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Introduction: Rectal prolapse is prevalent in children and the elderly, impacting quality of life significantly. Traditional surgical interventions carry risks, especially in pediatric patients. Ethanol sclerotherapy offers a less invasive alternative, inducing fibrosis and thickening of the rectal wall. Despite its potential benefits, procedural complications are possible, emphasizing the need for careful patient selection and procedural expertise. This study aims to evaluate the safety and efficacy of sclerotherapy in treating rectal prolapse in a tertiary referral center in southern Iran., Methods: Patient records from Nemazee Hospital covering January 2014 to December 2023 were retrospectively analyzed. Pediatric patients undergoing ethanol sclerotherapy for rectal prolapse were included. Data on demographics, presentation, procedures, and outcomes were collected. Ethical approval was obtained, and specific inclusion/exclusion criteria were applied. Statistical analyses were conducted using SPSS version 26., Results: One hundred thirty patients were evaluated, with a mean age of 10.74 ± 5.320 years. Most patients experienced constipation (56.9%). 74.2% responded well to sclerotherapy, with 12.9% needing a second injection. Complications were minimal, with bleeding being the most common (4.6%). Recurrence occurred in 18.6% of cases. Male patients showed a higher total complication rate (P = 0.010). Diarrhea-dominant patients had no recurrences post-sclerotherapy. Age significantly influenced treatment response and recurrence (P = 0.017, P = 0.035)., Conclusion: Male predominance contradicted global pediatric rectal prolapse ratios, possibly influenced by cultural factors. Sclerotherapy remains effective, though response rates vary. Older age correlated with lower response rates and higher recurrence. Constipation-dominant prolapse was associated with increased recurrence risk. Male patients had a higher complication rate, highlighting the need for tailored management strategies., Competing Interests: Declarations Ethics approval and consent to participate We made sure to secure ethical approval from the Shiraz University of Medical Sciences Institutional Review Board by the ethical approval code of IR.SUMS.MED.REC.1402.471. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Rectal prolapse, or procidentia, is a common pathology for the practicing colorectal surgeon. It is associated with lifestyle limiting symptoms for the patient and frequently co-exists with other types of pelvic prolapse making multidisciplinary management key. It is primarily managed with surgical reconstruction. A number of operative approaches exist, and the optimum procedure is varied dependent upon patient characteristics., Competing Interests: Disclosure The author has nothing to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Anorectal emergencies are rare presentations of common anorectal disorders, and surgeons are often called on to assist in their diagnosis and management. Although most patients presenting with anorectal emergencies can be managed nonoperatively or with a bedside procedure, surgeons must also be able to identify surgical anorectal emergencies, such as gangrenous rectal prolapse. This article provides a review of pertinent anatomy; examination techniques; and workup, diagnosis, and management of common anorectal emergencies including thrombosed hemorrhoids, incarcerated hemorrhoids, anal fissure, anorectal abscess, rectal prolapse, and pilonidal abscess and unique situations including rectal foreign body and anorectal sexually transmitted infections., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background and Study Aims: Outlet obstructive constipation (OOC) is a common type of chronic constipation that is usually caused by internal hemorrhoids (IH) and rectal mucosal prolapse (RMP). Cap-assisted endoscopic sclerotherapy (CAES) was demonstrated to be effective in the treatment of IH and RMP. This study explored the efficacy of CAES in treating OOC associated with IH and RMP., Methods: Thirty-one patients (15 males and 16 females) were diagnosed with OOC after colonoscopy and anorectal manometry (AM). CAES was used to treat IH and RMP. The self-rating anxiety scale (SAS), self-rating depression scale (SDS), and Wexner constipation score (WCS) were used to assess patients at baseline and at the end of follow-up. AM tests were performed before and after CAES., Results: The mean age of patients was 56.19 ± 7.969 years, and the follow-up time was 2.875 ± 3.703 months. After CAES treatment, subjective indices, including frequency of bowel movements (p < 0.05), defecation time (p < 0.05), SAS (p < 0.05), SDS (p < 0.05), and WCS (p < 0.05), were significantly improved. AM showed that the anal relaxation rate (p < 0.05), maximum squeeze pressure (p < 0.05), and rectal residual pressure (p < 0.05) were significantly improved. The ratio of Bristol stool form scale typeIII-Vincreased from 12.5 % to 56.25 % (p < 0.05)., Conclusions: CAES is effective for treating OOC caused by IH and RMP. The relief of OOC symptoms could improve anxiety and depression symptoms associated with the disease., Competing Interests: Declaration of competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Evaluation and management of older adults within emergency care settings is often complex and has the potential for avoidable complications. In an effort to prevent harm to the patient, treatment strategies need to be multifactorial. For geriatric patients presenting with rectal prolapse, unique management strategies, including the use of granulated sugar and gentle pressure, may assist in the reduction of the prolapsed tissue. Additional interventions that are important to incorporate into the older adult's plan of care include gentle approaches to positioning, involvement of family/caregivers, avoiding harmful medications, reducing risk for delirium, and a successful transition of care. A manual reduction completed in the emergency department can relieve discomfort and prevent further complications while the patient awaits surgical evaluation and intervention. Prompt evaluation and management by the advanced practice registered nurse may not only expedite recognition of the prolapse, but can reduce iatrogenic complications that may occur from delayed treatment., Competing Interests: Disclosure: The author reports no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Benign anorectal disease refers to a diverse group of frequent anorectal complaints that cause considerable discomfort, disability, and often constitute a significant problem for the child and his or her family. Hemorrhoids, fissures, rectal prolapse, and perianal abscess and fistulas are the most common anorectal disorders in pediatric population and their appearance may be age-specific. Although they generally follow a benign course, a careful examination must be performed in order to exclude other serious and complicated underlying pathology. Their diagnosis is based on the patient's medical history, physical examination, endoscopy, and imaging. Moreover, the management of these disorders includes medical and surgical treatment options, and if they are treated promptly and properly may be limited and short lived. This review presents the currently available data in the literature on the diverse aspects of these disorders, including the definition, epidemiology, clinical presentation, pathogenesis, diagnosis, indications for surgery, and long-term outcomes., Competing Interests: Conflicts of interest All authors declare that they have no conflict of interest., (Copyright © 2022 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

Background: Pelvic organ prolapse is a common problem in women. About 40% of women will experience prolapse in their lifetime, with the proportion expected to rise in line with an ageing population. Women experience a variety of troublesome symptoms as a consequence of prolapse, including a feeling of 'something coming down' into the vagina, pain, urinary symptoms, bowel symptoms and sexual difficulties. Treatment for prolapse includes surgery, pelvic floor muscle training (PFMT) and vaginal pessaries. Vaginal pessaries are passive mechanical devices designed to support the vagina and hold the prolapsed organs back in the anatomically correct position. The most commonly used pessaries are made from polyvinyl-chloride, polythene, silicone or latex. Pessaries are frequently used by clinicians with high numbers of clinicians offering a pessary as first-line treatment for prolapse.  This is an update of a Cochrane Review first published in 2003 and last published in 2013., Objectives: To assess the effects of pessaries (mechanical devices) for managing pelvic organ prolapse in women; and summarise the principal findings of relevant economic evaluations of this intervention., Search Methods: We searched the Cochrane Incontinence Specialised Register which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings (searched 28 January 2020). We searched the reference lists of relevant articles and contacted the authors of included studies., Selection Criteria: We included randomised and quasi-randomised controlled trials which included a pessary for pelvic organ prolapse in at least one arm of the study., Data Collection and Analysis: Two review authors independently assessed abstracts, extracted data, assessed risk of bias and carried out GRADE assessments with arbitration from a third review author if necessary., Main Results: We included four studies involving a total of 478 women with various stages of prolapse, all of which took place in high-income countries. In one trial, only six of the 113 recruited women consented to random assignment to an intervention and no data are available for those six women. We could not perform any meta-analysis because each of the trials addressed a different comparison. None of the trials reported data about perceived resolution of prolapse symptoms or about psychological outcome measures. All studies reported data about perceived improvement of prolapse symptoms. Generally, the trials were at high risk of performance bias, due to lack of blinding, and low risk of selection bias. We downgraded the certainty of evidence for imprecision resulting from the low numbers of women participating in the trials. Pessary versus no treatment: at 12 months' follow-up, we are uncertain about the effect of pessaries compared with no treatment on perceived improvement of prolapse symptoms (mean difference (MD) in questionnaire scores -0.03, 95% confidence interval (CI) -0.61 to 0.55; 27 women; 1 study; very low-certainty evidence), and cure or improvement of sexual problems (MD -0.29, 95% CI -1.67 to 1.09; 27 women; 1 study; very low-certainty evidence). In this comparison we did not find any evidence relating to prolapse-specific quality of life or to the number of women experiencing adverse events (abnormal vaginal bleeding or de novo voiding difficulty). Pessary versus pelvic floor muscle training (PFMT): at 12 months' follow-up, we are uncertain if there is a difference between pessaries and PFMT in terms of women's perceived improvement in prolapse symptoms (MD -9.60, 95% CI -22.53 to 3.33; 137 women; low-certainty evidence), prolapse-specific quality of life (MD -3.30, 95% CI -8.70 to 15.30; 1 study; 116 women; low-certainty evidence), or cure or improvement of sexual problems (MD -2.30, 95% -5.20 to 0.60; 1 study; 48 women; low-certainty evidence). Pessaries may result in a large increase in risk of adverse events compared with PFMT (RR 75.25, 95% CI 4.70 to 1205.45; 1 study; 97 women; low-certainty evidence). Adverse events included increased vaginal discharge, and/or increased urinary incontinence and/or erosion or irritation of the vaginal walls. Pessary plus PFMT versus PFMT alone: at 12 months' follow-up, pessary plus PFMT probably leads to more women perceiving improvement in their prolapse symptoms compared with PFMT alone (RR 2.15, 95% CI 1.58 to 2.94; 1 study; 260 women; moderate-certainty evidence). At 12 months' follow-up, pessary plus PFMT probably improves women's prolapse-specific quality of life compared with PFMT alone (median (interquartile range (IQR)) POPIQ score: pessary plus PFMT 0.3 (0 to 22.2); 132 women; PFMT only 8.9 (0 to 64.9); 128 women; P = 0.02; moderate-certainty evidence). Pessary plus PFMT may slightly increase the risk of abnormal vaginal bleeding compared with PFMT alone (RR 2.18, 95% CI 0.69 to 6.91; 1 study; 260 women; low-certainty evidence). The evidence is uncertain if pessary plus PFMT has any effect on the risk of de novo voiding difficulty compared with PFMT alone (RR 1.32, 95% CI 0.54 to 3.19; 1 study; 189 women; low-certainty evidence)., Authors' Conclusions: We are uncertain if pessaries improve pelvic organ prolapse symptoms for women compared with no treatment or PFMT but pessaries in addition to PFMT probably improve women's pelvic organ prolapse symptoms and prolapse-specific quality of life. However, there may be an increased risk of adverse events with pessaries compared to PFMT. Future trials should recruit adequate numbers of women and measure clinically important outcomes such as prolapse specific quality of life and resolution of prolapse symptoms.   The review found two relevant economic evaluations. Of these, one assessed the cost-effectiveness of pessary treatment, expectant management and surgical procedures, and the other compared pessary treatment to PFMT., (Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

The surgical management of children with rectal prolapse is wide ranging and without consensus within the pediatric surgical community. While the majority of rectal prolapse in infants and children resolves spontaneously or with the medical management of constipation, a small but significant subset of patients may require intervention for persistent symptoms. In this review, we discuss the etiology and pathophysiology of rectal prolapse in both infants and children, options for medical management, described interventions and surgical options and their outcomes, and future avenues for research and investigation., Competing Interests: None declared., (Thieme. All rights reserved.)

Purpose: Rectal prolapse is a relatively common condition in infants and young children with a multifactorial etiology. Despite its prevalence, there remains clinical equipoise with respect to secondary treatment in pediatric surgery literature. We conducted a systematic review to evaluate methods of secondary treatment currently used to treat rectal prolapse in children., Methods: We searched Pubmed, Medline, and Scopus with the terms "rectal prolapse" and "children" for papers published from 1990 to April 2017. Papers satisfying strict criteria were analyzed for patient demographics, intervention, efficacy, and complications. Procedures were grouped by like type. Pooled success rates were calculated., Results: Twenty-seven studies documenting 907 patients were included. Injection sclerotherapy had an overall initial success rate of 79.5%. Ethyl alcohol seemed the best sclerosing agent due to a high first-injection success rate, low complication rate, and ready accessibility. Several perineal repairs were found, with operative success rates ranging from 60.8%-100%. Laparoscopic rectopexy with mesh was the most commonly reported transabdominal procedure and had an overall success rate of 96.1%. Postoperative complications from all procedures were comparable., Conclusion: Though many secondary treatment options have been reported for rectal prolapse, sclerotherapy and laparoscopic rectopexy predominate in contemporary literature and appear to have high success and low complication rates., Level of Evidence: IV., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Sclerotherapy is a commonly utilized treatment for rectal prolapse in children. This study systematically evaluates the effectiveness and complications of various sclerosing agents in treating pediatric rectal prolapse., Methods: After protocol registration (CRD-42018088980), multiple databases were searched. Studies describing injection sclerotherapy for treatment of pediatric rectal prolapse were included, with screening and data abstraction duplicated. The methodological quality of included papers was assessed using the Methodological Index for Non-Randomized Studies (MINORS) score., Results: Nineteen studies were identified, published between 1970 and 2017. Most studies were single institution case series, with median "N" 57+/-88.9 and mean MINORS score of 0.51+/-0.17 (perfect score = 1). 1510 patients with a mean age of 4.5 years were accounted for: 36.2% female, most without comorbidities. Mean follow up length was 30 months. The most common sclerosing agent described was ethanol (45%), followed by phenol (33%). The mean number of treatments per patient was 1.1+/-0.34. The overall success rate after a single sclerotherapy treatment was 76.9%+/-8.8%. The overall complication rate was 14.4%+/-2%., Conclusions: Injection sclerotherapy appears effective and low-risk in the treatment of pediatric rectal prolapse and should be considered before more invasive surgical options. The available evidence is of relatively poor quality, and prospective comparative investigations are warranted., Level of Evidence: 3 (meta-analysis of level 3 studies)., (Copyright © 2019. Published by Elsevier Inc.)

Rectal prolapse, rectal procidentia, "complete" prolapse or "third-degree" prolapse is the full-thickness prolapse of the rectal wall through the anal canal and has a significant impact on quality of life. The incidence of rectal prolapse has been estimated to be approximately 2.5 per 100,000 inhabitants with a clear predominance among elderly women. The aim of this consensus statement was to provide evidence-based data to allow an individualized and appropriate management and treatment of complete rectal prolapse. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL and EMBASE. The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by the American College of Gastroenterology's Chronic Constipation Task Force. Five evidence levels were defined. The recommendations were graded A, B, and C.

Background: Rectal prolapse-both external rectal prolapse and internal rectal prolapse-is a disabling condition. In view of the overwhelming number of surgical procedures described for the treatment of rectal prolapse, a comprehensive update concerning the diagnostic and therapeutic pathway for this condition is required to draw recommendations for clinical practice. This initiative was commissioned by the Dutch Association for Surgery (Nederlandse Vereniging voor Heelkunde) as a multidisciplinary collaboration., Methods: Nine questions outlining the diagnostic approach, conservative and surgical management of rectal prolapse were selected. A systematic literature search for evidence was then conducted in the Medline and Embase databases., Results: Recommendations included diagnostic approach, methods to assess complaints of fecal incontinence and/or obstructive defecation and treatment options, both conservative and surgical. A level of evidence was assigned to each statement following the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system., Conclusions: These guidelines for clinical practice are useful in the diagnosis and treatment of rectal prolapse. There are many statements requiring a higher level of evidence due to a lack of studies.

Anorectal disorders are very common among a wide population of patients. Because patients may be embarrassed about the anatomic location of their symptoms, they may present to care late in the course of their illness. Care should be taken to validate patient concerns and normalize fears. This article discusses the diagnoses and management of common anorectal disorders among patients presenting to a primary care physician., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Known since antiquity, rectal prolapse was first studied systematically by Hippocrates (460-377 BC) who recognized the predisposing factors and proposed several therapeutic approaches such as defecation positions, manual retraction and specific herbal or mineral based anti-haemorrhagic and pain-killing poultices. Hippocratic medicine avoided invasive surgical procedures probably due to a lack of knowledge in human anatomy. However, Hippocrates' views astonishingly lasted in time, presenting similarities to current medical theories on rectal prolapse., (© Acta Gastro-Enterologica Belgica.)

Competing Interests: Competing interests: None declared.

Aim of the Study: To review the outcomes of injection sclerotherapy with oily phenol for mucosal rectal prolapse., Methods: Retrospective case note review of all children who underwent sclerotherapy with oily phenol injection as primary surgical intervention for mucosal rectal prolapse, from January 2007 to December 2015., Main Results: A total of 31 patients were identified. Mean age at presentation was 4.8 years (range 5 months-12 years). 23 patients with mucosal rectal prolapse underwent injection sclerotherapy with oily phenol as primary procedure. Patients with full-thickness rectal prolapse (n = 6) and 2 with mucosal prolapse who had Thiersch stitch were excluded from the study. The cause for mucosal rectal prolapse was considered to be due to constipation (n = 15), idiopathic (n = 7), spina bifida (n = 1). Follow-up was for minimum 6 months (median = 4 years; range 6 months-17 years). Recurrence following injection sclerotherapy with oily phenol requiring further procedures was 30.4% (7/23)., Conclusions: Injection sclerotherapy with oily phenol is a safe, effective and minimally invasive primary treatment option for mucosal rectal prolapse not responding to conservative management. In case of recurrence, a cautious re-examination under anaesthesia should be undertaken to exclude a missed full-thickness rectal prolapse before reinjecting.

Introduction and Hypothesis: Defecatory dysfunction is a relatively common and challenging problem among women and one that practicing pelvic reconstructive surgeons and gynecologists deal with frequently. A subset of defecatory dysfunction includes obstructed defecation, which can have multiple causes, one of which is descending perineum syndrome (DPS)., Methods: A literature search was performed to identify the pathophysiology, diagnosis, and management of DPS., Results: Although DPS has been described in the literature for many decades, it is still uncommonly diagnosed and difficult to manage. A high index of suspicion combined with physical examination consistent with excess perineal descent, patient symptom assessment, and imaging in the form of defecography are required for the diagnosis to be accurately made. Primary management options of DPS include conservative measures consisting of bowel regimens and biofeedback. Although various surgical approaches have been described in limited case series, no compelling evidence can be demonstrated at this point to support surgical intervention., Conclusions: Knowledge of DPS is essential for the practicing pelvic reconstructive surgeon to make a timely diagnosis, avoid harmful treatments, and initiate therapy early on.

Rectal prolapse is a herniation of the rectum through the anus. It is rare in children. When it does occur, it is usually prior to 4 years of age and due to anatomical variants. A few conditions predispose children to rectal prolapse, the most common being constipation. Cystic fibrosis used to be commonly associated with rectal prolapse, but with the advent of cystic fibrosis newborn screening, this association is no longer as frequently seen. Many recent case reports, detailed in this chapter, describe conditions previously unknown to be associated with rectal prolapse. Management is usually supportive; however, rectal prolapse requires surgical management in certain situations. This review details the presentation of rectal prolapse, newly described clinical manifestations, and associated conditions, and up-to-date medical and surgical management.

Many techniques are described to manage recurrent rectal prolapse in children, including repeated Thiersch stitch, phenol injections, Delorme and Altemeier procedures, and rectopexy. We describe a case of successful treatment of rectal prolapse by placing three Thiersch sutures circumferentially along the anal canal--a simple and novel modification of a well-known procedure. An 8-year-old boy with full-thickness rectal prolapse was treated with laxatives to no avail. He was subsequently treated with phenol-in-almond-oil injection and insertion of a 1/0PDS Thiersch suture. The effects were temporary with recurrence 3 months later. A further phenol-in-almond-oil injection was given and a 1/0PDS Thiersch suture placed, and the patient was discharged on laxatives. Recurrence occurred again at 3 months. This was treated with three circumferential Thiersch sutures along the anal canal--one Prolene 2/0 and two 1/0PDS. There has been no recurrence at follow-up. Placement of three sequential Thiersch sutures along the rectum is effective in treating recurrent rectal prolapse and a good alternative to major rectopexy., (2015 BMJ Publishing Group Ltd.)

Background: Fecal incontinence is frequently associated with rectal prolapse, but little is known about recovery after treatment of the prolapse., Objective: We therefore aimed to investigate the long-term outcome of fecal incontinence in a cohort of patients suffering from full-thickness rectal prolapse., Design: A database of 145 patients diagnosed with full-thickness rectal prolapse was compiled prospectively over a 7-year period (2003-2010)., Main Outcome Measures: Patients were referred to a single institution and assessed by standardized questionnaires, anorectal manometry, endosonography, and evacuation proctography. Fecal incontinence was evaluated according to the Cleveland Clinic Score; continence improvement was defined by ≥50% improvement of the Cleveland Clinic Score., Results: Among the population studied (134 women, 11 men; median follow-up, 38.9 months [range, 21.2-67.2]), 103 patients (71%) underwent operation for their prolapse and 42 (29%) did not. According to the Cleveland Clinic Score, 139 patients (96%) suffered from fecal incontinence before treatment and 64 (46%) reported improvement at the end of the follow-up. Pretreatment history of incontinence symptoms for >2 years (hazard ratio [HR], 1.99; 95% CI, 1.14-3.46; P = .015) and ventral rectopexy (HR, 1.86; 95% CI, 1.026-3.326; P = .04) were associated with continence improvement. Patients who underwent an operative procedure other than ventral rectopexy had similar outcome as compared with nonoperated patients. Conversely, chronic pelvic pain precluded fecal incontinence improvement (HR, 0.32; 95% CI, 0.135-0.668; P = .0017)., Limitations: Follow-up, returned questionnaires, and the heterogeneous reasons put forth for declining surgery may introduce some methodologic bias., Conclusion: Fecal incontinence in patients suffering from rectal prolapse is improved when ventral rectopexy is performed compared with other operative or medical therapies., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Defecography is a study to assess anorectal function during evacuation., Objective: To investigate the value of fluoroscopic defecography in directing diagnostic and therapeutic management in children with defecation disorders., Materials and Methods: We reviewed all fluoroscopic defecography studies performed (2003-2009) in children with defecation problems and normal anorectal motility studies. Results were classified into three groups: (1) normal pelvic floor function; (2) pelvic floor dyssynergia, including incomplete relaxation of pelvic musculature, inconsistent change in anorectal angle and incomplete voluntary evacuation; (3) structural abnormality, including excessive pelvic floor descent with an intra-rectal intussusception, rectocele or rectal prolapse., Results: We included 18 patients (13 boys, median age 9.1 years). Indication for fluoroscopic defecography was chronic constipation in 56%, fecal incontinence in 22% and rectal prolapse in 22%. Defecography showed pelvic floor dyssynergia in 9 children (50%), a structural abnormality in 4 (22%) and normal pelvic floor function in 5 (28%). In 12 children (67%) the outcome of fluoroscopic defecography directly influenced therapeutic management. After defecography 4 children (22%) were referred for anorectal biofeedback treatment, 4 children (22%) for surgery, 2 children (11%) for additional MR defecography, and 1 child to the psychology department, and medication was changed in 1 child. In 6 children (33%) the result did not change the management. In 9 children (75%) the change of management was successful., Conclusions: Fluoroscopic defecography can be a useful tool in understanding the pathophysiology and it may provide information that impacts management of children with refractory defecation disorders.

Background: Aluminum potassium sulfate and tannic acid is a sclerosant used for sclerosing therapy in the treatment of hemorrhoids, and a Leeds-Keio artificial ligament is a new anal-encircling material for the management of rectal prolapse., Objective: The aim of this study was to evaluate clinical data and recurrence rates in patients with rectal prolapse undergoing combined aluminum potassium sulfate and tannic acid injection and anal encirclement using the Leeds-Keio artificial ligament., Design: This was a retrospective review of patients who underwent this procedure., Settings: This study was conducted at a community-based hospital within a specialized colorectal unit., Patients: A total of 23 patients (20 women; median age, 83 years) with full-thickness rectal prolapse underwent treatment between 2005 and 2010., Main Outcome Measures: The main outcome measures were morbidity and recurrence rate., Results: The median duration of surgery was 36 minutes. Mean total injection dose of aluminum potassium sulfate and tannic acid was 30 mL. There were no postoperative deaths. Wound infection occurred in 2 patients (9%), and new or worsening symptoms of constipation after surgery occurred in 6 patients (26%). There were 3 recurrences at a median follow-up of 36 months (range, 7-86 months). Recurrence rate at 5 years was 14% (95% CI, 5%-35%)., Limitations: The limitations of this study include its retrospective nature, the potential for selection bias, and lack of a control group., Conclusions: This procedure is quick and easy to perform, with no formidable morbidity, and the recurrence rate is reasonably low. Therefore, it seems to be a reasonable alternative for rectal prolapse in frail, elderly, and high-risk patients.

Background: Rectal intussusception and external rectal prolapse are uncommon proctographic findings in men reflecting the lack of studies investigating such patients. The aim of this study was to identify the demographic, clinical, and physiological characteristics of this population with a view to appreciate the mechanism of development of this condition., Methods: All men, presenting with symptoms of constipation or fecal incontinence, who were diagnosed proctographically with recto-rectal intussusception (RRI)/recto-anal intussusception (RAI) or external rectal prolapse (ERP) between 1994 and 2007 at a tertiary academic colorectal unit were studied. Demographics, relevant comorbidities, distribution and symptom duration, and anorectal physiology results were analyzed retrospectively for each proctographic group and intergroup comparisons performed., Results: Two hundred five men (median age 50 y; range, 13-86) including 155 (75.6%) without any relevant comorbidities were studied. A significant proportion of patients in all proctographic groups reported rectal evacuatory difficulty ([RRI, 46.4%], [RAI, 39.4%], [ERP, 44.8%]; P = 0.38,analysis of variance). Patients also reported a combination of fecal incontinence symptoms (e.g., urge, passive, postdefecatory leakage) that did not differ across the proctographic groups. Anorectal physiological parameters were within normal range and were not found to be statistically different between the proctographic groups with the exception of anal resting pressure, which was lowest in ERP patients (62 cm H2O; range, 14-155) compared with patients with RRI (89 cm H2O; range, 16-250; P = 0.003) and RAI (92 cm H2O; range, 38-175; P = 0.006)., Conclusions: Men with rectal intussusception and prolapse present with a combination of symptoms, predominantly defective rectal evacuation. Anorectal physiological assessment has failed to shed light into the mechanism of development of this condition and thus, the need for large observational studies incorporating integrated defecographic and manometric assessments of the evacuation process., (Crown Copyright © 2014. Published by Elsevier Inc. All rights reserved.)

Rectal prolapse can present in a variety of forms and is associated with a range of symptoms including pain, incomplete evacuation, bloody and/or mucous rectal discharge, and fecal incontinence or constipation. Complete external rectal prolapse is characterized by a circumferential, full-thickness protrusion of the rectum through the anus, which may be intermittent or may be incarcerated and poses a risk of strangulation. There are multiple surgical options to treat rectal prolapse, and thus care should be taken to understand each patient's symptoms, bowel habits, anatomy, and pre-operative expectations. Preoperative workup includes physical exam, colonoscopy, anoscopy, and, in some patients, anal manometry and defecography. With this information, a tailored surgical approach (abdominal versus perineal, minimally invasive versus open) and technique (posterior versus ventral rectopexy +/- sigmoidectomy, for example) can then be chosen. We propose an algorithm based on available outcomes data in the literature, an understanding of anorectal physiology, and expert opinion that can serve as a guide to determining the rectal prolapse operation that will achieve the best possible postoperative outcomes for individual patients.

Background: Perineal approaches are widely applied for the treatment of rectal prolapse. Recently, less-invasive treatments such as sclerotherapy using aluminum potassium sulfate/tannic acid (ALTA) have been introduced for internal hemorrhoids. Herein, we report the results of ALTA injection for the treatment of rectal prolapse in high-risk patients., Methods: Between January 2009 and March 2011, we performed ALTA injection sclerosing therapy in 12 female patients with high risk for preoperative complications. Using the perineal approach, 0.5 to 1 mL of ALTA was injected into the submucosa at 30 to 60 different sites., Results: All patients were successfully treated without any operative or postoperative morbidity. Average operation time took 35±7 (mean±SD) minutes, and average volume of ALTA injected was 39±6 mL per patient. Neither complaints of bleeding nor findings of anal stenosis were noted. A slight degree of recurrence of prolapse developed in a patient after 8 months. The patient required an additional injection to be cured., Conclusions: ALTA injection could be administered for the treatment of rectal prolapse without any pain or complication and would be useful even for patients with risks due to preoperative complications and/or medical history.

Rectal prolapse, the protrusion of the layers of the rectal wall through the anal canal, may be partial (mucosal) or complete (full thickness). Although prolapse is most common among older women, it affects individuals of all ages, including children. Associated fecal incontinence and constipation are typical. Urinary incontinence and uterovaginal/bladder prolapse also may coexist. Some patients may have rectal ulcers. Diagnosis is predominantly clinical; visualization of the prolapse may require the patient to strain while sitting or squatting. Imaging studies, including fluoroscopic or dynamic magnetic resonance defecography, can confirm the prolapse if the diagnosis is uncertain, and endoscopy can aid in detecting other colonic/extracolonic pathology. Nonsurgical management (eg, increased fiber intake, fiber supplements, biofeedback) often is therapeutic in minor (first- or second-degree) mucosal prolapse and can help alleviate constipation and incontinence before and after surgery for patients with full-thickness prolapse. However, for full-thickness prolapse, transabdominal procedures are the most effective management and are favored for healthy patients, irrespective of age. Perineal procedures (eg, rubber band ligation, mucosal excision) can be used for patients with full-thickness prolapse who are not candidates for transabdominal surgery and for those with second- and third-degree mucosal prolapse.

Background/purpose: Sclerosing agents injected into the rectal submucosal area produce an inflammatory response and scar that prevent rectal prolapse. This study aimed to investigate the histopathological changes following submucosal injection of different sclerosing agents in rats., Methods: Rats (n=35) were divided into control, sham, and five experimental groups, each treated with a different sclerosing agent: cow's milk, 30% saline solution, 30% dextrose solution, 70% ethyl alcohol, and 5% phenol in almond oil (PAO). All agents were injected into the submucosal area. After 4 weeks, all animals were sacrificed. Histopathological evaluation was performed according to a semi-quantitative fibrosis scoring system (grades 0 to 3), by using Masson trichrome and hematoxylin and eosin staining., Results: Histopathological changes in the 5% phenol in almond oil group were significantly different from other groups (p=0.0001). Prominent submucosal fibrosis (grade 3), lymphatic vascular dilation, foreign body reaction, and lipogranuloma were observed in the 5% PAO group (p=0.007). No significant histopathological differences were seen between the 30% saline, 30% dextrose, and 70% ethyl alcohol groups. Significantly increased mucosal fibroblast proliferation (grade 2) was seen in 60% rats of the 30% dextrose group (p=0.026). The cow's milk and ethyl alcohol groups had mucosal erosions and congestion (grade 1) which were significantly different from the control group (p=0.024). No statically significant difference was observed between the 30% saline group and the control group., Conclusions: In this study we showed that 5% PAO can induce some histopathological changes in the submucosal area that increase the mucosal tightness of the mucosa, which are necessary for the treatment of rectal prolapse., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Surgery is the only validated means of treating overt rectal prolapses, but both patients and physicians may decline or postpone the surgical approach. However, little is known on the functional outcome of nonoperated rectal prolapse. The aim of the present study was to highlight the natural history of overt rectal prolapse in patients for whom surgery was avoided or delayed., Patients and Methods: A total of 206 patients complaining of full-thickness rectal prolapse were referred to a single institution that provided anorectal physiology for functional anorectal disorders. Standardized questionnaires, anorectal manometry, endosonography, and evacuation proctography constituted a prospective database. Fecal incontinence was evaluated with the Cleveland Clinic score (CCIS), and constipation was evaluated with the Knowles Eccersley Scott Symptom score (KESS)., Results: Forty-two nonoperated patients (mean age: 61 ± 16 years) were compared to those of operated patients paired according to age and gender: the mean follow-up was 44 ± 26 months. The two groups had a similar past-history, follow-up, stool frequency, and main complaints, but lower quantified symptomatic scores and a better quality of life were reported in the nonsurgical group. At the end of follow-up, the nonsurgical group did not show any variation in CCI and KESS scores. By contrast, these two scores significantly improved in the rectopexy group. Sixteen nonoperated patients experienced a degradation of their continence status with an average increase of 5 ± 4.3 points of the CCIS. The patients with a CCIS <7 at referral were likely to deteriorate as compared to those having a higher score. Patients with a symptom history longer than 4 years never improved and in two-thirds continence deteriorated throughout the follow-up., Conclusion: In the absence of the surgical option, patients with a 4-year duration of rectal prolapse and those with mild incontinence had no chance of improvement. These findings may be taken into account when surgery of rectal prolapse is not chosen.

Background: Pelvic organ prolapse is common, with some degree of prolapse seen in up to 50% of parous women in a clinic setting, although many are asymptomatic. The use of pessaries (a passive mechanical device designed to support the vagina) to treat prolapse is very common, and up to 77% of clinicians use pessaries for the first line management of prolapse. A number of symptoms may be associated with prolapse and treatments include surgery, pessaries and conservative therapies. A variety of pessaries are described which aim to alleviate the symptoms of prolapse and avert or delay the need for surgery., Objectives: To determine the effectiveness of pessaries (mechanical devices) for pelvic organ prolapse., Search Methods: We searched the Cochrane Incontinence Group Specialised Register of trials (searched 13 March 2012), which includes searches of CENTRAL, MEDLINE, PREMEDLINE and handsearching of conference proceedings, and handsearched the abstracts of two relevant conferences held in 2011. We also searched the reference lists of relevant articles., Selection Criteria: Randomised and quasi-randomised controlled trials which included a pessary for pelvic organ prolapse in one arm of the study., Data Collection and Analysis: Abstracts were assessed independently by two authors with arbitration from a third if necessary. Data extraction was completed independently for included studies by two review authors., Main Results: To date there is only one published randomised controlled trial assessing the use of pessaries in the treatment of pelvic organ prolapse., Authors' Conclusions: The review authors identified one randomised controlled trial comparing ring and Gellhorn pessaries. The results of the trial showed that both pessaries were effective for the approximately 60% of women who completed the study with no significant differences identified between the two types of pessary. However, methodological flaws were noted in the trial, as elaborated under risk of bias assessment. There is no consensus on the use of different types of device, the indications nor the pattern of replacement and follow-up care. There is an urgent need for randomised studies to address the use of pessaries in comparison with no treatment, surgery and conservative measures.

Prolapse rectum (PR) or protrusion of the rectum beyond the anus occurs frequently in populations at both extremes of age. In the pediatric population, in developed countries, the commonest cause for PR is thought to be cystic fibrosis (CF). Treatment options for CF include conservative management, surgical resection and fixation, suturing, and injection sclerotherapy (IS). The last is considered an attractive treatment option because it is minimally invasive. In this case report, the authors present the details about a 2-year-old female child, with PR and CF, who died after IS, using phenol as the sclerotherapeutic agent. Autopsy findings and toxicology tests performed to establish phenol toxicity are documented. The available literature is reviewed. This case report underscores the risks of using phenol for IS and emphasizes the point that the procedure is not innocuous and an adverse outcome including fatality is a possibility., (© 2012 American Academy of Forensic Sciences.)

Evisceration of the small bowel through a rectal perforation is rare. This is the case of a 66 year-old female presenting to the Accident and Emergency Department with transanal evisceration of her small bowel resulting from attempted digital reduction and subsequent tear of her chronically prolapsing rectum. Reduction of the prolapsed small bowel and primary repair of the rectal tear were carried out at laparotomy. The management of this case is discussed.

We report the case of a newborn with acute myeloid leukaemia, who developed perineal necrotizing fasciitis due to Pseudomonas Aeruginosa, after twenty days of life. Following surgical debridement, she was effectively treated with topical negative pressure therapy (V.A.C.(R) device) with silver foam dressings, this achieved complete closure in thirteen days. Negative pressure therapy should be considered when conventional wound care fails to achieve complete wound closure, even in neonates.

Purpose: The management of recurrent rectal prolapse following initial surgical procedures remains unclear. We present a series of pediatric patients with rectal prolapse and describe their surgical management, and the subsequent care for those children developing recurrence., Methods: The records of 29 pediatric patients with rectal prolapse refractory to conservative medical management who were managed with primary modified Thiersch procedures over a 14-year period were reviewed. Initial surgical management consisted of a modified version of the Thiersch anal encirclement procedure, which involved a combination of injection sclerotherapy, linear cauterization, and placement of a Thiersch anal encirclement absorbable stitch. Age at initial procedure, predisposing conditions, complications, recurrence, time to recurrence, and subsequent procedures utilized were reviewed., Results: Of 29 patients, 22 (71%) were male with a mean age at time of first Thiersch procedure of 7.1 years (range 3 months to 19 years). Seven patients were lost to follow-up. Nineteen patients (90%) experienced resolution of their prolapse following one or two modified Thiersch procedures; 14 (67%) following an initial Thiersch and 5 (23%) following a subsequent Thiersch. One additional child experienced recurrence after an initial Thiersch procedure, and underwent a perineal resection of redundant rectum (modified Altemeier procedure). Two patients developed a recurrence after their second Thiersch. These cases both required a modified Altemeier procedure. Mean follow-up for all patients was 1.5 years., Conclusion: For pediatric rectal prolapse refractory to conservative medical therapy, the modified Thiersch procedure appears reasonable. Initial recurrences are not uncommon, and their incidence increases with the age of the child. Recurrences should be initially managed by a repeat Thiersch procedure. However, subsequent recurrences should be treated with a modified Altemeier.

Background: To assess the role of the surged faradic stimulation to the pelvic floor muscles as an adjunct to the conservative management in the children of idiopathic rectal prolapse., Study Design: Prospective., Setting: Pediatric Surgery Department, Pt BD Sharma, Post Graduate Institute of Medical Sciences, Rohtak., Subjects: 47 consecutive children with idiopathic rectal prolapse attending the Pediatric Surgery out patient department from July 2005 to June 2006., Methodology: The information pertaining to duration and the extent of rectal prolapse, predisposing or associated medical conditions, results of local clinical examination were noted. Surged faradic stimulation using modified intraluminal rectal probe, was given on the alternate days. The conventional conservative medical management was also continued. The extent of relief and the number of the sittings of faradic stimulation required were noted at various stages of follow-ups., Statistical Methods: Mean values between those completely cured and others; poor responders and others were compared with t-test and proportions were compared with Chi square test. The p-value < 0.05 was considered statistically significant., Results: The mean number of sittings in the completely cured group (n = 28(64%)) was (12.4 +/- 7.8) and was comparable with very poor responder (n = 6(13%). There was higher percentage of relief (76%) at the first follow up (at 15 days) in completely cured Vs other (37%) and also the poor responders showed (20%) Vs other (68%) and was statistically significant., Conclusion: With use of faradic stimulation, even the long-standing rectal prolapse can be fully cured. The follow up visit at 2 weeks is very important to gauge the likely success of this modality in treatment of the patients with rectal prolapse. Those showing poor response at this stage may require alternative treatment or take a long time to get cured.

Indication: The management of rectal prolapse in presence of high-risk comorbidities can be challenging. We report the use of an anal plug as a noninvasive alternative in patients with contraindication of surgery., Method: This small device opens up in about 30 s to fit the contour of the lower rectum avoiding faecal leakage or in our case, the rectal prolapse. Although the plug is poorly tolerated in some cases, this device may be used up to 12 h per day and no adverse effects have been reported. COMPARISON WITH OTHER METHODS: Nonsurgical alternatives described in the literature, such as sclerotherpy in children, are not routinely used in the adult population. The main advantage of the anal plug is its simplicity and safety as in the series published for the treatment of faecal incontinence no adverse events were described., Conclusion: An anal plug for rectal prolapse is an alternative in high-risk patients or during the time before surgical treatment.

This article has summarized the assessment of a woman with pelvic floor muscle dysfunction or pain complaints and has briefly described the interventions used to treat women with these concerns. The American Physical Therapy Association explains: "As a woman in today's world, you enjoy a life of many choices. The choices we make will determine the way we use our body through the decades. A physical therapist will be there for you as you progress through all stages of your life."

Anorectal disorders like haemorrhoids, rectal prolapse, anal fissures, peri-anal fistulae and sexually transmitted diseases are bothersome benign conditions that warrant special attention. They, however, can all be diagnosed by inspection or proctoscopy (sexually transmitted proctitis). Constipation can play an underlying role in haemorrhoids, rectal prolapse and anal fissures, and it is important to treat these conditions in order to avoid recurrences. Haemorrhoids and anal fissures are generally treated conservatively and surgery is seldom required. Rectal prolapse and cryptoglandular peri-anal fistulae are treated surgically. In a recurrent peri-anal fistula, the fistular tract needs to be visualised with anal ultrasound or magnetic resonance imaging (MRI). There are different techniques available for this evaluation, and care must be taken not to damage the anal sphincter. Peri-anal fistulae in Crohn's disease are treated conservatively and surgery is only required in cases with abscesses. Sexually transmitted proctitis needs to be adequately recognised and treated according to the infectious agent.