Rectal prolapse is defined as a spontaneous protrusion of the rectum or the rectum and the sigmoid colon into the intestine below and/or outside the anal canal. It is a rare condition. Epidemiological data estimate that 4/1,000 adults are affected. Although full-thickness rectal prolapse is more common in older women (women > 75 years of age account for 85%), it may develop in men and women at any age (1). People have been suffering from rectal prolapse for centuries. The treatment of rectal prolapse was already described by Hippocrates. It involved hanging patients upside down on a tree, which was rather ineffective, but at least less aggressive compared to methods described in the Middle Ages, which involved, among other things, burning the anus to obtain a scar, and thus prevent rectal prolapse. Contemporary surgeons were and still are involved in the treatment of rectal prolapse. Frederick Salmon, the founder of the The Benevolent Dispensary for the Relief of the Poor Afflicted with Fistula and other Diseases of the Rectum (now St. Mark’s Hospital), published his monograph “Practical Observations on Prolapsus of the Rectum” in 1831. Currently, a number of transabdominal (laparotomy, laparoscopy) and transperineal techniques are used. Proper preoperative qualification is of key importance for therapeutic success in a patient with rectal prolapse.

Despite many published concepts on the aetiology of rectal prolapse, no consensus has been reached among researchers. A historical study conducted more than 50 years ago by Broden and Snellman, who described an internal intussusception in proctography, emphasising that the intussusception originated in the anterior rectal wall, was a milestone in the research on the disease (2). However, later defecographic studies in healthy volunteers failed to fully confirm this theory as they revealed the presence of intussusception in half of subjects, none of whom presented with proctological symptoms (3). Later theories pointed to the possible neurogenic causes of rectal prolapse, such as nerve damage and weak pelvic floor muscles (4). According to the historical Moschcowitz’s hypothesis from the beginning of the 20th century, rectal prolapse is a type of pelvic floor hernia (5). It is currently believed that the aetiology of prolapse is multifactorial, with a different predominant causative factor in each age group. Excess length of bowel and mesentery is the dominant cause in young patients with fully sufficient pelvic floor muscles. Weak pelvic muscles and the lack of rectal support are the main causes in patients with anorexia and spinal injury. This is also the case in women with obstetric trauma or after hysterectomy as the presence of uterus in the pelvis is an important stabilising element. Weak pelvic muscles accompanied by passage difficulties due to a double sigmoid loop, diverticular disease or tumours are the dominant cause in elderly patients. However, one or more cofactors are seen in each of the above cases. Nearly all patients with rectal prolapse suffer from constipation, although the disease is certainly multifactorial. Generally, the risk factors for full-thickness rectal prolapse may be classified as anatomical and functional.

Anatomical factors include female sex, a deep rectouterine pouch, pelvic floor muscle insufficiency (usually age-related), anal sphincter insufficiency (usually postpartum), obstetric injuries, long bowel mesentery, pelvic organ prolapse, and a history of radical hysterectomy with bilateral salpingo-oophorectomy.

Functional factors include chronic constipation, neurological diseases, spinal cord injury, and mental disorders.

Other risk factors include had physical work, obesity (or rapid weight loss, for example rectal prolapse is seen in anorectic patients), and multiple childbirths.

The following factors should be considered when choosing surgical technique for a patient with rectal prolapse: the mechanism and extent of rectal prolapse (the length of the prolapsed bowel in particular), patient’s age and overall health status, as well as comorbidities (e.g. POP in women). Before choosing surgical technique, the operator should verify whether anal sphincter insufficiency is the result or cause of prolapse.

In the 20^th century, surgery through the perineum was the main strategy in patients with rectal prolapse. In 1891, Thiersch (Germany) reported narrowing the anal opening using a ring of wire. In 1900 (6), Delorme (France) described resection of the rectal mucosa (7). In 1889, Mikulicz reported perineal rectosigmoidectomy. In 1971, Altemeier presented a full, improved description of the procedure (8).

Indications for perineal rectal prolapse repair include:

? advanced age,

? general comorbidities disqualifying from general anaesthesia,

? short-segment prolapse,

? incarceration and necrotic rectal prolapse.