Effects are treated next first the cause to restore as normal anatomy as we can understanding defecation . AROO or SRUS -internal rectal prolapse occurs because of any cause which strains the fibrous junctions between the rectal tube with the Funnel of Levatores anii-just like what happens in oesophageal diaphragm junction frenooesopageal membrane.It is seen when we enter the plane behind loops of levatores behind the rectal tube posteriorly PR sleeve -a pathological gap not reported by any one else..The anterior mucosa with wall comes down and blocks the lumen as defecation takes place increasing the anorectal angle slwoly.Patience taught to patients with adequate Hi fibre diet with prokinetics Cinetapride or the banned Cisapride helps.Toilet training use commode sit up and most imp slogan-waittt! for IT to come out You do not try push ..ever! stand up again and again but never use fingers even go out leave toilet come back again after food etc is taught apart from biofeedback once with our finger in rectum .Taught to relax anii Levatores.Muscle. For gross physical damage seen on rectoscopy I have designed a Extended parks post anal repair plane anterior posterior repair where the Rectal tube is joined back to funnel outlet and rectum sclerosed to sacrum to restore as normal anatomy as possible. Rectoscopy for you and Defecography for patient record would help us assess the extent of prolapse and internal blockage.For severe prolapse out of anus we need resection and repair.Never the star procedure stapler which destroys crucial anorectal sensitive zone not curing the cause  or lap mesh repair till third grade prolapse.I have worked in St marks Hospital in 1991 and given two CME lectures on Anorectal physiology and Defecatory disorders ,Descending perrenial syndrome.But have minimum cases to do or make a paper!

I would  have a enterodefaecography  before taking any decision

Sounds like pretty classical symptoms of ODS.

Your patient ought to have a Transit Study first, to rule out slow transit constipation (unlikely given the history I accept) but necessary. I suspect the markers will be sat at the rectum.

Defecating proctogram/MR-DP is essential to define the anatomy (internal rectal prolapse/paradoxical contraction of puborectalis/anismus/rarely rectocele if prostatectomy etc).

Once the diagnosis is made and symptoms quantified (e.g. Renzi score) management always ought to start conservatively:

• Biofeedback
• Laxatives (prucalopride/lubiprostone if slow transit, otherwise standard)
• Irrigation (e.g. Peristeen/Qufora)
• Botox if paradoxical contraction of puborectalis/anismus.

If surgery is required it ought to target the pathology. Usually lap VMR is the most efficacious treatment. Bear in mind however, that correction of anatomy does not always equate to resolution of symptoms. Interestingly the “haemorrhoids” may be a manifestation of internal rectal prolapse, which I suspect is the underlying diagnosis.

Hope that helps,

JB.

I agree with the majority of what both John and Dr Sant say, and would just like to add to this, as my context is formative from India and formative and summative from UK and New Zealand ( we never stop learning). 

1. I have subjective (digital rectal examinatory) evidence to say that the ARP varies between the Indian subcontinent and the West, both in men and women, with higher anal canal pressures in the East, in general. (Happy to collaborate in well-designed objective studies). This results in different manifestations of similar conditions.

2. I agree with John completely - anatomical abnormality does not correlate well with symptoms, such that surgery is a last resort - and should be restricted to those with gross anatomical abnormalities - in this case, rectal external procudentia or circular internal prolapse, which does not revert completely at the end of the examination. This belief comes from my experience of supporting 4 Urogynaecologists in a pelvic floor service where I managed 300-400 patients a year, single-handedly in the NHS with no nurse/physiologist support and very limited physio therapy support. 

3. The crux is in a detailed history of the bowel movements - change from a baseline of "normality" going back to teenage years or 20s-30s etc. Diet is essential, but more often than not, as general surgeons unfortunately we inappropriately recommend excessive fibre, which just adds to the problem. A local dietician would be able to assist with this, ensuring no pseudo " allergies" to foods are diagnosed, but modifications are made to add just significant bulk with prokinetic foods (eg dry fruit taken as medicine at night)

4. Biofeedback in this context though paramount, involves no more or less than a detailed discussion with the patient, giving them written instructions on re-learning and using their gastro-colic reflex; not responding to rectal urges to defeacate, performing sets of anal canal excercises instead of sitting on the commode. And performing exercises at least 5 times a day. All that is required in each set of excercises is 10 fast and 5 slow anal canal squeezes, putting a hand on the buttocks to ensure they are not being squeezed and then a finger superficially ( even on top of undergarments) to ensure the anal ring is contracting - anterior perineal contraction can only be of benefit, though not essential. The main instruction I give patients is a sign they write themselves and stick on the door/wall in front of the toilet: "I will not sit here, unless my tummy tells me to; I may need to squat; but whatever I do, I will get up and walk away in a minute". 

5. SRUS is an extension of rectal hyperawareness I.e. Rectal IBS. The diagnosis is endoscopic and histological. The treatment - as above. I would not consider surgical interventions for atleast 6-9 months after labour- intensive active, "conservative" management (the labour is by the patient).

6. Eventually, if surgery is required, think minimalistic, non-excisional and just to treat the residual. Eg vertical (usually anterior in women and circumferential in men) series of rectopexies, to supplement diet and defaecatory regimes; topical treatment for any residual SRUS, Botox, if appropriate - but I would suggest only once, to assess the effects, and then intensify and tailor the physio therapy. I say this as I know of no long term good quality data on PPRC in India. I have even used TEMS to excise a fibrotic, prolapsing healed true SRUS - a 3cm anterior scar, which had initially required topical formalin under GA on two occasions to get it to stop bleeding. 

7. Again, John is right that for residual, major symptomatic prolapses that fail all other measures, in this day and age in the West I would go for a lap VMR, but, only if one is trained to do so and within the context of long term trials, which India lacks. 

8. Finally, if intervention is planned, then and only then is radiology indicated. I know of only one ex-colleague and respected peer who has moved back to India; a holistic and interventional radiologist, specialising in GI radiology. His expertise includes functional MRIs of the pelvis, and trained a number of registrars and colleagues whilst in the UK over a period of 15-20 years, whist working at busy teaching hospitals in Yorkshire and the Midlands all of which had busy anorectal and Urogynae teaching units. I am aware the hospital chain he works with refers patients to him from all over India, and he leads the interventional service. Details provided on request.

True.I did not mention transit studies and proximal causes of Constipation as here Question was clearly Obstructive symptoms and SRUS seen on rectoscopy.I had hardly got any cases since 1992 to do transit study as Diet oF Indians right from childhood is different from West.In times to come I foresee such case as diet has changed.Only in those who do Upwaas fasting on religious grounds-real one like Jains not eating at all before or after sunset rise,we may find loss of GI protein mass who may get Slow Transit Constipation .These are opposite end of the spectrum than STC seen in the west.

(Permit me to share open thoughts regarding Dietary additives as cure for STC constipation before it has progressed to gross AROO- in Indian culture-

Diet full of complex carbohydrates -legumes and spices like Mint ,Hing=asaefoetida, Garlic Ginger ,Cloves, bay leaves and more are routine part of Indian diet any corner of this vast varied land.Mixture of three ingradients TRIPHALA --(Triphala. Triphala (/triːˈfɑːlə/ or /triːˈfælə/; Hindi/Sanskrit: त्रिफला, triphalā [trɪˈpʰɐlaː], “three fruits”) is an Ayurvedic herbal rasayana formula consisting of equal parts of three myrobalans, taken without seed: Amalaki (Emblica officinalis),

Bibhitaki (Terminalia bellirica-Two varieties of T. belerica are found in India, one with nearly globular fruit, 1/2 to 3/4 inch in diameter, the other with ovate and much larger fruit. The pulp of the fruit (Beleric myrobalan) is considered by Hindu physicians to be astringent and laxative, and is prescribed with salt and long pepper in affections of the throat and chest. As a constituent of the triphala (three fruits), i.e., emblic, beleric and chebulic ),

and Haritaki (Terminalia chebula).and Hingastaka Churna powder (Dry ginger powder – 1 tea spoon

Long pepper powder (pippali) – 1 tea spoon

Black pepper powder – 1 tea spoon

Ajwain or carom seed powder – 1 tea spoon

Rock salt – 1 tea spoon

Cumin seed powder or jeera powder – 1 tea spoon

Black cumin seed or kala jeera powder – 1 tea spoon

Pure asafetida powder or hing powder – 1 tea spoon)

Harde -Its botanical name is Terminalia chebula and it belongs to Combretaceae family.Its fruit pulp is used as laxative.)

Even external use-A sitz bath with – 2 tablespoons of Haritaki or Triphala powder, in half a bucket of water, for 10 minutes, before bath, is useful in reducing the swelling and healing.

Please see the Asian perspective of Chronic Constipation

http://www.jnmjournal.org/journal/view.html?uid=165&vmd=Full

Just as today's science fiction is tomorrow's science so too is today's pharmaceutical wonder tomorrow's poison. For example, Warfarin, a rat poison will soon be phased out with the APPROPRIATE introduction of DOACs - even the term has changed! A year ago they were called NOACs! They're not novel anymore. 

Personally, I would be very wary of any loco-regional recommendations, due to the fear of starting unscientific trends and vogues. I do believe while the information you provide above might be of some relevance to the Indian society, if freely and easily available (I.e. Unadulterated spices and legumes at a price cheaper than reliable pharmaceuticals) then by all means start a well- designed randomised controlled trial, with at least 5-10 years follow up, given the vast number of compounding variables. If not, one is only able to make suggestions based on personal observation to individual patients in good faith. Faith, albeit well- intended is not science! 

Please remember, all this is an international forum of communication, and it's called research gate! In the interim, thank you for providing the linked article. I will definitely go through it to look at the quality of the data provided. 

Please remember, Charaka Samhiti, the origins of Ayurveda, lists the ethical duties of the Doctor, the nurse, the patient and the drug - the drug must do what it is expected to do! There was an ethical requirement for the doctor to study all the international literature he could get hold of, and make intelligent adjustments to his prescriptions accordingly, so the nurse-compounder could mix better potions and the patient remained trusting and the doctor respected and trustworthy. 

If one has knowledge of ancient cultural practices, and if one wishes to utilise such information in treating another - human or non-human person, I believe they are duty-bound to do so in a scientific manner!

It is not without unfortunate reason that despite an exceedingly high level of knowledge and information in the East those of us from the Western scientific community do not publish our work nor rely upon information published in Eastern journals. 

Again, Dr Reddy please do source locally relevant dietary modifications and do not rely too much on surgical techniques tried and tested in a different part of the world in an area where John Bunni will tell you there remains a lot of controversy, because colleagues "treat" using techniques on which there is little consensus data. 

Thanks to all for the excellent detailed discussion.I too agree that early surgery is not an answer in these situations.We have not done colonic transit or MR-DP as these are not being done in our centre except Technetium labelled transit which is not very useful.3D anorectal U/S is also useful.In the absence of of above I have advised him to foliow Motility drugs,DIET, perineal exercises and Bio feed back for at least  an year before I can think of LVMR,even though it is our favourite procedure.