Akeel N, Rajasingh CM, Earley M, Au Hoy S, Neshatian L, Enemchukwu E, Mishra K, Gurland B. Perception of rectal prolapse symptoms in patients with psychiatric disorders. World J Gastrointest Surg 2026; 18(1): 114452 [DOI: 10.4240/wjgs.v18.i1.114452]
Corresponding Author of This Article
Nouf Akeel, MD, Associate Professor, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Idara S, Jeddah 21589, Makkah al Mukarramah, Saudi Arabia. nakeel@kau.edu.sa
Research Domain of This Article
Surgery
Article-Type of This Article
Retrospective Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Jan 27, 2026 (publication date) through Jan 28, 2026
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Publication Name
World Journal of Gastrointestinal Surgery
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1948-9366
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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
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Akeel N, Rajasingh CM, Earley M, Au Hoy S, Neshatian L, Enemchukwu E, Mishra K, Gurland B. Perception of rectal prolapse symptoms in patients with psychiatric disorders. World J Gastrointest Surg 2026; 18(1): 114452 [DOI: 10.4240/wjgs.v18.i1.114452]
Nouf Akeel, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah 21589, Makkah al Mukarramah, Saudi Arabia
Charlotte Mary Rajasingh, Michelle Earley, Sydni Au Hoy, Department of Surgery, Stanford University, Stanford, CA 94305, United States
Leila Neshatian, Division of Gastroenterology and Hepatology, Stanford University, Redwood City, CA 94063, United States
Ekene Enemchukwu, Department of Urology, Center for Academic Medicine, Stanford University, Stanford, CA 94305, United States
Kavita Mishra, Department of Obstetrics and Gynecology, Stanford Pelvic Health Center, Stanford University School of Medicine, Stanford, CA 94305, United States
Brooke Gurland, Department of Colorectal Surgery, Stanford University, Stanford, CA 94305, United States
Author contributions: Akeel N contributed to data interpretation; Akeel N, Neshatian L, Enemchukwu E, and Gurland B edited the manuscript; Rajasingh CM and Hoy SA reviewed the manuscript; Earley M, Neshatian L, Enemchukwu E, Mishra K, and Gurland B conception and design of the study; Earley M, Rajasingh CM, and Hoy SA contributed to data collection; Earley M participated in the statistical analyses, and interpretation of results to ensure accuracy, validity, and scientific rigor; Gurland B contributed to supervision. All authors have read and approved the final manuscript.
Institutional review board statement: The study was reviewed and approved by Stanford University Institutional Review Board (approval No. 46691).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Nouf Akeel, MD, Associate Professor, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Idara S, Jeddah 21589, Makkah al Mukarramah, Saudi Arabia. nakeel@kau.edu.sa
Received: September 22, 2025 Revised: October 30, 2025 Accepted: December 1, 2025 Published online: January 27, 2026 Processing time: 124 Days and 10.6 Hours
Abstract
BACKGROUND
The perception of symptoms in individuals with rectal prolapse (RP) can be influenced by psychiatric disorders (PD). It was hypothesized that women with a history of PD would experience higher levels of bother from RP symptoms.
AIM
To examine the relationship between PD and symptom severity in women with RP.
METHODS
A retrospective analysis was conducted on female patients with RP from an approved registry. Demographic data, medical history, and prolapse-associated symptoms were collected. Validated questionnaires were used to measure the severity of symptoms and degree of associated bother. Patients with and without psychiatric history were compared.
RESULTS
Among the 200 patients included in the study, 83 (42%) had a PD, with depression (n = 46) and anxiety (n = 38) being the most prevalent. Patients with psychiatric history were younger (mean age: 58 ± 16) compared to those without PD (mean age: 66 ± 15; P < 0.001). The patients with PD reported higher scores on the Pelvic Floor Distress Inventory Questionnaire-20 [median (interquartile range): 137.5 (77.08, 180.21) vs 101.04 (67.71, 150)] and Pelvic Floor Impact Questionnaire-7 [median (interquartile range): 100 (59.52, 171.43) vs 80.95 (38.10, 142.86)]. The bowel symptoms were the primary contributors to the distress experienced by these patients.
CONCLUSION
Women with RP have a higher prevalence of PD and perceive bowel symptoms as more severe. Routine screening for PD is recommended and may improve patients’ outcomes.
Core Tip: The prevalence of coexisting psychiatric disorders in women with rectal prolapse is 42%. These patients were younger and had higher rates of chronic constipation. The Pelvic Floor Distress Inventory Questionnaire-20 and the Pelvic Floor Impact Questionnaire-7 revealed greater symptom distress and a more significant impact on quality of life in this group. The bowel symptoms were the main contributors to the distress experienced by these patients. This study supports the importance of screening for psychiatric conditions in rectal prolapse patients, which may improve individualized care.
Citation: Akeel N, Rajasingh CM, Earley M, Au Hoy S, Neshatian L, Enemchukwu E, Mishra K, Gurland B. Perception of rectal prolapse symptoms in patients with psychiatric disorders. World J Gastrointest Surg 2026; 18(1): 114452
Rectal prolapse (RP) symptoms are troubling and affect the patient’s quality of life. Patients may present with protruding mass, pain, fecal incontinence, obstructed defecation, bleeding, mucus discharge, and rectal urgency[1]. Several studies revealed an increased prevalence of psychiatric disorders (PD) in patients with RP, pelvic organ prolapse (POP)[2,3], and functional gastrointestinal disorders; almost half of the patients of RP suffered from psychiatric diseases[4-7]. There are several possible explanations for these findings. One explanation is that medications prescribed for PD may exacerbate baseline bowel symptoms in patients with RP, including exacerbating pelvic floor weakness. Moreover, PD may be a barrier participating in positive lifestyle modifications that can help with RP[8]. Toileting habits such as avoiding prolonged time on the commode or straining and performing diaphragmatic breathing to relax the pelvic floor muscles are components lifestyle changes that can help with RP - however, complying with these behaviors can be challenging and require patients to be diligent and consistent. Additionally, anxiety and depression can heighten attention to bodily sensations and lower pain thresholds, leading to psychological amplification of pelvic and bowel symptoms[9]. Previous studies examined the impact of POP symptoms on patients with PD. They concluded that the depressive symptoms and their impact on the quality of life (QoL) do not always correlate with the POP-quantitation stage. However, the perception of prolapse and the impact of urinary and bowel dysfunction on the QoL were associated with depressive symptoms[5,6,10,11]. The relation between PD and the perception of symptoms related to RP remains underexplored in existing literature. Evaluating this relationship would help understanding patients’ needs and improve management approaches by establishing additional mental health resources and counseling for affected individuals. We hypothesized that the RP symptoms would be more bothersome to the women with PD. The primary outcomes of this study were to evaluate the clinical characteristics and determine the severity and bothersome symptoms of RP in patients with PD compared with patients without PD (NPD) using validated questionnaires.
MATERIALS AND METHODS
This is a retrospective study analyzed data from the prospective Stanford University Institutional Review Board-Approved Research Prolapse Registry (approval No. 46691). The registry included all female patients evaluated in our clinic with an International Classification of Diseases, 10th Revision, diagnosis code for RP (K62.3). Patients were consented at the initial surgical evaluation, and data were collected subsequently. Demographic data, medical, obstetric, and surgical history, including history of prior RP repair, and prolapse-associated symptoms were collected. The patients were evaluated at a colorectal and pelvic health clinic. We did not explore the duration of their symptoms; instead, we assessed the active symptoms based on their medical history and medication usage. Patients also prospectively completed multiple validated questionnaires to measure the severity of symptoms and degree of associated bother. The patients received the Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20), Pelvic Floor Impact Questionnaire-7 (PFIQ-7), the 5-item Cleveland Clinic Fecal Incontinence (CCFI) and the 5-item Obstructed Defecation Syndrome (ODS) scales[12-15]. The PFDI-20 measures distress and has three subscales: The Urinary Distress Inventory, POP Distress Inventory, and Colorectal-anal Distress Inventory (CRADI) - each subscale scores from 0 to 100. The PFIQ-7 evaluates the impact of pelvic floor symptoms on the patient’s life, and it also has three scales: Urinary Impact Questionnaire, POP Impact Questionnaire, and Colorectal-anal Impact Questionnaire. Each scale has a score range from 0 to 100. A higher score on the PFDI-20 and the PFIQ-7 indicates more bothersome symptoms and a greater impact on daily activities, respectively. The ODS questionnaire quantifies the frequency of five symptoms of obstructed defecation: Excessive straining, incomplete rectal evacuation, use of enemas and laxatives, vaginal or perineal digital pressure during defecation, and abdominal discomfort or pain due to obstructed defecation. Each item was graded from 0 (never) to 4 (always). The CCFI score assesses the type and frequency of incontinence and the alteration in lifestyle, with a score ranging from 0 (normal continence) to 20 (complete incontinence). Our registry also captured questions about patient-specific prolapse symptoms, such as the length of prolapse symptoms and whether prolapse occurs all the time or with defecation. This analysis included consecutive female patients with intra-anal prolapse (Oxford grade IV) and full-thickness external prolapse who were evaluated for surgery, had data on the presence or absence of PD, and had a baseline PFDI-20 score[16]. Patients who did not complete the PFDI-20 questionnaire or were non-English speakers were excluded from the analysis. All data were recorded in Research Electronic Data Capture. This is a live registry with ongoing data collection. Data collection began on July 1, 2017. Data for this analysis were frozen on July 11, 2023.
Statistical analysis
Differences between female patients with and without a PD were evaluated using Fisher’s exact test for categorical variables and a Wilcoxon test for continuous variables. Median QoL scores were also compared using linear quantile regression, adjusting for age, history of chronic constipation, history of chronic diarrhea, and history of sexual trauma. P value < 0.05 (2-tailed) was considered statistically significant. All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC, United States).
RESULTS
Demographics and clinical characteristics
Among 344 female patients with RP in the database as of July 2023, 200 patients met the inclusion criteria. Of these 200 patients, 83 (42%) had a history of PD. Depression (n = 46) and anxiety (n = 38) were the most prevalent conditions. Patients with psychiatric history were younger {median [interquartile range (IQR)] age: 62 (45,68) vs 69 (59,76), P < 0.001}. A higher proportion of women in the PD group had a history of chronic constipation (52% vs 36%, P = 0.03), and a history of chronic diarrhea (27% vs 15%, P = 0.05). The history of sexual trauma was similar between the two groups (18% PD vs 9% NPD, P = 0.09). There were no differences between the groups regarding body mass index, race, comorbidities, and previous hysterectomy, pelvic floor, or RP surgeries. The majority of the included patients had full-thickness RP (86%), while 15% had internal RP (Oxford IV), with no differences between the study groups. Of the 200 patients, 148 women have given birth. The obstetric history was comparable between the two groups, including the number of vaginal deliveries or cesarean sections, operative vaginal deliveries, and history of fourth-degree tears (Table 1).
Table 1 Demographics and clinical characteristics, n (%).
Prolapse-related history was compared between the groups (Tables 2 and 3). The primary bothersome symptoms reported by the patients in the PD group did not differ from the NPD group (Table 2).
Distributions of baseline PFDI-20, PFIQ-7, CCFI, and ODS scores were compared between groups (Tables 4, 5, and 6). Patients in the PD group had a significantly higher total PFDI-20 score than the NPD group [median (IQR): 137.5 (77.08, 180.21) vs median (IQR) 101.04 (67.71, 150)]. This difference remained significant after adjusting for confounders in a quantile regression model [adjusted difference in medians (95% confidence interval): 38.24 (3.71-53.96)] (Figure 1A). Further evaluation of the subscale scores showed that the CRADI score was significantly higher among PD patients [median (IQR): 62.5 (43.75-81.25) vs median (IQR): 50 (34.38-68.75)], while POP Distress Inventory and Urinary Distress Inventory scores were comparable. Quantile regression models did not reveal differences in subscale scores (Figure 1B).
The PFIQ-7 showed a similar pattern, with significantly higher scores in the PD group [median (IQR): 100 (59.52, 171.43) vs median (IQR): 80.95 (38.10, 142.86)], primarily driven by the impact of the bowel symptoms rather than the prolapse and urinary symptoms. Quantile regression did not reveal significantly different median PFIQ-7 scores between groups (Figure 2). There was a minimal difference in the distribution of ODS score [median (IQR): 9 (5, 13) in the PD group vs median (IQR): 7 (4, 12) in the NPD group]; however, no difference was observed in the CCFI score. Quantile regression did not reveal statistically significant differences in ODS or CCFI scores.
Figure 2 Distribution of Pelvic Floor Impact Questionnaire and subscale scores.
A: Pelvic Floor Impact Questionnaire; B: Pelvic Floor Impact Questionnaire subscale. The box represents the interquartile range, spanning from the 25th percentile (lower edge) to the 75th percentile (upper edge), with a line inside the box indicating the median. The dot within the box marks the mean. Whiskers extend to the smallest and largest values within 1.5 times the interquartile range from the lower and upper quartiles. Values beyond this range are considered outliers and are shown as individual points. Boxplots illustrate the distribution across groups; statistical comparisons are reported in Tables 4 and 5. PFIQ: Pelvic Floor Impact Questionnaire; PD: Psychiatric disorders; NPD: No psychiatric disorders; UIQ: Urinary Impact Questionnaire; CRAIQ: Colorectal-Anal Impact Questionnaire; POPIQ: Pelvic Organ Prolapse Impact Questionnaire.
DISCUSSION
Bowel, bladder, and prolapse symptoms are common in some women, and it is conceivable that women with POP may experience depression and anxiety as the lack of control over bodily function negatively impacts their self-perception6. In this study, we demonstrated that women with RP and a history of PD, predominately depression and anxiety, are younger, and report a history of constipation and a higher degree of bother from bowel symptoms as compared to women without a psychiatric history. Using validated tools, we demonstrated that total PFDI-20 scores were significantly higher among this group; after sub-item analysis, CRADI was the leading cause of this difference. Likewise, PFIQ-7 scores were also significantly higher, primarily due to the impact of bowel symptoms. However, regression model results suggest that observed differences in PFIQ-7 scores may be explained by confounders included in the model. The CCFI score did not differ between the patients; however, the PD group had slightly higher ODS scores. These findings suggest rectal urgency and obstructive constipation are the main disturbing symptoms rather than fecal incontinence.
Previous studies have found that patients with RP who experience symptoms of depression have notably lower levels of physical and mental QoL[17]. Additionally, they were more likely to have bowel-related symptoms, particularly constipation and the need for laxatives and digital evacuation[4,7]. Several explanations may account for these findings. One possibility is that medications for PD could worsen existing bowel issues in patients with RP, including pelvic floor weakness. PD may further complicate adherence to beneficial lifestyle changes, such as avoiding prolonged sitting on the toilet or straining, both of which are crucial for managing RP[8]. Interventions that improve coping skills and disease acceptance have been shown to improve QoL in other diseases, such as irritable bowel syndrome[18,19].
Given this interplay between psychiatric disease and RP, identifying PD is crucial in preoperative planning, counseling patients, and managing their expectations before surgery. Numerous studies have highlighted a significant association between preexisting mental illness and several adverse outcomes, including higher rates of morbidities, longer hospital stays, increased 90-day mortality, higher readmission rates, non-home discharge, and an overall increase in post-discharge expenses. Numerous studies have highlighted a significant association between preexisting mental illness and several adverse outcomes, including higher rates of morbidities, longer hospital stays[20,21], increased 90-day mortality, higher readmission rates, non-home discharge, and an overall increase in post-discharge expenses[22-25].
CONCLUSION
PD is common among RP patients and associated with negative impact. This association is highlighted by higher PFDI-20 and PFIQ-7 scores in PD patients. This is a retrospective study; therefore, it has its limitations. There was substantial overlap in score distributions, suggesting that observed differences may be small in magnitude; as such, results should be interpreted with caution. Further, nonsignificant effects from quantile regression do not rule out small effects or residual confounding, due to the observational nature of the study. We did not report many aspects of the psychiatric history, such as the duration of the disease and whether it had been treated. Hence, the effect of controlling the psychiatric illness could not be evaluated. We recommend screening for PD when assessing a patient with RP and utilization of PFDI-20 and PFIQ-7 questionnaires to determine how symptoms impact a patient’s QoL. This practice could enhance patient care by identifying individuals who require mental health support in preparation for surgery. Future studies should address the surgical outcomes and the impact of implementing these measures on patients’ reported outcomes, especially bowel function.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Corresponding Author's Membership in Professional Societies: Saudi Society of Colon and Rectal Surgery.
Specialty type: Gastroenterology and hepatology
Country of origin: Saudi Arabia
Peer-review report’s classification
Scientific Quality: Grade A, Grade B
Novelty: Grade A, Grade A
Creativity or Innovation: Grade A, Grade B
Scientific Significance: Grade A, Grade B
P-Reviewer: Deng J, PhD, Lecturer, China S-Editor: Hu XY L-Editor: A P-Editor: Xu ZH
