How is rectal prolapse diagnosed and what are current treatment options?

1. How clinicians make the diagnosis: look, ask, and reproduce

Diagnosis begins with history (protrusion on straining, bleeding, incontinence, constipation) and a careful physical exam while the patient is standing or straining; a full‑thickness (external) prolapse classically shows concentric mucosal folds and is usually evident on inspection ^{[2] [1] [6]}. If the prolapse is intermittent or not reproduced on the table, clinicians may ask the patient to strain on a commode, give an enema to provoke prolapse, or perform an exam while seated to visualize it ^{[7] [6]}. Digital rectal exam should assess sphincter tone and look for other pelvic floor findings ^{[7] [8]}.

2. When and why additional tests are used

Additional tests are not required for obvious external prolapse but are used selectively: video or MRI defecography and dynamic fluoroscopic studies can distinguish internal intussusception from full‑thickness prolapse and reveal associated pelvic organ prolapse; colonoscopy or CT may be done to rule out neoplasm or other pathology before operative repair ^{[3] [9] [4]}. Functional testing such as urodynamics may be added when urinary symptoms coexist (20–35% report urinary incontinence) or for multidisciplinary planning ^[3].

3. Conservative and nonoperative measures

In children and some internal prolapse cases, conservative care—bowel regimen, fiber, stool softeners, pelvic‑floor physiotherapy and biofeedback—is a primary strategy; many pediatric cases resolve without surgery and adults may receive medical therapy for associated constipation or incontinence before operative decisions ^{[10] [11] [5]}. For acute externally visible prolapse, gentle manual reduction is appropriate; if edema makes reduction difficult, measures such as sedation, local blocks, cold compresses, or topical hyperosmolar agents have been described ^{[5] [12]}.

4. Surgical options: two broad philosophies

Surgical management in adults generally falls into two categories: abdominal procedures (rectopexy with or without bowel resection, open or laparoscopic, sometimes using mesh or sutures) and perineal procedures (Delorme, Altemeier/perineal rectosigmoidectomy), with the choice guided by patient fitness, symptoms (constipation vs incontinence), and surgeon expertise ^{[5] [13] [14]}. Abdominal rectopexy is often preferred in fit patients and may be combined with sigmoid resection for coexisting constipation; perineal approaches are favored for frail or high‑risk patients because they carry lower operative stress ^{[15] [12]}.

5. Evidence, controversies, and outcomes

No single operation has clear superiority: systematic reviews and recent literature note persistent controversy and a lack of definitive randomized trials identifying one best technique; comparisons (e.g., mesh vs resection rectopexy) often show similar outcomes for recurrence, complications, and functional results ^{[4] [5] [16]}. Recurrence is possible after any procedure and functional outcomes (improvement or worsening of constipation and incontinence) vary, so the surgical goal emphasized by guidelines is to correct the prolapse while minimizing new bowel dysfunction ^{[4] [16]}.

6. Practical implications and red flags

Clinicians should distinguish mucosal prolapse from full‑thickness disease because treatments differ markedly ^[16]. Urgent care is required if a prolapse cannot be reduced or appears strangulated—the blood supply can be compromised. Preoperative workup should rule out malignancy and evaluate coexisting pelvic organ prolapse when present ^{[4] [17]}.

Limitations: available sources summarize consensus, guidelines, and reviews but note ongoing debate about the optimal surgical method and the relative long‑term functional benefits of specific procedures ^{[4] [16]}. Available sources do not mention any single new, universally accepted "best" operation (not found in current reporting).