Rectal prolapse (rectal procidentia) has been described for centuries and is defined by the circumferential full-thickness protrusion of all layers of the rectum through the anal sphincter complex beyond the anal verge. Diagnosis can be made by physical exam and must be differentiated from prolapsing hemorrhoidal tissue. Rectal intussusception, also known as occult or internal prolapse, likewise involves all layers of the rectum infolding down into the anal canal but not beyond. Therefore, rectal intussusception is not visible on inspection. Partialthickness prolapse, or mucosal prolapse, involves protrusion of a redundant layer of rectal or anal mucosa.

The reported incidence of rectal prolapse is low at 0.25%, with a clear predominance in elderly multiparous women suffering from long-standing constipation.¹ Although its pathophysiology is not well defined, rectal prolapse is associated with attenuation of the supportive tissues surrounding the rectum. Commonly, patients are noted to have a deep peritoneal cul-de-sac, weak pelvic floor and/or sphincter musculature, and rectal redundancy. Chronic straining during defecation as a result of anatomic or functional disorders of elimination has been implicated in the etiology. A higher incidence of psychiatric disorders has been noted in patients with rectal prolapse compared to the general population.² Additionally, although rare, neurologic disease, connective tissue disorders, and schistosomiasis may contribute.¹

A number of operations, from both perineal and transabdominal approaches, have been described for the treatment of rectal prolapse, alluding to the lack of an ideal procedure. A history of prior pelvic or perineal surgery increases operative risk and should be considered when determining surgical approach. Age, comorbid conditions, functional activity level, and fecal continence are also important components of decision-making for individualized treatment.

This chapter describes the clinical features, evaluation, common surgical repairs, recurrence, and outcomes of patients with rectal prolapse.

The majority of patients with rectal prolapse will present with a history of a mass protruding from the anus, or the feeling of “sitting on a ball.” The prolapse is often triggered by an episode of straining during defecation, but in more severe cases can occur with prolonged standing or ambulation. The prolapsed tissue usually retracts on its own, but may require manual pressure to reduce and in more severe cases can become incarcerated. An acute rectal prolapse may present with ulceration, bleeding, incarceration, strangulation, or gangrene. Symptoms of chronic rectal prolapse include constipation, tenesmus, mucus discharge, bleeding, fecal incontinence, fecal staining, pruritus, and perianal skin excoriation due to chronic moisture. Intermittent severe pain may be present secondary to spasm of the levator ani muscles. A feeling of fullness in the pelvis or incomplete evacuation requiring splinting and positioning maneuvers to eliminate may indicate internal prolapse or other sequelae of pelvic floor dysfunction such as enterocele, cystocele, or rectocele.

Treatment should be tailored based on the physical severity as well as the psychological impact of rectal prolapse. A detailed history of bowel function is essential. Constipation, which is present in up to 70% of patients, increases the risk of recurrence.¹ It often precedes the onset of rectal prolapse by many years and may result from internal rectal intussusception leading to obstruction, pelvic floor dyssynergia, and colonic dysmotility. A thorough history may identify other causes of constipation and excessive straining, such as inadequate dietary fiber intake, sedentary lifestyle, medications, and medical conditions. Fecal incontinence can be found in the majority of patients and usually appears late in the course of rectal prolapse as a result of weakening of the anal sphincter muscles. If fecal incontinence is severe and associated with lack of anal squeeze on exam, the patient should be counselled regarding the risk of complete fecal incontinence following surgical correction of the prolapse. In such cases, creation of an ostomy should be discussed as an option.

A wide variety of surgical repairs have been described for rectal prolapse, underscoring the lack of an ideal procedure. Operative techniques are traditionally divided by approach: perineal or transabdominal. The two main perineal procedures are the Delorme procedure and the Altemeier procedure (perineal rectosigmoidectomy).
Mucosal prolapse and short segment full-thickness prolapse can be managed by the Delorme procedure, whereas the Altemeier procedure can be used for any degree of protrusion. Perineal stapled prolapse resection (PSPR) is a relatively new perineal procedure. Transabdominal repair can be completed via laparotomy, laparoscopy, or robotic technique and consists of fixation of the rectum in its normal anatomic position with or without colonic resection.

The first procedures described for rectal prolapse were performed via a perineal approach. With its introduction in 1955, transabdominal repair became the standard of care for patients who could tolerate laparotomy. Those who could not (frail, older adults) underwent perineal repair. The advent of laparoscopy and robotic surgery allowed for avoidance of the trauma of a laparotomy, thereby reducing surgical stress and allowing for more rapid recovery. Determination of operative approach should take into account patient age, comorbid conditions, previous abdominal or perineal operations, risk of recurrence, presence of fecal incontinence or constipation, and presence or absence of incarceration.