |title=Functional Disorders: Rectoanal Intussusception. |journal=Clinics in Colon and Rectal Surgery |date=February 2017 |volume=30 |issue=1 |pages=5–11 |doi=10.1055/s-0036-1593433 |pmid=28144206|pmc=5179278 }}</ref>

=={{Anchor|In pornography}}Society and culture==

Rosebud pornography and prolapse pornography (rosebudding / rectal prolapse pornography) is an anal sex practice that occurs in some extreme anal pornography, wherein a pornographic actor or actress deliberately performs a rectal prolapse. "Rosebudding" is an example of producers making extreme content due to the easy availability of free pornography on the internet. Rosebudding is a way for pornographic actors and actresses to distinguish themselves.<ref name="VICE1">{{cite web| vauthors = Lhooq M |url=https://www.vice.com/en/article/a-rosebud-by-any-other-name-would-smell-like-shit/ |title=Extreme Anal Porn's Shitty Consequences | VICE |publisher=VICE |date=2014-06-17 |access-date=2020-08-31}}</ref> Some who participate in this form of pornography may be unaware of the consequences.<ref name="VICE1"/>

==Etymology==

Prolapse refers to "the falling down or slipping of a body part from its usual position or relations". It is derived from the Latin ''pro-'' - "forward" + ''labi'' - "to slide". {{MerriamWebsterDictionary|Prolapse}} [[Prolapse]] can refer to many different medical conditions other than rectal prolapse.

Procidentia has a similar meaning to prolapse, referring to "a sinking or prolapse of an organ or part". It is derived from the Latin ''procidere'' - "to fall forward".<ref>{{cite web|title=Procidentia on the Free Dictionary|url=http://medical-dictionary.thefreedictionary.com/procidentia|publisher=Farlex Inc.|access-date=14 October 2012}}</ref> [[Procidentia]] usually refers to [[uterine prolapse]], but rectal procidentia can also be a synonym for rectal prolapse.

Intussusception is defined as [[invagination]] (infolding), especially referring to "the slipping of a length of intestine into an adjacent portion". It is derived from the Latin ''intus'' - "within" and ''susceptio'' - "action of undertaking", from ''suscipere'' - "to take up". {{MerriamWebsterDictionary|Intussusception}} Rectal intussusception is not to be confused with other [[intussusception (medical disorder)|intussusception]]s involving [[colon (anatomy)|colon]] or [[small intestine]], which can sometimes be a medical emergency. Rectal intussusception by contrast is not life-threatening.

Intussusceptum refers to the [[Anatomical terms of location#Proximal and distal|proximal]] section of rectal wall, which telescopes into the [[lumen (anatomy)|lumen]] of the [[Anatomical terms of location#Proximal and distal|distal]] section of [[rectum]] (termed the intussuscipiens).<ref name="ASCRS textbook" /> What results is 3 layers of rectal wall overlaid. From the lumen outwards, the first layer is the proximal wall of the intussusceptum, the middle is the wall of the intussusceptum folded back on itself, and the outer is the distal rectal wall, the intussuscipiens.<ref name="ASCRS textbook" />

== References ==
{{reflist|30em}}

== External links ==
{{Medical resources
| DiseasesDB = 11189
| ICD10 = {{ICD10|K|62|3|k|55}}
| ICD9 = {{ICD9|569.1}}
| ICDO =
| OMIM = 176780
| MedlinePlus = 001132
| eMedicineSubj = med
| eMedicineTopic = 3533
| MeshID = D012005
}}
{{Gastroenterology}}

{{DEFAULTSORT:Rectal Prolapse}}
[[Category:Colorectal surgery]]
[[Category:Rectal diseases]]

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Rectal prolapse