1. Lars Påhlman Dept. Surgery, Colorectal unit, University Hospital, Uppsala, Sweden Rectal Prolapse

2. Case 1

3. Rectal prolapse - Case 1  25 year old woman  > 2 years with constipation. 2 months history of full-thickness prolapse. Only at defecation.  What type of examinations ?

4. Rectal prolapse - Case 1  Check the colon ?  Anal manomatry ?  Defecography ?  Anal ultrasound ?  What type of operation ?

5. Rectal prolapse - Case 1  Abdominal procedure  What type of rectopexy ?  Sigmoid colon ?

6. Case 2

7. Rectal prolapse - Case 2  84 year old woman  Several years history with a full-thickness prolapse. Does not disappear after defecation.  What type of examinations ?

8. Rectal prolapse - Case 2  Check the colon ?  Anal manomatry ?  Defecography ?  Anal ultrasound ?  What type of operation ?

9. Rectal prolapse - Case 2  Perineal approach  Delorme or Altemeier ?

10. Case 3

11. Rectal prolapse - Case 3  33 year old man  No constipation. 6 months history of full- thickness prolapse. Only at defecation.  What type of examinations ?

12. Rectal prolapse - Case 3  Check the colon ?  Anal manomatry ?  Defecography ?  Anal ultrasound ?  What type of operation ?

13. Case 4

14. Rectal prolapse - Case 4  54 year old woman  No real constipation, but some outlet disorders and slight IBS - problems.  What type of examinations ?

15. Rectal prolapse - Case 4  Check the colon ?  Anal manomatry ?  Defecography ?  Anal ultrasound ?

16. Rectal prolapse - Case 4  Rectoscopy disclosed a solitary ulcer ?  Defecography could showed an intussusception?  Anal ultrasound normal sphincters ?  What type of operation ?

17. Rectal prolapse - Case 4  STARR procedure ?  Biofeedback ?  Abdominal approach ?

18. Rectal prolapse Mucosal prolapse  3rd degree internal haemorrhoids  ectropion - sphincteric defects followinganorectal surgery  atony and relaxation of both sphincters in elderly

19. Rectal prolapse Aetiology (children)  absence of sacral curve giving a vertical straight tube  diminution in the amount of supporting fat and tissues in the ischiorectal fossae

20. Rectal prolapse Aetiology (adults) Sliding hernia (Moschowitz)  a sliding hernia with the whole pouch of Douglas  anterior rectal wall is pressed into the rectal lumen

21. Rectal prolapse Aetiology (adults) Intussusception (Brodén and Snellman)  a circumferential intussusception  starts 6 - 8 cm from the anal verge  appex passes into lower rectum

22. Rectal prolapse Aetiology (adults) Intussusception (Brodén and Snellman)  after fully descended pouch of Douglas the bowel will protrude through the anus  initiation of the intussusception ?

23. Rectal prolapse Aetiology (adults) Lack of fixation (Ripstein)  abnormal mobility of the rectum  a consequense to rectal prolapse rather than a cause ?

24. Rectal prolapse Aetiology (adults) Lax pelvic floor (Muir)  patients with cauda equina with paralysis of the pelvic floor  patients with rectal prolapse and associated incontinence