rectal prolapse involves intussusception of bowel , and is characterized by protrusion of all layers of the rectum through the anus . it may be confused with hemorrhoids , and it is important to note that rectal prolapse involves concentric protrusion whereas a prolapsed hemorrhoid is a radial bulging of veins in the anal region . there are many contributing factors : constipation , pregnancies , diastasis of the levators , redundant sigmoid colon , deep cul - de - sac , abnormal rectal angle , and lack of retroperitonealization of the rectum . patients with rectal prolapse may present with abdominal discomfort , incomplete bowel evacuation , mass protruding through the anus , and incontinence . surgical treatment is indicated to improve quality of life when medical treatment , including stool softeners and kegel exercises , fails . incarceration and strangulation of the prolapsed rectum is rare , but is one of the most noticeable and serious complications of rectal prolapse requiring prompt surgical consultation . ulceration and weakening of the rectal mucosa is also seen in patients with chronic prolapse ; however , there is no literature describing ulceration and its associated risk of perforation in the setting of chronic rectal prolapse . while colonoscopic evaluation for rectal prolapse at the initial presentation is recommended to rule out other mucosal abnormalities that may be contributing to the disease such as neoplasm , there are no recommendations for surveillance of prolapse being managed non - operatively . the risk of perforation from colonoscopy is higher in elderly females ; however there is no evidence that rectal prolapse is associated with an increased risk of colonoscopic perforation . her comorbidities included hypothyroidism , depression , hypertension , dyslipidemia , esophageal reflux , urinary retention with an indwelling urinary catheter , and chronic back pain managed with opioids . the prolapsed rectum was 20  cm in length , demonstrated viable mucosa with shallow ulceration and was reducible , but recurred immediately . a preoperative colonoscopy was performed , but could not be completed due to poor bowel preparation . the patient was scheduled for an elective perineal proctosigmoidectomy ( altemeier procedure ) . within a week of the colonoscopy , the patient presented to the emergency department ( ed ) with malaise , lower abdominal pain and decreased level of consciousness . initial evaluation was significant for hypotension ( blood pressure 67/45  mm hg ) , leukocytosis ( white blood count 21    10/l ) and acute kidney injury ( creatinine 346 she was initially diagnosed with urosepsis attributed to a blocked urinary catheter and required intensive care unit ( icu ) admission for resuscitation with intravenous fluids and vasopressors . the original ed document noted rectal prolapse on physical examination . upon assessment of the perineum the next day , a segment of sigmoid colon was found herniating though a perforation in the rectal prolapse ( fig . subsequent to general surgery consultation , an emergency hartmann s procedure with a sacral rectopexy was performed . the prolapse and strangulated sigmoid were reduced back into the abdominal cavity by the application of manual pressure on the perineum . there was a perforation of the rectum 10  cm from the anal verge through which the sigmoid colon had protruded . 2 . pathology of the resected sigmoid showed ischemic necrosis of the resected sigmoid and viable margins . following a short stay in icu post - operatively her bladder function also normalized following the resolution of her rectal prolapse and her indwelling catheter was removed . she was transferred to a rehabilitation facility within a few weeks , and discharged home a week later . in this case , the patient had typical risk factors for developing a rectal prolapse . colonoscopy that was done a week prior may have been contributory to the sigmoid evisceration through the rectal prolapse , but more importantly , the patient in this case had constipation secondary to chronic opioid use as well as two previous vaginal deliveries . a number of cases of ileal evisceration through rectal prolapse have been previously reviewed in the literature . there have also been cases reported on strangulated ileal herniation through coloanal anastomosis following an altemeier repair , as well as following a failed reduction . sigmoid evisceration is much more rare , with only one previous case reported in the literature , involving a 96 year - old female who underwent an altemeier procedure and had an uneventful recovery . the current case is unique in that the sigmoid not only eviscerated through the prolapsed rectum but also became strangulated and necrotic . a delay in diagnosis of up to 24  h may have occurred as an alternate etiology for sepsis was first identified . unlike most patients with strangulated bowel , this woman had no abdominal symptoms as the affected bowel was eviscerated , and she therefore did not develop peritonitis . the most common factors provoking transmural evisceration of bowel through rectal prolapse include defecation , spontaneous perforation , blunt trauma , and other maneuvers associated with increased intra - abdominal pressure such as heavy lifting , vomiting , and valsalva maneuver . the site of evisceration is most frequently reported to be the anterior rectal wall due to the chronic friction exerted by small bowel with the anterior rectal wall . however , in this case , the ulceration was seen laterally during colonoscopy and evisceration occurred at the left posterolateral aspect . chronic rectal prolapse can lead to a number of complications that require urgent surgical attention . health care providers should recognize the typical appearance of rectal prolapse , prescribe medical management with stool softeners , and advise avoidance of increased abdominal pressure . rectal prolapse is usually a benign condition , however , if the prolapse appears atypical or if there is any doubt regarding the viability of the bowel in a prolapsed segment , urgent surgical consultation is recommended .
highlightsrectal prolapse occurs particularly in elderly females.complications include incarceration , strangulation , and , rarely , perforation with evisceration of other viscera requiring urgent operation.such complications can be prevented by a strict bowel regimen and avoidance of activities that increase intra - abdominal pressure.prompt surgical consult is warranted if any signs or symptoms suggestive of complications from prolapse are present .