Cases of rectal prolapse are rare surgical presentations. A Rectal prolapse commonly contains all the layers of the rectum protruding per anum as a cylindrical, elongated mass or an ovoid mass with pinkish fleshy tissue. The causes of the Prolapse may be varied but, it usually follows urogenital or anorectal disorders, recurrent diarrhoea from colitis or proctitis and chronic constipation from tumors of the colon, rectum, or anus [7]. It is commoner in women above the age of 50 years and the peak age of incidence is the seventh decade in women, whereas majority of males that develop rectal prolapse are seen at the age of 40 or less. Some have reported an increased predilection in young victims for autism, developmental disorders, and psychiatric comorbidities requiring multiple medications [8]. They were also reported to present with significant symptoms of bowel motility dysfunction, especially, constipation [7]. Our patient reflected the above finding. He is a 30-year-old male and the predominant complaint was that of constipation.

Although symptoms at presentation may vary, it is estimated that up to 50% to 75% of patients with rectal prolapse present with faecal incontinence, and 25% to 50% of them will report constipation [9–13]. However, in most surgical units the presentation occurs in stages. The presentation in complete rectal prolapse is that of a huge bulge of fleshy mass protruding per anum with associated spontaneous reduction after completion of defaecation, then progressing to reduction through manual manipulation. A fraction of these patients has rather a subtler presentation [14,15]. They may present with complaint of feeling of rectal fullness, constipation, faecal incontinence, per anal mucous discharge, and per anal bleeding. If the condition progresses to a Procidentia, rectal incarceration or even strangulation may occur from sphincteric constriction and intrinsic oedema. The presentation here will be that of a huge, painful, irreducible prolapsed rectal mass [16]. Patients with sigmoido-rectal intussusception only, may present with acute onset of constipation or colicky abdominal pain. Many may remain asymptomatic, only picked up incidentally on defeacography [17]. Our patient presented with an incarcerated external prolapse, hence the main complaints were the painful, immobile, prolapsed rectal tissue, with evidence of patchy mucosal infarction.

The faecal incontinence seen in complete rectal prolapse is said to be a result of disruption of the external anal sphincter mechanism, loss of sphincteric muscle integrity due to excessive stretch from the prolapsed rectum and the persistent activation of recto-anal inhibitory reflex by the same prolapsed rectal complex [18]. Some reports have indicated the presence of pudendal neuropathy in these patients and it can be demonstrated in about 50% of those presenting with incontinence [19], the pudendal neuropathy is said to lead to denervation-related atrophy of the external sphincter muscles [20]. Despite its preponderance, our patient however, did not report faecal incontinence.

Constipation is noted to be commoner in those with sigmoido-rectal intussusception, with the intussuspicient sigmoid mucosa occluding the rectal lumen. These patients may also have an associated pelvic floor weakness, and colonic motility disorder [11,12]. Our patient presented with constipation, possibly from combined complete and incomplete rectal prolapse.

Apart from the history of chronic constipation, our patient has a history of chronic cough, was treated for pulmonary Tuberculosis during childhood. Chronic cough and chronic obstructive airway diseases are known to result in chronic episodic increases in abdominal pressure. It has been reported in one case control study that chronic cough and chronic airway obstruction are associated with increased risk of pelvic organ prolapse in women < 45 years of age (14%) compared to controls (2.4%) [21]. Another important risk factor is the history of recurrent diarrhoea following weaning in our patient. Many studies have implicated the loss of Ischio-rectal fat due to malnutrition, chronic constipation and/or straining during defecation, or due to idiopathic causes in the aetiology of rectal prolapse [22,23,24].

Late presentation as in the index patient was widely reported, especially in an ignorant peasant who the vicissitude of daily living is his utmost concern. We noted this in our previous report on an incarcerated gravid uterus in a prolapsed rectum [25]. The only diagnostic investigation we were able to do was an Ultra-Sound Scan. It clinched the diagnoses and helped in the surgical decision taken. Previous reports from Nigeria also relied on same radiological tool [25].

Despite several years of handling cases of rectal prolapse, a consensus treatment has remained elusive. It started with the attempt to restore the altered anatomy to normalcy, up to the gamut of procedures now deployed with variable degree of success [4]. Although our patient is conversant with manual reduction, this manoeuvre has been unfruitful for months prior to presentation. This may perhaps be the result of significant size of the incarcerated prolapsed rectum due to oedema. Some reports have indicated successful reduction after application of table sugar. This was related to the hygroscopic property of incarcerated rectal prolapse which absorbs the oedema fluid of the swollen rectal tissue [26]. A successful reduction is however an incomplete victory, because, relapse is inevitable following another straining.

Surgery has so far remained the most successful treatment option [4]. The number of surgical procedures deployed for rectal prolapse indicates that none has been considered gold standard. The surgical options include both open and minimally invasive surgeries and the approaches may be perineal or abdominal, depending on the clinical presentation and the past medical history [4,5]. These may include Thiersch encircling anal suture, rectal mucosal excision, rectal anterior resection with or without rectopexy, rectopexy to the sacral fascia, perineal procto-sigmoidectomy, or posterior sagittal rectopexy in children [27]. Many of the surgical anchorages of the prolapsing rectum is done with the use of synthetic meshes attached to the presacral fascia. The choice of either open or laparoscopic approach or the extent of surgery is dictated by the background medical condition of the patient, the competence of the Surgeon and perhaps, how old is the patient and the presence or absence of faecal incontinence [28]. A Thiersch encircling anal suture was used after a successful reduction in the theatre in this patient. This was chosen because, the patient presented as an emergency with evidence of mild acute kidney injury, it can be done fast and safely, and has been reported to carry less complications [29]. It has so far successfully prevented a recurrence, even after return of normal defeacatory function.

Whatever the type of Surgical procedure chosen, the aims should be to reduce the prolapsed rectum and restore the normal sigmoido-recto-anal anatomy, correct troubling morbidities of faecal incontinence or chronic constipation, and to as much as possible minimise surgical complications from the procedure [7]. A recurrence rate of 16% to 30% has been reported after most perineal repairs of rectal prolapse, even after perineal resection of the rectum or rectopexy [30,31,32].