Background

Rectal prolapse and procidentia are medical conditions that involve the protrusion or descent of the rectum through the anal opening. 

Rectal prolapse is a condition in which the rectum, the last segment for the large intestine, stretches and emerges through the anus.This happen due to weakening of the muscles and ligaments that support the rectum, often caused by factors such as age, chronic constipation, straining during bowel movements, childbirth, or previous pelvic surgery. Rectal prolapse can vary in severity, from a mild protrusion to a complete protrusion of the rectum. 

Procidentia, also known as complete rectal prolapse, is the most severe form of rectal prolapse. In this condition, the entire wall of the rectum protrudes through the anus and may even turn inside out. It can cause symptoms like fecal incontinence, trouble passing gas, pain, discomfort, and irritation, all of which can have a major negative impact on a person’s quality of life. 

Both rectal prolapse and procidentia require medical attention. Treatment options may include changes such as dietary modifications to prevent constipation, pelvic floor exercises to strengthen the muscles, and avoiding heavy lifting or straining. 

Epidemiology

Age and Gender: 

• Rectal prolapse is more commonly observed in older adults, with a higher prevalence in individuals over the age of 60. 
• Women are generally more affected by rectal prolapse than men. 

Incidence and Prevalence: 

• The incidence and prevalence of rectal prolapse are relatively low, making it a rare condition. 
• Studies suggest that the prevalence may range from 1% to 3% in the general population. 
• The prevalence may increase in certain subgroups, such as the elderly. 

Risk Factors: 

• Chronic straining and constipation during the bowel movements are significant risk factors for the development of rectal prolapse. 
• Other factors, such as multiple childbirths, previous pelvic surgeries, and neurological disorders affecting pelvic floor muscles, may contribute to the condition. 

Geographical Variation: 

• There may be some geographical variation in the prevalence of rectal prolapse, but comprehensive global data are not always readily available. 

Anatomy

Pathophysiology

Pelvic Floor Weakness: 

• The rectum and other organs in the pelvis are supported by the intricate web of ligaments, muscles, and connective tissue that makes up the pelvic floor. Weakening of these structures is a central factor in the pathophysiology of rectal prolapse. 
• Age-related changes, multiple childbirths, and chronic straining during bowel movements can contribute to pelvic floor weakness. 

Connective Tissue Disorders: 

• Conditions that affect the integrity of connective tissues, such as Ehlers-Danlos syndrome or Marfan syndrome, may increase the risk of rectal prolapse. 

Chronic Constipation and Straining: 

• Pressure in the abdomen and pelvic areas may rise as a result of long-term constipation and frequent straining during bowel motions. This increased pressure might lead to deterioration of the muscles of the pelvic floor and supporting structures. 

Neurological Factors: 

• Neurological disorders affecting the nerves that control the pelvic floor muscles may play an important role in the pathophysiology of rectal prolapse. 
• Damage to these nerves can disrupt the normal coordination of muscle contractions needed for maintaining the position of the rectum. 

Previous Pelvic Surgeries: 

• Surgeries involving the pelvic area, such as those for gynecological or colorectal conditions, may disrupt the normal anatomy and contribute to pelvic floor dysfunction. 

Hereditary Factors: 

• There may be a genetic predisposition to pelvic floor disorders, including rectal prolapse, suggesting a hereditary component. 

Increased Intra-abdominal Pressure: 

• Any condition or activity that raises intra-abdominal pressure, such as obesity or heavy lifting, can contribute to the descent of the rectum. 

Procidentia in Women: 

• In women, procidentia (complete rectal prolapse) may be associated with uterine or vaginal prolapse, suggesting a shared weakness in the supporting structures of the pelvic organs. 

Loss of Rectal Support: 

• The loss of normal attachments and support mechanisms for the rectum can result in its descent through the anal opening. 

Etiology

Intrinsic Causes: 

• Pelvic Floor Weakness: Weakening of the pelvic floor muscles, ligaments, and connective tissues is a primary intrinsic cause. This weakness can be associated with aging, hormonal changes, and genetic factors. 
• Connective Tissue Disorders: Conditions such as Ehlers-Danlos syndrome or Marfan syndrome, which affect the integrity of connective tissues, may predispose individuals to rectal prolapse. 
• Neurological Disorders: Diseases or injuries affecting the nerves controlling the pelvic floor muscles can disrupt normal muscle function and contribute to prolapse. 
• Previous Pelvic Surgeries: Surgical interventions in the pelvic region, especially those involving the rectum or adjacent structures, can alter normal anatomy and weaken support structures. 

Extrinsic Causes: 

• Chronic Constipation and Straining: Persistent constipation and straining during bowel movements can increase intra-abdominal pressure, leading to pelvic floor strain and contributing to rectal prolapse. 
• Childbirth: Multiple pregnancies and vaginal deliveries, especially with large babies, can stretch and weaken the pelvic floor muscles. 
• Aging: The aging process can result in natural degeneration of connective tissues and muscles, making individuals more susceptible to pelvic floor disorders. 
• Obesity: Excess body weight can increase intra-abdominal pressure, stressing the pelvic floor and contributing to prolapse. 
• Heavy Lifting: Regular engagement in heavy lifting activities can strain the pelvic floor and increase the risk of prolapse. 
• Chronic Coughing: Conditions such as persistent coughing due to other reasons can contribute to the development of rectal prolapse. 

Urogenital Conditions: 

• Uterine or Vaginal Prolapse in Women: Women may experience a combination of rectal prolapse with uterine or vaginal prolapse, indicating shared weaknesses in pelvic support. 

Hereditary Factors: 

• A genetic predisposition to pelvic floor disorders may contribute to the development of rectal prolapse. 

Genetics

Prognostic Factors

• Severity of Prolapse: The extent and severity of rectal prolapse play a crucial role in determining the prognosis. Severe or complete procidentia may have different treatment considerations compared to milder forms of prolapse. 
• Duration of Symptoms: The length of time a person has been experiencing symptoms can impact the prognosis. Early intervention may lead to better outcomes compared to cases where the condition has been present for an extended period. 
• Age of Onset: The age at which symptoms of rectal prolapse or procidentia first appear can be a prognostic factor. In general, older individuals may face additional challenges in treatment and recovery. 
• Underlying Health Conditions: The presence of comorbidities, such as chronic constipation, obesity, diabetes, or cardiovascular diseases, can influence the prognosis and complicate the management of rectal prolapse. 
• Pelvic Floor Function: The overall function and strength of the pelvic floor muscles are critical. If the pelvic floor can be strengthened through exercises and rehabilitation, it may positively affect the prognosis. 

Clinical History

Age Group: 

• Pediatric Population: Rectal prolapse is relatively rare in children. It may be associated with conditions such as cystic fibrosis, neurological disorders, or constipation. Presentation may include the visible protrusion of the rectum during bowel movements. 
• Adults: More common in the elderly population, especially individuals over the age of 60. In women, rectal prolapse is often associated with childbirth and menopause. 

Associated Comorbidities or Activity: 

• Chronic Constipation: Individuals with a history of chronic constipation are at a higher risk. Straining during bowel movements contributes to the weakening of pelvic floor muscles. 
• Obesity: Excess body weight can increase intra-abdominal pressure, contributing to prolapse. 
• Multiparity: Multiple pregnancies and vaginal deliveries, especially with large babies, are associated with an increased risk in women. 
• Neurological Disorders: Conditions affecting the nerves controlling pelvic floor muscles, such as spinal cord injuries, can be associated with rectal prolapse. 
• Connective Tissue Disorders: Individuals with conditions like Ehlers-Danlos syndrome may have a predisposition to rectal prolapse. 
• Heavy Lifting: Regular engagement in heavy lifting activities can strain the pelvic floor and contribute to prolapse. 

Acuity of Presentation: 

• Chronic Presentation: Gradual onset of symptoms over time. Mild to moderate prolapse may not cause acute issues but can lead to chronic discomfort, bleeding, or a feeling of incomplete evacuation. 
• Acute Presentation: Sudden onset of symptoms, especially with complete procidentia. Acute cases may involve severe pain, bleeding, or the inability to reduce the prolapse manually. 

• Intermittent or Recurrent Episodes: Some individuals may experience intermittent episodes of prolapse that resolve spontaneously or can be manually reduced. 

Physical Examination

Patient History: 

• Start by getting a thorough medical history that covers the beginning and end of symptoms, any linked conditions (such long-term constipation, delivery, or prior surgeries), and how the symptoms affect day-to-day functioning. 

Positioning: 

• Place the patient in the left lateral decubitus position or lithotomy position for a comprehensive examination. 

General Inspection: 

• Inspect the perianal area for signs of inflammation, skin changes, or external hemorrhoids. 
• Look for any protrusion or full-thickness protrusion of the rectum. 

Digital Rectal Examination (DRE): 

• Perform a digital rectal examination using a lubricated gloved finger. 
• Assess anal sphincter tone and contractility. 
• Evaluate for any masses, lesions, or abnormalities in the rectum. 
• Assess for tenderness, ulceration, or signs of inflammation. 

Dynamic Maneuvers: 

• Ask the patient to bear down or strain during the examination to assess the degree of prolapse and its response to increased intra-abdominal pressure. 

Full Rectal Prolapse Assessment: 

• Differentiate between mucosal prolapse and full-thickness rectal prolapse. 
• Assess the extent of the prolapse, whether it involves only the mucosa or the entire thickness of the rectal wall. 
• Determine if the prolapse is reducible or irreducible. 

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

• Prolapsed Hemorrhoids: Hemorrhoids that prolapse during bowel movements can be mistaken for rectal prolapse. However, hemorrhoids are vascular structures, and the protruding tissue is generally softer compared to the full-thickness rectal prolapse. 
• Solitary Rectal Ulcer Syndrome: This condition can present with rectal bleeding, mucous discharge, and a sensation of incomplete evacuation. The rectal mucosa may exhibit ulceration, inflammation, and solitary rectal ulcers. 
• Rectocele: A rectocele occurs when the front wall of the rectum protrudes into the vaginal space. It may cause symptoms such as difficulty with bowel movements and a feeling of rectal fullness but is distinct from rectal prolapse. 
• Enterocele: Enterocele involves the protrusion of the small intestine into the vaginal space. It can cause a bulging sensation but is different from rectal prolapse. 
• Anal Fissures: There are tears in the lining of the anus, often associated with pain and bleeding during bowel movements. While they don’t involve protrusion, the symptoms may overlap with rectal prolapse. 
• Pelvic Organ Prolapse (POP): POP can involve the descent or prolapse of pelvic organs, including the bladder, uterus, or vagina. In women, it may coexist with rectal prolapse. 
• Inflammatory Bowel Disease (IBD): Conditions such as Crohn’s disease or ulcerative colitis can cause inflammation in the rectum and may present with symptoms similar to rectal prolapse, such as bleeding and abdominal pain. 
• Colon or Rectal Tumors: Tumors or masses in the colon or rectum can cause obstructive symptoms, altered bowel habits, and rectal bleeding. 
• Anal Stenosis: Narrowing of the anal canal can cause difficulty with bowel movements and may be mistaken for rectal prolapse. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Conservative Management: 

Lifestyle Modifications: 

• Dietary changes, including increased fiber intake, can help prevent or alleviate constipation, which is often associated with rectal prolapse. 
• Adequate fluid intake and regular exercise can contribute to overall bowel health. 

Pelvic Floor Exercises: 

• The muscles supporting the rectum can be strengthened and symptoms may be alleviated with the use of exercises from Kegel along with additional pelvic floor muscle training. 

Medications: 

• To treat constipation and decrease straining during bowel movements, laxatives or stool softeners may be advised. 
• Topical therapies, such as lotions or ointments, can help with symptoms including irritation and discomfort. 

Surgical Interventions: 

• Perineal Procedures: For selected cases, perineal procedures (such as Delorme or Altemeier procedures) may be considered, involving the removal of a portion of the rectal mucosa and reinforcement of the rectal wall. 
• Abdominal Procedures: Abdominal surgeries, including rectopexy, can be performed to reposition and secure the rectum, addressing the underlying structural issues. The choice of procedure (laparoscopic or open surgery) depends on the patient’s overall health and the surgeon’s expertise. 
• Rectal Resection: In cases where there is significant damage to the rectum or associated conditions (e.g., rectal intussusception), a segmental resection of the rectum may be necessary. 
• Combined Procedures: Some patients may benefit from combined abdominal and perineal approaches, depending on the extent and characteristics of the prolapse. 
• Biofeedback Therapy: It can be used to train patients to improve pelvic floor muscle function, helping with symptom management. 

Considerations for Special Populations: 

• Elderly Patients: Surgical interventions in elderly patients should be carefully considered based on the patient’s overall health and life expectancy. 
• Pediatric Patients: Conservative measures are often the first line of treatment in pediatric cases, with surgical intervention reserved for severe or refractory cases. 
• Women with Uterine Prolapse: For women with both uterine and rectal prolapse, coordination with gynecologists may be necessary to address both conditions. 
• Patients with Associated Conditions: Managing comorbidities, such as chronic constipation or inflammatory bowel disease, is integral to the overall treatment plan. 

Postoperative Care: 

• Rehabilitation: Physical therapy may be recommended postoperatively to aid in recovery and strengthen pelvic floor muscles. 
• Follow-up: Regular follow-up appointments are important to monitor postoperative healing, address any complications, and assess long-term outcomes. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-a-non-pharmacological-approach-for-treating-rectal-prolapse-and-procidentia

Dietary Modifications: 

• Increased Fiber Intake: A high-fiber diet can prevent or alleviate constipation, reducing the strain during bowel movements. Fiber supplements or dietary adjustments, such as consuming more fruits, vegetables, and whole grains, may be recommended. 

Hydration: 

• Maintaining adequate hydration is essential for softening stools and promoting regular bowel movements. Patients are encouraged to drink an adequate amount of water throughout the day. 

Biofeedback Therapy: 

• Pelvic Floor Exercises (Kegel Exercises): Biofeedback is a non-pharmacological method used to improve pelvic floor muscle function.  

Behavioral Strategies: 

• Bowel Training: Establishing a regular bowel routine can help regulate bowel movements and prevent constipation. Patients are encouraged to set aside time for bowel movements, ideally after meals, to take advantage of the body’s natural reflexes. 

Weight Management: 

• For individuals who are obese, weight management through diet and exercise can reduce intra-abdominal pressure, potentially easing symptoms and preventing further progression. 

Avoidance of Straining: 

• Patients are educated about the importance of avoiding excessive straining during bowel movements. This may include teaching proper toilet habits and techniques. 

Physical Therapy: 

• It involves working with a specialized physical therapist to improve pelvic floor muscle coordination, strength, and overall function. 

Pessary Use: 

• In some cases, especially for women with both uterine prolapse and rectal prolapse, a pessary may be considered to alleviate symptoms. 

Use of Stool Softeners in the treatment of Rectal Prolapse and Procidentia

Stool softeners are commonly used as part of the treatment plan for rectal prolapse and procidentia, especially when constipation is a contributing factor. The primary purpose of stool softeners is to make bowel movements more comfortable and reduce the strain during defecation.  

Stool softeners work by promoting water retention in the stool, making it easier and softner to pass. This helps prevent constipation, a common factor associated with rectal prolapse and procidentia. Constipation and straining during bowel movements can contribute to the development or worsening of rectal prolapse. Stool softeners help in maintaining softer stools, reducing the need for excessive straining. Softening the stool can help minimize discomfort and irritation in the anal and rectal region, providing relief to individuals with rectal prolapse. 

• Docusate Sodium: Docusate sodium is a commonly used stool softener. It works by enhancing the amount of water that the stool can absorb, making it softer and easier to pass. 
• Polyethylene Glycol (PEG): Polyethylene glycol is an osmotic laxative that can also function as a stool softener. It draws water into the stool, resulting in softer and more easily passed bowel movements. 

Use of pain medications in the treatment of Rectal Prolapse and Procidentia

Pain medications may be used in the treatment of rectal prolapse and procidentia to help manage discomfort associated with the condition. However, it’s important to note that pain medications are typically used as part of a broader treatment plan, and the choice of specific medications depends on the pain severity and individual patient factors.  

• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs, such as ibuprofen , may be used to reduce the pain and inflammation associated with rectal prolapse. 
• Acetaminophen (Paracetamol): It is commonly used to relieve pain and reduce fever. While acetaminophen is generally considered safe, patients should adhere to recommended dosages to avoid potential liver toxicity. 
• Opioid Analgesics: Opioid medications, such as oxycodone or tramadol, may be prescribed for moderate to severe pain. 
• Topical Analgesics: Topical analgesic creams or ointments containing agents like lidocaine or prilocaine may be applied locally to the perianal area to alleviate pain and discomfort. 

use-of-intervention-with-a-procedure-in-treating-rectal-prolapse-and-procidentia

Perineal Procedures: 

• Delorme Procedure: The Delorme procedure, also known as a perineal rectosigmoidectomy, involves removing a portion of the rectal mucosa and reinforcing the rectal wall to correct prolapse. Suitable for patients with a full-thickness rectal prolapse without significant internal rectal intussusception. 
• Altemeier Procedure: Similar to the Delorme procedure, the Altemeier procedure involves the removal of a portion of the rectal mucosa and the reinforcement of the rectal wall. Appropriate for cases of rectal prolapse where the prolapsed segment can be easily reduced and is not associated with significant internal rectal intussusception. 

Abdominal Procedures: 

• Rectopexy: It is a surgical procedure that involves repositioning and fixing the rectum to the sacrum to prevent prolapse. It can be performed via an abdominal or laparoscopic approach. Suitable for patients with internal rectal intussusception or significant rectal prolapse. It aims to correct anatomical abnormalities contributing to the prolapse. 
• Rectal Resection: In cases where there is extensive damage to the rectum or associated conditions, a segmental resection of the rectum may be performed. Appropriate for patients with significant rectal pathology, such as tumors or chronic inflammation, requiring removal of a portion of the rectum. 

Combined Procedures: 

• Some patients may benefit from a combination of perineal and abdominal approaches, such as combining the Delorme or Altemeier procedure with rectopexy, to address multiple aspects of the prolapse. 

Stapled Transanal Rectal Resection (STARR): 

• STARR is a minimally invasive procedure that uses a stapling device to remove excess rectal mucosa and correct rectal prolapse. Appropriate for patients with internal rectal intussusception and mucosal prolapse. 

Biofeedback Therapy: 

•  Biofeedback involves a specialized training program to improve pelvic floor muscle function through visual or auditory feedback. Used in combination with other interventions to enhance pelvic floor muscle strength and coordination. 

Transanal Procedures: 

• Transanal excision involves the removal of prolapsed tissue through the anal canal. Suitable for patients with mucosal prolapse or a small segment of full thickness prolapse. 

Transanal Repair Techniques: 

• Various transanal repair techniques, including suturing or stapling, may be employed to correct rectal prolapse through a transanal approach. Used in selected cases based on the characteristics of the prolapse. 

use-of-phases-in-managing-rectal-prolapse-and-procidentia

Phase 1: Evaluation and Diagnosis 

• Medical History: Obtain a thorough medical history that includes information on the symptoms, duration, complicating factors, and previous therapies. 
• Physical Examination: To determine the degree of prolapse and related findings, perform a comprehensive physical examination that includes a digital rectal examination. 
• Diagnostic Tests: Perform additional diagnostic tests as needed, such as colonoscopy, imaging studies (e.g., defecating proctogram), or anorectal manometry, to evaluate the underlying pathology and pelvic floor function. 

Phase 2: Symptomatic Management 

• Conservative Measures: Initiate conservative measures, such as dietary modifications (increased fiber intake), fluid management, and lifestyle changes (e.g., avoiding straining during bowel movements), to alleviate symptoms and improve bowel habits. 
• Medications: Use pharmacological agents as needed to manage symptoms, such as stool softeners to prevent constipation and pain medications to alleviate discomfort. 
• Pelvic Floor Rehabilitation: Consider pelvic floor rehabilitation, including pelvic floor muscle training and biofeedback therapy, to improve pelvic floor muscle function and coordination. 

Phase 3: Surgical Intervention 

• Surgical Evaluation: Based on the patient’s general health, the degree of prolapse at the and the intensity of symptoms, determine whether surgery is necessary. 
• Selection of Procedure: Based on the prolapse’s features, related findings, and the patient’s preferences, choose the most suitable surgical approach. 
• Surgical Intervention: Perform the chosen surgical procedure, which may include perineal procedures (e.g., Delorme or Altemeier procedure), abdominal procedures (e.g., rectopexy or rectal resection), or minimally invasive techniques (e.g., stapled transanal rectal resection). 

Phase 4: Postoperative Care and Rehabilitation 

• Recovery Period: Monitor the patient during the postoperative period for complications and ensure adequate pain management. 
• Dietary Adjustments: Provide dietary guidance and recommendations for postoperative care, including gradual reintroduction of solid foods and maintaining adequate hydration. 
• Physical Therapy: Consider physical therapy and pelvic floor rehabilitation as part of the postoperative recovery process to promote healing and optimize pelvic floor function. 

Phase 5: Long-Term Management and Follow-Up 

• Monitoring and Follow-Up: Make routine follow-up appointments so that you can keep an eye on the patient’s progress, evaluate their bowel movement, and handle any issues or difficulties. 
• Lifestyle Modifications: Encourage long-term lifestyle modifications, including maintaining a healthy diet, regular exercise, and proper bowel habits, to prevent recurrence and optimize long-term outcomes. 
• Patient Education: Provide ongoing education and support to the patient, including information on signs of recurrence, strategies for symptom management, and the importance of adherence to postoperative care instructions. 

Medication

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References

Pediatric Rectal Prolapse:ncbi.nlm.nih 

Evaluation, Diagnosis, and Medical Management:pubmed.ncbi.nlm.nih. 

Rectal prolapse:ncbi.nlm.nih.