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Background  Clinically diagnosing high-grade (III–V) rectal prolapse might be difficult, and the prolapse can often be overlooked. Even though defecography is the significant diagnostic tool for rectal prolapse, it is noticed that rectoanal inhibitory reflex (RAIR) can be associated with rectal prolapse. This study investigated whether RAIR can be used as a diagnostic factor for rectal prolapse.    Methods  In this retrospective study, we evaluated 107 patients who underwent both anorectal manometry and defecography between July 2012 and December 2019. Rectal prolapse was classified in accordance with the Oxford Rectal Prolapse Grading System. Patients in the high-grade (III–V) rectal prolapse (high-grade group, n = 30), and patients with no rectal prolapse or low-grade (I, II) rectal prolapse (low-grade group, n = 77) were analyzed. Clinical variables, including symptoms such as fecal incontinence, feeling of prolapse, and history were collected. Symptoms were assessed using yes/no surveys answered by the patients. The manometric results were also evaluated.    Results  Frequencies of fecal incontinence ( p  = 0.002) and feeling of prolapse ( p  < 0.001) were significantly higher in the high-grade group. The maximum resting (77.5 vs. 96 mmHg,  p  = 0.011) and squeezing (128.7 vs. 165 mmHg,  p  = 0.010) anal pressures were significantly lower in the high-grade group. The frequency of absent or impaired RAIR was significantly higher in the high-grade group (19 cases, 63% vs. 20 cases, 26%,  p  < 0.001). In a multivariate analysis, the feeling of prolapse (odds ratio [OR], 23.88; 95% confidence interval [CI], 4.43–128.78;  p  < 0.001) and absent or impaired RAIR (OR, 5.36; 95% CI, 1.91–15.04,  p  = 0.001) were independent factors of high-grade (III–V) rectal prolapse. In addition, the percentage of the absent or impaired RAIR significantly increased with grading increase of rectal prolapse ( p  < 0.001). The sensitivity of absent or impaired RAIR as a predictor of high-grade prolapse was 63.3% and specificity 74.0%.    Conclusions  Absent or impaired RAIR was a meaningful diagnostic factor of high-grade (III–V) rectal prolapse. Furthermore, the absent or impaired reflex had a positive linear trend according to the increase of rectal prolapse grading.

Absent or impaired rectoanal inhibitory reflex as a diagnostic factor for high-grade (grade III–V) rectal prolapse: a retrospective study