Rectal Prolapse: Pathophysiology

  • Filippo Pucciani


Rectal prolapse, procidentia, “complete” prolapse or “first-degree” prolapse, is defined as a circumferential, full-thickness intussusception of the rectal wall with protrusion beyond the anal canal [1]. This definition emphasises two important points: (1) rectal prolapse is the expression of a fullthickness intussusception, and (2) protrusion is outside the anus. The cause of rectal prolapse is still not completely understood. It is likely the result of a multifactorial aetiology, and any single standard theory would be improbable and imprecise. This implies that each patient potentially has his or her own specific pathogenetic profile, which is the result of a mix of several aetiological factors. A great division has developed between supporters of the “sliding hernia” and those who support the rectal intussusception theory. Rectal prolapse has been related to either a form of sliding hernia, as most patients have a redundant sigmoid colon, deep pelvic-peritoneal cul-de-sac, diastasis of the levator ani muscles, loss of posterior rectal fixation and loss of the usual anorectal angle; or to the final stages of a progressively worsening intussusception, as similarities in manometric findings can be found among patients with rectal prolapse, rectoanal intussusception and solitary rectal ulcer syndrome.


Pelvic Floor Pelvic Organ Prolapse Faecal Incontinence Pelvic Floor Muscle Rectal Prolapse 
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  1. 1.
    Lowry AC, Simmang CL, Boulos P et al (2001) Consensus statement of definitions for anorectal physiology and rectal cancer, Washington, D.C., May 1, 1999. Dis Colon Rectum 44:915–919PubMedCrossRefGoogle Scholar
  2. 2.
    Kairaluoma MV, Kellokumpu IH (2005) Epidemiologic aspects of complete rectal prolapse. Scand J Surg 94:207–210PubMedGoogle Scholar
  3. 3.
    Harewood JC, Coulie B, Camilleri M et al (1999) Descending perineum syndrome: audit of clinical and laboratory features and outcome of pelvic floor retraining. Am J Gastroenterol 94:126–130PubMedCrossRefGoogle Scholar
  4. 4.
    Moschcowitz AV (1912) The pathogenesis, anatomy and cure of prolapse of the rectum. Surg Gynecol Obstet 15:7–21Google Scholar
  5. 5.
    Rao SS, Tutya AK, Vellema T et al (2004) Dyssynergic defecation: demographies, symptoms, stool patterns and quality of life. J Clin Gastroenterol 38:680–685PubMedCrossRefGoogle Scholar
  6. 6.
    Choi GS, Hwang YH, Salum MR et al (2001) Outcome and management of patients with large rectoanal intussusception. Am J Gastroenterol 96:740–744PubMedCrossRefGoogle Scholar
  7. 7.
    Devadhar DS (1965) A new concept of mechanism and treatment of rectal procidentia. Dis Colon Rectum 8:75PubMedCrossRefGoogle Scholar
  8. 8.
    Broden B, Snellman B (1968) Procidentia of the rectum studied with cineradiography. Dis Colon Rectum 11:330–347PubMedCrossRefGoogle Scholar
  9. 9.
    Mackle EJ, Parks TG (1986) The pathogenesis and pathophysiology of rectal prolapse and solitary rectal ulcer syndrome. Clin Gastroenterol 15:985–1002PubMedGoogle Scholar
  10. 10.
    Dvorkin LS, Gladman MA, Epstein J et al (2005) Rectal intussusception in symptomatic patients is different from that in asymptomatic volunteers. Br J Surg 92:866–872PubMedCrossRefGoogle Scholar
  11. 11.
    Pucciani F, Boni D, Perna F et al (2005) Descending perineum syndrome: are abdominal hysterectomy and bowel habits linked? Dis Colon Rectum 48:2094–2099PubMedCrossRefGoogle Scholar
  12. 12.
    Altemeier WA, Culbertson WR, Schowengerdt C, Hunt J (1971) Nineteen years experience with the onestage perineal repair of rectal prolapse. Ann Surg 173:993–1001PubMedCrossRefGoogle Scholar
  13. 13.
    Shorvon PJ, McHugh S, Diamant NE et al (1989) Defecography in normal volunteers: results and implications. Gut 30:1737–1749PubMedCrossRefGoogle Scholar
  14. 14.
    Choi GS, Salum MR, Moreira H et al (2000). Physiologic and clinical assessment of patients with rectoanal intussusception. Tech Coloproctol 4:29–33CrossRefGoogle Scholar
  15. 15.
    Mellgren A, Schultz I, Johansson C et al (1997) Internal rectal intussusception seldom develops into total rectal prolapse. Dis Colon Rectum 40:817–820PubMedCrossRefGoogle Scholar
  16. 16.
    Shafik A, Ahmed I, Shafik AA et al (2005) Surgical anatomy of the perineal muscles and their role in perineal disorders. Anat Sci Int 80:167–171PubMedCrossRefGoogle Scholar
  17. 17.
    Shafik A, El-Sibai O, Shafik AA, Ahmed I (2003) Effect of straining on perineal muscles and their role in perineal support: identification of the straining-perineal reflex. J Surg Res 112:162–167PubMedCrossRefGoogle Scholar
  18. 18.
    Shafik A, Shafik AA, Shafik I, El-Sibai O (2006) Study of the role of the transverse perineal muscles during rectal filling. Int J Colorectal Dis 21:698–704PubMedCrossRefGoogle Scholar
  19. 19.
    Fox JC, Fletcher JG, Zinsmeister AR et al (2006) Effect of aging on anorectal and pelvic floor functions in females. Dis Colon Rectum 49:1726–1735PubMedCrossRefGoogle Scholar
  20. 20.
    Tsiaoussis J, Chrysos E, Athanasakis E et al (2005) Rectoanal intussusception: presentation of the disorder and late results of resection rectopexy. Dis Colon Rectum 48:838–844PubMedCrossRefGoogle Scholar
  21. 21.
    Baessler K, Schuessler B (2005) Anatomy of the sigmoid colon, rectum, and the rectovaginal pouch in women with enterocele and anterior rectal wall procidentia. Clin Anat 19:125–129CrossRefGoogle Scholar
  22. 22.
    Arakawa T, Muratami G, Nakajima F et al (2004) Morphologies of the interfaces between the levator ani muscle and pelvic viscera, with special reference to muscle insertion into the anorectum in elderly Japanese. Anat Sci Int 79:72–81PubMedCrossRefGoogle Scholar
  23. 23.
    Hsu Y, Chen L, Huebner M et al (2006) Quantification of levator ani cross-sectional area differences between women with and those without prolapse. Obstet Gynecol 108:879–883PubMedCrossRefGoogle Scholar
  24. 24.
    Petros PE (2004) The female pelvic floor function, dysfunction and management according to the integral theory. Springer, Heidelberg, pp 180–190Google Scholar
  25. 25.
    Fritsch H, Lienemann A, Brenner E, Ludwikowski B (2004) Clinical anatomy of the pelvic floor. Adv Anat Embryol Cell Biol 175:1–64Google Scholar
  26. 26.
    Carmeliet P, Schoonjans L, Kieckens L et al (1994) Physiological consequences of loss of plasminogen activator gene function in mice. Nature 368:419–424PubMedCrossRefGoogle Scholar
  27. 27.
    Yiou R, Delmas V, Carmeliet P et al (2001) The pathophysiology of pelvic floor disorders: evidence from a histomorphologic study of the perineum and a mouse model of rectal prolapse. J Anat 199:599–607PubMedCrossRefGoogle Scholar
  28. 28.
    Hussein AM, Helal SF (2000) Schistosomal pelvic floor myopathy contributes to the pathogenesis of rectal prolapse in young males. Dis Colon Rectum 43:644–649PubMedCrossRefGoogle Scholar
  29. 29.
    Gearhart SL, Pannu HK, Cundiff GW et al (2004) Perineal descent and levator ani hernia: a dynamic magnetic resonance imaging study. Dis Colon Rectum 47:1298–1304PubMedCrossRefGoogle Scholar
  30. 30.
    Nash DF (1972) Bowel management in spina bifida patients. Proc R Soc Med 65:70–71PubMedGoogle Scholar
  31. 31.
    Belizon A, Levitt M, Shoshany J et al (2005) Rectal prolapse following posterior sagittal anorectoplasty for anorectal malformations. J Ped Surg 40:192–196CrossRefGoogle Scholar
  32. 32.
    Gourgiotis S, Baratsis S (2007) Rectal prolapse. Int J Colorect Dis 22:231–243CrossRefGoogle Scholar
  33. 33.
    Boccasanta P, Venturi M, Barbieri S, Roviaro G (2006) Impact of new technologies on the clinical and functional outcome of Altemeier’s procedure. A randomized controlled study. Dis Colon Rectum 49:652–660PubMedCrossRefGoogle Scholar
  34. 34.
    Peters WA, Smith RM, Drescher CW (2001) Rectal prolapse in women with other defects of pelvic floor support. Am J Obstet Gynecol 184:1488–1495PubMedCrossRefGoogle Scholar
  35. 35.
    Altman D, Zetterstrom J, Schultz I et al (2006) Pelvic organ prolapse and urinary incontinence in women with surgically managed rectal prolapse: a populationbased case-control study. Dis Colon Rectum 49:28–35PubMedCrossRefGoogle Scholar
  36. 36.
    Maubon A, Aubard Y, Berkane V et al (2003) Magnetic resonance imaging of the pelvic floor. Abdom Imaging 28:217–225PubMedCrossRefGoogle Scholar
  37. 37.
    Farouk R, Duthie GS, MacGreor AB, Bartolo DCC (1994) Rectoanal inhibition and incontinence in patients with rectal prolapse. Br J Surg 81:743–746PubMedCrossRefGoogle Scholar
  38. 38.
    Damon H, Henry L, Roman S et al (2003) Influence of rectal prolapse on the asymmetry of the anal sphincter in patients with anal incontinence. BMC Gastroenterol 3:23PubMedCrossRefGoogle Scholar
  39. 39.
    Neill ME, Parks AG, Swash M (1981) Physiological studies of the anal sphincter musculature in faecal incontinence and rectal prolapse. Br J Surg 68:531–536PubMedCrossRefGoogle Scholar
  40. 40.
    Roiq JV, Buch E, Solana A et al (1998) Anorectal function in patients with complete rectal prolapse. Differences between continent and incontinent individuals. Rev Esp Enfferm Dig 90:794–805Google Scholar
  41. 41.
    Parks AG, Swash M, Urich H (1977) Sphincter denervation in anorectal incontinence and rectal prolapse. Gut 18:656–665PubMedCrossRefGoogle Scholar
  42. 42.
    Keighley MRB, Shouler PJ (1984) Abnormalities of colonic function in patients with rectal prolapse and faecal incontinence. Br J Surg 71:892–895PubMedCrossRefGoogle Scholar
  43. 43.
    Dolk A, Broden G, Holstrom B et al (1990) Slow transit of the colon associated with severe constipation after the Ripstein operation. A clinical and physiologic study. Dis Colon Rectum 33:786–790PubMedCrossRefGoogle Scholar
  44. 44.
    Siproudis L, Robert A, Gosselin A et al (1993) Constipation after rectopexy for rectal prolapse. Where is the obstruction? Dig Dis Sci 38:1801–1808CrossRefGoogle Scholar
  45. 45.
    Kellokumpu IH, Vironen J, Scheinin T (2000) Laparoscopic repair of rectal prolapse. A prospective study evaluating surgical outcome and changes in symptoms and bowel function. Surg Endosc 14:634–640PubMedCrossRefGoogle Scholar
  46. 46.
    Brown AJ, Nicol L, Anderson JH et al (2005) Prospective study of the effect of rectopexy on colonic motility in patients with rectal prolapse. Br J Surg 92:1417–1422PubMedCrossRefGoogle Scholar
  47. 47.
    Brown AJ, Anderson JH, McKee RF, Finlay IJ (2004) Strategy for selection of type of operation for rectal prolapse based on clinical criteria. Dis Colon Rectum 47:103–107PubMedCrossRefGoogle Scholar
  48. 48.
    Frykman HM, Goldberg SM (1969) The surgical treatment of rectal procidentia. Surg Gynecol Obstet 129:1225–1230PubMedGoogle Scholar
  49. 49.
    McKee RF, Lauder JC, Poon FW (1992) A prospective randomized study of abdominal rectopexy with and without sigmoidectomy in rectal prolapse. Surg Gynecol Obstet 174:145–148PubMedGoogle Scholar
  50. 50.
    Luukkonen P, Mikkonen J, Järvinen H((1992) Abdominal rectopexy with sigmoidectomy vs rectopexy alone for rectal prolapse: a prospective randomized study. Int J Colorectal Dis 7:219–222PubMedCrossRefGoogle Scholar
  51. 51.
    Speakman CTM, Madden DV, Nicholls RJ, Kamm MA (1991) Lateral ligament division during rectopexy causes constipation but prevents recurrence: results of a prospective randomized study. Br J Surg 78: 1431–1433PubMedCrossRefGoogle Scholar
  52. 52.
    Kang YS, Kamm MA, Nicholls RJ (1995) Solitary rectal ulcer and complete rectal prolapse: one condition or two? Int J Colorectal Dis 10:87–90PubMedCrossRefGoogle Scholar
  53. 53.
    Morio O, Meurette G, Desfourneaux V et al (2005) Anorectal physiology in solitary ulcer syndrome: a case matched series. Dis Colon Rectum 48:1917–1922PubMedCrossRefGoogle Scholar
  54. 54.
    Van Outryve MJ, Pelckmans PA, Fierens H, Van Maercke YM (1993) Transrectal ultrasound study of the pathogenesis of solitary rectal ulcer syndrome. Gut 34:1422–1426PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 2008

Authors and Affiliations

  • Filippo Pucciani
    • 1
  1. 1.Department of Medical and Surgical Critical CareUniversity of FlorenceFlorenceItaly

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