The most common presenting complain is a mass protruding from the anus. At first, the mass protrudes only after defecation and it retracts spontaneously. As the disease progresses, it protrudes more often and even during normal daily activities like walking. Eventually there is a full prolapse that may require manual reduction. Sometimes, replacement becomes impossible due to incarceration of the prolapse but this is rare. Some patients may also complain of pain. Other presenting features are prolapse of other pelvic organs, constipation and fecal incontinence [6].

Physical examination will reveal decreased sphincter tone, protruding anal mucosa, thick concentric mucosal rings and sulcus between the rectum and anal canal.

• Pain

  Ten per cent had been labelled 'chronic idiopathic pelvic pain' and 60% had undergone previous haemorrhoidal surgery. Complications were minor and included urinary retention (10%). [ncbi.nlm.nih.gov]

  Anal itch, irritation and pain may also be present. Diagnosis: This is usually made after examination by a doctor. [symptoma.com]

  Pelvic and anorectal pain Pelvic pain remained unchanged after STARR in 20% of patients at one year [ 128 ]. [doi.org]

• Surgical Procedure

  CONCLUSION: Gate Keeper implant is feasible and safe when associated to surgical procedures like Delorme's prolapse resection. Preliminary results are positive even if a study with a larger numbers of patients is needed to confirm the efficacy. [ncbi.nlm.nih.gov]

• Swelling

  Apply an ice pack to help decrease swelling. Be sure to keep a damp cloth between your child's skin and the ice pack so that the cold doesn't damage the skin. For yourself Put on latex gloves, and put lubricating jelly on your finger. [healthlinkbc.ca]

  The scrotal swelling and redness subsided gradually. The child was discharged without any complications. Follow up was uneventful for both the scrotal redness and swelling as well as the rectal prolapse. [dx.doi.org]

• Constipation

  Cause: It is caused mainly by constipation and straining while defecating. [symptoma.com]

  No postoperative constipation or recurrence was reported during the median follow-up period of 6 years (range 2-13). [ncbi.nlm.nih.gov]

• Fecal Incontinence

  Conversely, chronic pelvic pain precluded fecal incontinence improvement (HR, 0.32; 95% CI, 0.135-0.668; P = .0017). [ncbi.nlm.nih.gov]

  Fecal continence was evaluated by using the Rockwood Fecal Incontinence Severity Index score before and 1 year after surgery. [doi.org]

• Rectal Bleeding

  This case, a 63-year-old female patient, had suffered from a rectal prolapse since childhood and presented as a case of rectal cancer. At presentation, she complained of constipation and rectal bleeding for the previous six months. [ncbi.nlm.nih.gov]

  In conclusion, the presence of a rectal polypoid mass with ulceration in a child with obstructed defecation and rectal bleeding should raise the suspicion of SRUS. [doi.org]

  Probably the most common sign heralding colon cancer is rectal bleeding, but this symptom can also be caused by other conditions such as hemorrhoids and rectal prolapse. [verywellhealth.com]

• Rectal Pain

  […] as a primary process often involving hematochezia, rectal pain and tenesmus. [doi.org]

  Rectal Pain Causes Rectal pain has many causes. Common causes are hemorrhoids, anal fissures, and fleeting spasms. Less common causes of may include: Cancer Infection Inflammatory bowel disease Rectal prolapse Foreign bodies in the rectum. [emedicinehealth.com]

  It may be asymptomatic, but it can cause rectal pain, rectal bleeding, rectal malodor, incomplete evacuation and obstructed defecation (rectal outlet obstruction). [en.wikipedia.org]

• Dyschezia

  This is the case of a 72-year-old woman with a previous history of hysterectomy presenting also with dyschezia and moderate incontinence and a grade III rectal prolapse. [websurg.com]

  Pucciani F, Ringressi RM, Giani J (2007) Persistent dyschezia after double stapled transanal rectal resection for outlet obstruction: four case reports. Pelviperineology 26:132–135 Google Scholar 139. [doi.org]

  Compared with each of the three control groups (dyschezia, rectal prolapse without mucosal change, and rectal prolapse with mucosal change), subjects with solitary ulcer syndrome more frequently had an increasing anal pressure at strain (15 vs. 5, 3, [pelvicfloordigest.org]

• Prolapse

  It is often used to describe complete rectal prolapse when in actual sense, it is comprised of three different entities including internal prolapse, mucosal prolapse and full thickness prolapse. [symptoma.com]

  Faecal Incontinence is associated with prolapse in a large percentage of patients, due to the sphincter damage caused by the prolapsed rectum through the anal canal. [ncbi.nlm.nih.gov]

• Urinary Incontinence

  She committed suicide," 30 May 2018 With vaginal deliveries, there is a real possibility not only of vaginal tearing, but pelvic floor problems that can manifest as urinary incontinence, anal sphincter injury and fecal incontinence, and pelvic organ prolapse [merriam-webster.com]

  A 53-year-old female with prior history of abdominal hysterectomy, presented to the urogynecology clinic with complaints of vaginal bulge, urge urinary incontinence, and rectal bulge on straining with no fecal incontinence for several years. [ncbi.nlm.nih.gov]

  Marfan syndrome Ehlers-Danlos disease Urinary incontinence (found in 25–35% of patients with rectal prolapse) Renal calculi (particularly bladder stones) Nutritional disorders Progressive systemic sclerosis Chronic constipation or diarrhea -- To view [unboundmedicine.com]

  As mentioned above, attention should be focused on complaints of constipation, fecal incontinence, and any complaints of urinary incontinence (inability to control urine) or bulging into the vagina. [fascrs.org]

  Other symptoms MAY include: Urinary frequency, nighttime voiding, loss of bladder control and recurrent bladder infections—usually due to the bladder not emptying well Stress urinary incontinence (SUI) with activity such as laughing, coughing, sneezing [uclahealth.org]

• Headache

  The patient’s headache was treated with a single dose of IV toradol 15 mg and her potassium was replenished via IV supplementation. [jeatdisord.biomedcentral.com]

  This autonomic alteration has been found to be gut specific in gut targeted biofeedback in the same way that specificity of response has been described for biofeedback applied to hypertension and tension headache. 13, 14 SRUS is a functional disorder [doi.org]

• Since rectal prolapse is a clinical diagnosis as well a symptom of an underlying disease, investigations should be targeted at identifying these underlying conditions.
• Laboratory tests are usually dictated by the age of the patients and underlying comorbidities. No specific laboratory investigation can aid the diagnosis of rectal prolapse. In children, because of the string association with cystic fibrosis, a sweat chloride test should be performed. Stool examination and culture is also important in this age group [7].
• A barium enema and colonoscopy should be done to evaluate the colon and identify any other colonic lesions. This is important pre-operatively so the conditions may be addressed together and it also helps in making the choice of procedure.
• If it is not clinically possible to distinguish rectal prolapse from mucosal prolapse, video defecography is used while rigid sigmoidoscopy can be used to check for additional lesions in the rectum. Anal manometry, Sitz marker study and pudendal nerve terminal motor lucency are other helpful investigations.

• Medical treatment involves the use of bulking agents, stool softeners, enemas and suppositories. If there is paradoxical contraction of the pelvic floor muscles, biofeedback retraining may be helpful. Underlying factors like constipation or diarrhea should be managed. Despite all these, the mainstay of treatment is surgical.
• The surgical approach could be abdominal or perineal and the choice is dictated by patient’s age and comorbidities [8]. 
• Types of perineal procedures are anal encirclement, Delorme mucosal sleeve resection, Altermeier perineal rectosigmoidoscopy, hemorrhoidectomy, and perineal stapled prolapse resection.
• Abdominal procedures include suture rectopexy, anterior resection, resection rectopexy, and marlex rectopexy. A fifth type, laparoscopic surgical rectopexy is relatively new and is associated with shorter hospital stay and patients comfort [9].

With appropriate treatment, the prognosis is usually favorable. 90% of pediatric patients do well on conservative management. Post-surgical mortality is also very low but there may be complications like bleeding and dehiscence at the op site as well as mucosal ulceration and necrosis of the rectal wall. Recurrence rate ranges from 0% to 50% depending on the type of corrective procedure employed [5].

Even though the cause of this condition remains unclear, over half of the cases have been found to be associated with constipation and chronic straining on defecation. Other factors that may contribute to the development of this condition include previous anal surgery, pregnancy, diarrhea, chronic obstructive pulmonary disease, and benign prostatic hypertrophy. Others are pertussis, parasitic infections like schistosomiasis, neurologic disorder from previous pelvic trauma or spinal tumors and disordered defecation.

Some anatomic features that are present in some patients like patulous anal sphincter, levator diastasis, redundant sigmoid, posterior rectal fixation with a long mesentery and deep anterior Douglas cul-de-sac have been found during surgery for this condition. Whether these features are predisposing factors or results of the condition remains unclear [2].

Cases of rectal prolapse remain highly unreported and as such, the true incidence is unknown. It has a bimodal peak age of occurrence, occurring mostly in the 4th and 7th decades of life. It is primarily a disease of women as up to 80% of affected individuals are female and it occurs together with prolapse of some other organs, like uterus, and pelvic floor descent.

Pediatric patients can also be affected, most commonly in the first year of life. In pediatric age group, the incidence is distributed evenly among both sexes [3].

• There are two main theories to explain the pathophysiology of rectal prolapse, although none has been completely agreed upon. 
• The first theory postulates that it starts as a circumferential internal intussusception of the rectum beginning around 6 – 8 cm proximal to the anal verge. This internal intussusception then progresses to full thickness prolapse as time passes and also due to continued staining. The second theory hold that rectal prolapse is a sliding hernia through a defect in the pelvic fascia. 
• It is however likely that the pathophysiology of mucosal prolapse differs from that of full thickness prolapse and internal intussusceptions [4].
• When the connective tissue of the attachments of the rectal mucosa are loosened and stretched, they allow the tissue to prolapse through the anus leading to mucosal prolapse. This often occurs as a continuation of long standing hemorrhoids. 
• It may also begin initially with prolapse of the anterior rectal wall from where it progresses to full prolapse.

The following may help reduce chances of getting rectal prolapse: avoiding constipation by eating high fiber diet and staying hydrated, Kegel exercises to improve pelvic floor muscles and avoid delaying the urge to defecate [10].

Rectal prolapse is most commonly a disease of the elderly, especially elderly women. It presents with a wide array of symptoms although it could be asymptomatic in many cases [1].

• Definition: Rectal prolapse is the protrusion of part or all of the wall of the rectum through the anus. Not all rectal prolapses can be seen with the eyes.
• Cause: It is caused mainly by constipation and straining while defecating. Some other factors are however associated with developing this condition including pregnancy, childbirth, enlarged prostate, diarrhea, parasitic infections and whooping cough.
• Symptoms: There is usually a mass protruding from the anus, at first it goes back on its own but as it worsens, it has to be pushed back. Other symptoms are leakage of feces, blood or mucus from the anus as well as passing of very small stools. Patients will also feel the need to empty the rectum frequently. Anal itch, irritation and pain may also be present.
• Diagnosis: This is usually made after examination by a doctor. Some investigations might however be required to check for other associated conditions, differentiate the type of prolapse and choose the preferred surgical method.
• Treatment: The definitive treatment is surgery. There are several approaches and the doctor will choose the one which is best for the patient. Medical agents like stool softeners and suppositories maybe used to manage conservatively.

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