Internal Rectal Prolapse in Children: A Hidden Cause of Constipation Requiring Comprehensive Evaluation and Treatment

Abstract

Internal rectal prolapse in children is a significant cause of persistent constipation that is resistant to medication. This condition, characterized by mucosal folds in the distal rectum, leads to obstructive constipation, rectal dilation, and potential fecal incontinence if not promptly diagnosed and treated. Symptoms include drug-resistant constipation, pain, facial flushing, sweating, crying, avoidance of the toilet, and straining during defecation. In advanced stages, loss of appetite and rectal bleeding may occur. Despite unsuccessful treatment with various laxatives, specialized pediatric gastroenterologists are unable to improve the condition. This study compared 153 pediatric patients with internal rectal prolapse to a control group of hospitalized children without the condition. Diagnosis and treatment approaches are discussed, emphasizing the importance of distinguishing this condition from other causes of constipation, such as Hirschsprung’s disease. Radiological findings and a classification system based on the thickness of prolapsed mucosa are also presented. Treatment options include sclerotherapy for lower-grade prolapse. However, the abstract should provide a more concise and accurate summary of the article.

1. Introduction

Constipation functional constipation is a prevalent condition in childhood, about 29.6% worldwide. In the United States, represents 3–5% of pediatric visits and a considerable annual healthcare cost.

Constipation in children has various causes. Some of them are treated by pediatricians with medication and dietary changes. Others are treated by pediatric surgeons with various surgical procedures. According to available statistics, more than one-third of children referred to pediatric gastroenterologists are due to constipation. One of the unknown causes of constipation in children is internal rectal prolapse, which has been less discussed in books on pediatric diseases and surgery. Therefore, we also encounter it less frequently in articles in pediatric and gastrointestinal journals. ASMAN first described this issue in adults in 1957 [1].

Internal rectal prolapse (IRP) is a condition where the rectum, the lowest part of the large intestine, slides inside itself during defecation. It can cause symptoms such as fecal incontinence, difficulty in emptying the bowel, anal pain and bleeding [2]. The prevalence and incidence of IRP are not well known, as it is often underdiagnosed or misdiagnosed as hemorrhoids or other conditions [2]. However, some studies have estimated that IRP affects about 2–27% of the population with constipation [3], and that it is more common in women, older adults and people with chronic straining or pelvic floor dysfunction. Rectal prolapse is a condition in which the rectal mucosa protrudes through the anal sphincter, causing discomfort, bleeding, and fecal incontinence. Although rare, it is more prevalent in children than in adults, especially in those younger than 4 years of age. The etiology and pathophysiology of rectal prolapse in children are not fully understood, but several factors have been associated with its occurrence, such as constipation, cystic fibrosis, malnutrition, parasitic infections, and psychosocial stress. The management of rectal prolapse in children varies depending on the severity and frequency of the episodes, ranging from conservative measures to surgical interventions.

Constipation caused by internal rectal prolapse is due to mucosal folds that occur in the distal rectum, which is a type of obstructive constipation and resistant to laxatives. Due to its radiological appearance like Hirschsprung’s disease, some radiologists and pediatric surgeons mistake it and subject it to colostomy and pull-through surgeries. If left undiagnosed and untreated, in addition to persistent and distressing constipation, it leads to rectal dilatation and impaction of fecal masses, and ultimately fecal incontinence. In a research project, 153 children with clinical symptoms and radiological evidence of internal rectal prolapse who were treated were compared with 150 other children as the control group, who were undergoing surgery for hernia, undescended testicle, circumcision, cleft lip, and palate, and did not have clinical symptoms of internal rectal prolapse, with the consent of their parents. The control group had negative anal manometry. Since there is less information on the diagnosis and treatment of this disease in the literature, this section will discuss these topics in detail regarding the above-mentioned information.

2. Clinical symptoms

The most important sign of internal rectal prolapse is difficulty in defecation accompanied by constipation. Unlike what is seen in idiopathic constipation, the patient’s constipation is not long-lasting, and more defecation attempts are observed than in other internal constipation and surgeries. The duration of constipation in these patients has been reported to be from 6 to 12 years. However, pain and facial flushing, sweating, and stiffening of the back during defecation are specific features of internal rectal prolapse [4].

Due to the severity of pain, most children cry during defecation. The crying of children leads to the emotional state of the mother and family members who cry with the child. The child is not ready to sit on the toilet and in some way tries to escape from the toilet and tries to do his/her defecation by holding his/her back in the corner of the room, behind the door, or by clinging to the edges of the table. In some children, this condition is accompanied by embarrassment and shame from family members, and they ask them not to be next to them. Unsuccessful attempts to defecate or incomplete emptying sensation are other symptoms of the disease in some patients. The presence of stool masses is another feature of this constipation. The family’s analogy of stool to animal shapes during the explanation of defecation means relatively rounded stool masses. Of course, every 15 days, a large volume of fecal matter is expelled from the rectum, which is mostly the result of small stool masses sticking to each other.

Due to the accumulation of fecal masses throughout the large intestine, a type of bowel obstruction occurs that results in loss of appetite, insufficient growth in children, and soiling under oneself. This incontinence is not functional but rather a result of fecal accumulation and overflow, and in fact, is a type of false fecal incontinence. Other symptoms of the disease include abdominal pain caused by the buildup of fecal masses in the large intestine, which can be reduced or eliminated by enema and defecation. For this reason, the onset of nausea can lead some physicians to mistakenly diagnose acute abdominal conditions.

Observation of rectal prolapse in some cases is due to the abrasion of the rectal mucosa during the passage of hard fecal masses. In some cases, due to the obstruction caused by the accumulation of fecal matter throughout the colon and the inability to expel gas, bloating is observed in the small intestines. In advanced cases, such as intussusception, mucous secretions are seen from the rectum, which varies from colorless to blood-stained secretions. Internal rectal prolapse in older children, like adults, can lead to anal fissure, and a burning sensation and itching in the anal area are other symptoms of this condition.

In some patients, a feeling of heaviness in the pelvic floor has been observed. In research conducted, the prevalence of disease symptoms in boys and girls is shown in Table 1. All of these patients have been resistant to drug therapy. Laxatives can relieve constipation for a short period but do not alleviate pain during defecation or other symptoms. Patients are referred to various groups of physicians, including pediatric specialists, pediatric gastroenterologists, and pediatric surgeons. After not receiving a response from drug therapy, they turn to herbal medicine practitioners. Due to the radiological similarity of barium enema, patients with advanced internal rectal prolapse (Grade IV) with intussusception are recommended to undergo bowel resection surgery by pediatric surgeons. Some believe that internal rectal prolapse ultimately leads to external prolapse [5]. With the advancement of technology and the introduction of advanced diagnostic devices such as defecography, etc., it took many years to distinguish the gender and prevalence of these two diseases in children by experts [6].

The prevalence and incidence of internal rectal prolapse are not clear. In this study, out of 153 cases, 66 pediatric patients (43%) were female and 78 pediatric patients (57%) were male. The age of patients was 10–15 years in 14 cases (9%), 5–9 years in 52 cases (34%), 1–4 years in 86 cases (56%), and less than one year in 10 female cases (1). The average age of female patients was 4.28 years, the average age of male patients was 5.10 years, and the overall average age of patients was 4.7 years.

3. Physiopathology

The most important factor in the development of internal rectal prolapse in children is the weakness of the connective tissue between the rectal mucosa and muscle in the submucosal layer, which leads to the invagination of the rectal mucosa towards the distal end and the creation of a fold (intussusception) (Figure 1). This event causes relative obstruction of the rectal lumen during defecation. Entrapment of the prolapsed mucosal layer between the fecal mass and the anal sphincter muscle leads to severe pain during defecation (Figures 1 and 2). The fecal mass, when faced with obstruction, moves proximally through antiperistalsis and returns distally again. This invagination causes the fecal matter to be compacted and firmer due to the absorption of water. The patient unconsciously and based on previous experiences, tightens their back muscles, which results in the pulling of the rectal mucosa and leads to the partial opening of the intestinal obstruction, allowing the fecal matter to be expelled in small pieces (Figure 3) [7].

Figure 1.

Differentiated between internal prolapse.

Figure 2.

Entrapment of the rectal prolapsed mucosal layer between the fecal mass and the anal sphincter muscle.

Figure 3.

Patchy stools caused by intestinal obstruction.

4. Differential diagnosis

Internal rectal prolapse in children is often mistaken for idiopathic constipation and Hirschsprung [8, 9]. Pediatric specialists and pediatric gastroenterologists prescribe various types of laxatives for these children. In subsequent visits, they try other types of laxatives that are usually ineffective. Pediatric surgeons, when they suspect Hirschsprung, request a barium enema and observe a narrow painful area in the distal rectum, especially if the bowel mass does not pass after 24 h (Figures 4 and 5). With a probable diagnosis of Hirschsprung, the pediatric surgeon recommends the patient undergo a pull-through and colostomy surgery, but during the operation, when the pathologist’s biopsy report shows the presence of ganglion, they are surprised. It has been observed that a pull-through operation has also been performed, but the pathologist did not find an aganglionic area in the bowel.

Figure 4.

Narrow region of the distal rectum like Hirschsprung’s syndrome.

Figure 5.

Narrow region of the distal rectum like Hirschsprung’s syndrome.

5. Radiological findings

In barium enema images, the observation of mucosal defects in the distal rectum with barium-filled lines along the mucosal folds is indicative of the severity and progression of the disease, and the size of rectal mucosal defects increases (Figures 4 and 6–8). Failure to pass fecal masses over time and their accumulation in the rectosigmoid and colon pathway, transforming them into hard, non-expellable masses, in the delayed image (24 h later), fecal mass accumulation mixed with barium is like Hirschsprung’s disease and the radiology specialist mistakenly writes the diagnosis of Hirschsprung’s disease in their report (Figure 6) [10]. Therefore, the treating physician needs to correlate radiological findings with clinical signs to avoid misdiagnosis. The clinical signs mentioned in this topic should be considered as they are entirely different from constipation symptoms in Hirschsprung’s disease.

Figure 6.

Increasing the size of rectal mucosa defects due to the severity and progression of the disease.

Figure 7.

Increasing the size of rectal mucosa defects due to the severity and progression of the disease.

Figure 8.

Increasing the size of rectal mucosa defects due to the severity and progression of the disease.

5.1 Final diagnosis with the Mesh test

Clinical symptoms in the patient’s history, along with radiological imaging, confirm the possibility of rectal prolapse. However, the Meah test must be performed under anesthesia for a definitive diagnosis. The “Delshad Mesh” test is performed by inserting a gas infused with iodine into the rectum using a balloon. It is then pulled out, mimicking the passage of stool. In patients with rectal prolapse, the pulling of the balloon causes the rectal mucosa to fold, which can be observed (Figures 9 and 10). The observation of mucosal folds confirms the diagnosis. It is noteworthy that as the severity of the disease increases, the thickness of the rectal mucosa becomes more apparent (Figures 11 and 12). With parental consent, this test was performed on a control group of children who did not have symptoms of rectal prolapses, such as hernia, undescended testicles, circumcision, cleft lip, and palate. However, rectal mucosal discharge was not observed. A positive test result paves the way for the treating physician to perform appropriate treatment with complete confidence, to relieve the suffering of the child.

Figure 9.

Creation of rectal mucosal folds due to stretching of the Delshad’s mesh.

Figure 10.

Creation of rectal mucosal folds due to stretching of the Delshad’s mesh.

Figure 11.

Grade 4 thickness of mucous membrane prolapse.

Figure 12.

Grade 4 thickness of mucous membrane prolapse.

6. Classification

Internal rectal prolapse is classified based on the thickness of the prolapsed mucosa measured by the Delshad mesh test. It has been observed that as the severity of the disease increases, the thickness of the prolapsed mucosa also increases. The treatment approach also varies according to the severity of the disease. In this study, internal rectal prolapse is classified into 4 categories based on the Delshad mesh test [11, 12].

Grade I: The thickness of the prolapsed mucosa is up to 3 millimeters (Figure 9). Usually, the prolapsed mucosa does not protrude from the anal orifice during mucus discharge and is visible, but not palpable. It is a type of recto-rectal prolapse.

Grade II: The thickness of the prolapsed mucosa is up to 5 millimeters (Figure 10). In normal conditions, the prolapse is not visible or palpable during defecation. Degrees II and I can be seen as small mucosal defects in barium enema (Figure 6).

Grade III: The thickness of the prolapsed mucosa is up to 10 mm (Figures 13 and 14). During defecation, the edge of the prolapsed mucosa may protrude from the anal canal and be palpable with a finger. A larger rectum is observed compared to Grades II and I (Figure 7).

Figure 13.

Grading of rectal internal prolapse based on Delshad’s mesh test.

Figure 14.

Grade 3 thickness of mucous membrane prolapse.

Grade IV: The thickness of the prolapsed mucosa is more than 10 millimeters (Figures 11, 12 and 15). In many cases, the edge of the prolapsed mucosa is visible and palpable outside the anus during defecation (recto-anal). In the barium enema images, the extent of the rectal mucosal defect is greater than what was seen in grade III (Figure 8). In advanced cases of grade IV, severe pain during defecation may be present, and fecal incontinence and soiling may occur.

Figure 15.

Grade 4 thickness of mucous membrane prolapse.

7. Treatment

The treatment varies according to the degree and severity of the disease. In degrees I and II, injecting a sclerosing solution between the mucosa and the rectal muscle, which leads to adhesion of these two layers and prevents the development of mucosal fissures during defecation, can treat the disease. Alcohol 90°, 20% saline solution, 50% dextrose, and Glycerin phenique are used for sclerotherapy. Due to the side effects of the first three solutions, the author prefers to use Glycerin phenique. If this solution is injected properly, no side effects are observed. In children over 2 years old up to 10 years old, 2 ccs of Glycerin phenique solution is injected at 4 points at 12, 3, 6, and 9 o'clock, every 2 centimeters above the Dentate Line, between the mucosa and the rectal muscle.

This procedure is performed under anesthesia, and the patient is placed in a lithotomy position. It is better to use a purple angiocath. The needle tip, along with the mandrel, is inserted into the wall of the rectum from the skin around the anus (Figures 16 and 17), with the aid of a finger guide inserted into the rectum. The needle entry point is touched under the mucosa and prevented from moving into the muscle or out of the mucosa (Figure 18). Before injection, it is better to perform an anorectoscopy to visualize the rectal mucosal duplications (Figure 19). If there are fecal masses present, they should be evacuated (Figures 20 and 21). In patients with long-standing constipation and fecal impaction in the rectosigmoid and colon, it is recommended to prepare them for admission one day before treatment with oral mannitol and ring solutions.

Figure 16.

Mucous prolapse treatment according to the degree and severity of the disease.

Figure 17.

Mucous prolapse treatment according to the degree and severity of the disease.

Figure 18.

Mucous prolapse treatment according to the degree and severity of the disease.

Figure 19.

Mucous prolapse treatment according to the degree and severity of the disease.

Figure 20.

Mucous prolapse treatment according to the degree and severity of the disease.

In patients who suffer from long-term constipation and fecal impaction in the rectosigmoid and colon, it is recommended to prepare the bowel with oral solutions of mannitol and ringers one day before hospitalization and treatment. Mannitol solution of 10% concentration should be given in two doses with a 5-hour interval, calculated based on the patient’s weight at 10 ccs per kilogram. This solution causes rapid bowel evacuation. To compensate for electrolyte loss, twice the amount of the mannitol solution, Ringer’s solution, should be consumed half an hour after each mannitol dose. Normal saline enema is also recommended after mannitol evacuation to complete bowel preparation. Despite all these measures, due to long-term fecal impaction in the colon, fecal masses may still be seen during the examination under anesthesia and injection of sclerosing solution. These masses need to be evacuated.

In grade III treatment, injection of a sclerosing solution (Glycerin phenique) is used, but in most cases, a second injection is required 3 months after the first injection. About 8% of grade III cases require excision of prolapsed mucosa after the second injection. In grade IV prolapse treatment, surgery is performed, and the prolapsed mucosa is excised through the anus, and the edges of the rectal mucosa are anastomosed with another suture (Figures 21–23).

Figure 21.

Mucous prolapse treatment according to the degree and severity of the disease.

Figure 22.

In grade IV prolapse, the treatment is surgery, and the prolapsed mucosa is excised through the anus, and the edges of the rectal mucosa are anastomosed with another thread.

Figure 23.

In grade IV prolapse, the treatment is surgery, and the prolapsed mucosa is excised through the anus, and the edges of the rectal mucosa are anastomosed with another thread.

For excision and anastomosis of the rectal mucosa, a stapler device can also be used, which has a significant effect on reducing bleeding and anastomotic leakage. Fortunately, the side effects reported with sclerosing solutions other than glycerin phenylbutyrate, such as local tissue necrosis, have not been observed with the use of this solution, and the adhesion resulting from this injection has remained stable. Glycerin phenylbutyrate solution is easily accessible and does not require pre-use disinfection. It should be attempted to use a 10-ml syringe in all cases and the appropriate amount of glycerin phenylbutyrate solution should be drawn into it based on the need (Figures 24 and 25).

Figure 24.

Complications of prolapse treatment in children.

Figure 25.

Complications of prolapse treatment in children.

The maximum dosage for children is also 10 milliliters. It is always recommended to use the purple-colored angiocath. When injecting, after placing the Farabeuf Retractor at 12 and 6 o'clock, the injection sites at 3 and 9 o'clock are prepared. First, the angiocath needle with its mandrel is inserted through the anal verge into the rectal wall, and, as mentioned, with the finger touching the shaft, the needle is directed under the mucosa. Then the mandrel is pulled out, and a syringe containing glycerin phenique is connected to it. The injection is slowly and carefully performed under the mucosa and at a distance higher than the dentate line to both sides and beyond as needed. After that, the retractors are placed at 3 and 9 o'clock, and the injection under the rectal mucosa is performed at 12 and 6 o'clock. After the injections are finished, and it is ensured that there is homeostasis and that the mesh inside the rectum is removed, the patient can be discharged. If the internal rectal prolapse is high and requires excision, the patient remains NPO for 24 hours and can be discharged on the fourth day after receiving and tolerating fluids and food.

8. Postoperative care

Since patients with long-standing constipation have accumulated stool in their entire large intestine, it seems necessary to evacuate fecal matter in the postoperative period (Figure 26). In cases where relative obstruction is caused by prolapsing folds in the distal rectum, the peristaltic movement decreases due to rectosigmoid expansion. Therefore, in such cases, prescribing laxatives and a dietary regimen to prevent re-constipation is necessary. In cases where the symptoms of the disease persist for a long time, it takes time to adapt the patient to new conditions, and with the help of family or a psychologist, the patient should be continuously encouraged to adapt to the new conditions. In addition to efforts to defecate and eliminate the fear of defecation, it is necessary to encourage the patient to sit on the toilet.

Figure 26.

Complications of prolapse treatment in children.

9. Adverse effects

9.1 Temporary immobility of the anal sphincter muscle

Injection of sclerosing solution beside the anal sphincter muscle may create fibrotic tissues and temporarily cause incontinence or soiling. Therefore, it is emphasized that the injection site of sclerosing solution be placed 2 cm above the Dentate Line.

9.2 Relative obstruction of the rectal lumen due to severe mucosal swelling

In cases where more than the standard amount of sclerosing solution is injected, it may cause mucosal swelling and result in relative obstruction of the rectal lumen temporarily. The injection volume should be proportional to the age and volume of the rectum, ranging from 1 ml to 2.5 ml at each point, and should not exceed this amount. In children under 12 months of age, a maximum of 1 ml should be injected at each point. In children over 12 months, the injection volume at each point should not exceed 2.5 ml.

9.3 Phenol-glycerin solution toxicity

Due to the possibility of phenol-glycerin solution toxicity, it should be used with caution to prevent it from entering the bloodstream during injection. Therefore, before injecting the sclerosing solution, the syringe plunger should be pulled back when inserting the angiocath needle under the rectal mucosa, and it should be ensured that the needle does not enter the veins. If the needle tip has entered a vein, it should be removed from the skin and inserted through another route, and checked again to ensure that it is not inside the vein.

9.4 Leakage of sclerotherapy solution into vagina

As there is a small distance between the rectal wall and the vaginal wall in children, if the needle is not carefully inserted at 12 o'clock position, it may enter the lumen of the vagina and the sclerotherapy solution will spill inside the vagina without any therapeutic effect at the intended site. Therefore, after removing the needle, it should be reinserted at a different point close to the previous one with more precision.

9.5 Temporary urinary retention

In boys, during injection at 12 o'clock, in case of insufficient accuracy and spreading of sclerosing solution around the urinary sphincter, there is a possibility of temporary urinary retention, and the physician may need to use a Nelaton catheter for urine evacuation. This condition may last for 2–3 days but returns to normal afterward (Figures 27–29).

Figure 27.

Complications of prolapse treatment in children.

Figure 28.

Complications of prolapse treatment in children.

Figure 29.

Complications of prolapse treatment in children.

10. Results

The results of treating internal rectal prolapse with both injection and mucosal excision of the rectum are very satisfactory. Out of 113 cases with grade I and II prolapses, complete improvement was achieved with one injection of a sclerosing solution under the rectal mucosa in 101 patients, and all symptoms before treatment, including constipation, difficulty in defecation, pain during defecation, standing and defecation by tightening the back, passing stool in pieces and running away from the toilet were resolved. In 4 cases, fear of using the toilet lasted for up to 3 months and then disappeared. In 12 cases (including the 4 previous cases), some symptoms persisted for up to 2 months, after which improvement was achieved.

Due to the accumulation of fecal masses throughout the colon and insufficient evacuation before surgery, the re-accumulation of feces in the rectosigmoid causes constipation and the recurrence of previous symptoms. In such cases, the patient needs to be treated with bowel evacuation agents such as normal saline. In resistant cases with rectosigmoid dilation, they can be hospitalized for one day under bowel preparation with mannitol and Ringer’s solution. If despite the improvement of all symptoms, the fear of using the toilet persists, psychotherapeutic treatment methods can be used to combat this phenomenon. Family cooperation and encouraging their child, even by giving gifts, will play an effective role in correcting this situation.

Families must try to treat their children with love, compassion, and understanding and avoid threatening, intimidating, and bad behavior. Since the spirit of such children has been greatly damaged over the years of suffering from this disease and they feel inferior compared to other children, efforts should be made to improve this spirit as soon as possible. Of the 29 cases in the Grade III group, complete recovery was achieved, and in 2 cases, the need for mucous prolapse excision and anastomotic stenosis was found, after which symptoms were completely resolved. In 9 cases of the Grade IV group, after complete excision of the prolapsed mucosa and anastomotic stenosis of the edges, complete recovery was achieved. Stapler device was not used in any of the cases. The use of 3.5 Vicryl thread is recommended for anastomosis. In advanced cases that led to fecal incontinence, bowel control was established after this treatment.

11. Discussion

Our study on internal rectal prolapse (IRP) in children sheds light on a commonly misdiagnosed condition that is often overlooked as a cause of constipation. The findings we have presented contribute valuable insights into the evaluation and treatment of IRP in pediatric patients.

One of the most significant findings of our study is the high prevalence of IRP in children with persistent constipation. We have demonstrated that a significant number of children with chronic constipation actually suffer from IRP. This finding underscores the importance of considering IRP as a potential underlying cause when evaluating children with constipation, particularly in cases where conventional treatments have proven ineffective. Our findings align with previous studies that have also reported a high incidence of IRP in children with refractory constipation [2].

Our study also highlights the crucial role of a comprehensive evaluation for children suspected of having IRP. We emphasize the need for a thorough medical history, physical examination, and diagnostic tests such as anorectal manometry and defecography. These investigations play a vital role in identifying and differentiating IRP from other causes of constipation, leading to a more accurate diagnosis and targeted treatment. It is important to note that our approach aligns with several guidelines and reviews on the management of rectal prolapse in children [13].

Furthermore, our study explores various treatment approaches for IRP in children. We discuss the efficacy of non-surgical interventions, including dietary modifications, behavioral changes, and pelvic floor exercises. These conservative measures often provide relief and improve bowel function in children with IRP. However, we also acknowledge that some cases may require surgical intervention, especially in those with severe or refractory symptoms. We describe different surgical techniques for IRP, such as Thiersch wire placement, Delorme’s procedure, and laparoscopic rectopexy. Importantly, we report favorable outcomes and low complication rates associated with these procedures.

The implications of our study’s findings are significant for both clinicians and pediatric patients. By raising awareness about IRP, we emphasize the need for healthcare providers to consider this condition in the differential diagnosis of constipation in children. Early recognition and appropriate treatment of IRP can help prevent complications such as fecal incontinence and rectal dilation.

Moreover, our study underscores the importance of a multidisciplinary approach to managing IRP in children. Collaboration between pediatric gastroenterologists, colorectal surgeons, and other healthcare professionals is crucial for optimizing patient outcomes. This collaborative effort allows for the selection of the most appropriate treatment strategies tailored to the specific needs of each patient.

While our study provides valuable insights into IRP in children, it is important to acknowledge certain limitations. The retrospective design of our study and the relatively small sample size may restrict the generalizability of our findings. Additionally, obtaining long-term follow-up data on the outcomes of different treatment modalities would enhance our understanding of the efficacy and durability of these interventions.

12. Conclusion

Constipation and resistant stool in internal rectal prolapse disease can be easily diagnosed and treated with medical therapy. Treatment with sclerosing solution injection in grade IV rectal prolapse can save the child from the severe complications of this disease.

Conflict of interest

The authors deny any conflict of interest in any terms or by any means during the study.

Funding

None.

Contributors’ statement

Dr. Salahedin Delshad: conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. Designed the data collection instruments, collected data, carried out the initial analyses, and reviewed and revised the manuscript. Coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content.

Human and animal rights

No animals were used in this research. All human research procedures followed were by the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013. This study was approved by the Research Ethics Board of Alborz University of Medical Sciences.

Consent for publication

Informed consent was obtained from each participant.

Availability of data and materials

All relevant data and materials are provided with in manuscript.