RP either internal or protruding through the anal canal is common in children and elderly patients. Interestingly, RP is rare in young adults less than 30 years old. To date, the exact cause of RP is not completely understood. Marceau et al. studied risk factors for RP in patients under 50 years of age and reported 50% had severe psychiatric disease that required chronic medication (neuroleptics or antidepressants) which may induce severe constipation [
6]. Similarly, our study found that 18 (41%) patients had chronic psychiatric diseases requiring medical treatment. These patients experienced significantly more
constipation and needed more laxatives than non-psychiatric patients.
Of the 44 young patients, 61% were found intraoperatively to have a redundant rectosigmoid colon, and some of the patients in addition had symptoms of constipation. We found that 30% had previous pelvic surgery. These surgeries may result in pelvic floor weakness and contribute to the occurence of RP. Interestingly, we found one patient with hidradenitis suppurativa (HS) who had a continuous deep abscess with a fistula and she had several surgeries to address it. Finally she developed a RP in between undergoing treatments for HS. It is unclear if this patient’s HS and the surgical treatment contributed to RP, but the RP did occur while the prolonged treatment was on going. Perhaps damage to support structures during debridement of deep tissue may have occurred to predispose to the RP.
Considering other possible conditions associated with RP, some patients (9%) had uterovaginal prolapse mostly associated with an obstetric history or previous pelvic surgery. In our study group, 3(7%) of the patients had EDS. EDS is a connective tissue disorder characterized by skin hyperextensibility, abnormal wound healing, and joint hypermobility. This disease has a wide spectrum of gastrointestinal manifestations ranging from life threatening spontaneous perforation of the intestine and massive gastrointestinal bleeding to a more benign involvement such as RP, hernias, intestinal diverticula. Our data showed similar occurrences of RP and EDS to that reported in other studies involving young patients [
7].
The chief clinical feature of RP is a protruding mass following defecation. At times, the prolapse may occur spontaneously upon standing or coughing [
2]. Other symptoms that may coexist include constipation, incomplete evacuation, rectal bleeding, rectal pain, incontinence, urgency and tenesmus [
8]. Similarly, the most common symptom at presentation in our study was a prolapsed rectum in 91% of patients mostly associated with defecatory straining or outlet obstructive symptoms in 77% of patients. Constipation and hematochezia were also commonly observed. In addition, we noticed rectal bleeding in 55% and this may have been caused by a solitary rectal ulcer in some as it was seen in 23% of our patients. One study also has reported that bleeding can commonly be seen in 90% patients with underlying rectal ulcer associated with rectal prolapse [
9].
Numerous surgical procedures have been described for the treatment of RP. The choice of the initial treatment is based on the assessment, age, comorbidities, the stage and workup of prolapse. Laparoscopic abdominal surgery for the treatment of RP has been highlighted because of the potential benefits of a minimally invasive approach, including less pain, shorter hospital stay, faster recovery, and fewer complications, compared with open abdominal surgery [
10]. One study reported the rate of recurrent prolapse was significantly higher for perineal procedures than that for abdominal procedures [
11]. According to these studies, laparoscopic surgery is a safe and feasible approach in patients with RP [
12,
13]. In our study, the most common procedure was laparoscopic rectopexy with or without resection in young patients. The recurrence rate was similar compared to published literature for older individuals [
11]. The majority of the young patients underwent rectopexy with resection, per surgeon’s choice, mostly based on the findings of a redundant rectosigmoid colon intraoperatively. It has been speculated that a sigmoid resection may increase the morbidity due to potential complications secondary to performing an anastomosis, although it also may provide improvement for constipation symptoms [
14]. In our study the complication rate was low and there was no mortality. Therefore, laparoscopic rectopexy with or without resection appears to be a safe and effective surgical option for young patients.
In recent years, robotic assisted laparoscopic rectopexy has been added to the surgical repertoire for RP in our hospital. One study focused on robotic rectopexy for rectal prolapse and demonstrated longer operative time and greater cost but excellent visualization and suturing as well as equivalent operative outcomes to laparoscopy [
15]. Although only 4 of 44 patients had a robot-assisted laparoscopic rectopexy in our study group, there were no complications and no recurrences noted. Because of the small number of patients who had the robotic approach, it is difficult to assess the role of robotic assisted surgery for this group but it may become more popular in the future.
The limitation of this study is its retrospective nature. Although the data was collected in a prospective database, some data points required chart review. Additionally, a longer follow-up period is desirable to determine if over time the recurrence rates will increase.
In conclusion, medically induced constipation in psychiatric patients and possible pelvic floor weakness in patients with previous pelvic surgery may be important contributing factors for young adults who develop RP. The laparoscopic approach appears be a safe and effective surgical option for young patients. Long-term follow-up and a larger sample size would optimally improve the data to definitively enable reporting of the recurrence rate and optimal surgical procedure.
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