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Prolapse of the rectum, also known as anal prolapse, can occur frequently, or it may be triggered by defecation, coughing, or exertion. The first recorded mention of this condition is found in the Zhubing Yuanhou Lun.

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1. Sinking of Spleen Qi︰Anal prolapse, which protrudes during coughing or defecation and requires manual massage to be repositioned. The anal area appears pale without redness, swelling, or pain. The complexion is white, lips are pale, and there is shortness of breath, possibly accompanied by a cough. The tongue texture is pale with scant coating, and the pulse is weak and feeble. Only symptoms of qi deficiency are present, such as shortness of breath, cough, pale complexion, and pale lips. Treatment involves tonifying qi to lift the sinking and astringing to secure prolapse. The recommended prescription is Middle-Tonifying Qi-Replenishing Decoction.
2. Kidney Yang Deficiency︰Prolapse of rectum accompanied by dizziness, blurred vision, forgetfulness, diarrhea before dawn, or seminal emission, impotence, soreness and weakness of the waist and knees, general fear of cold, frequent urination, a swollen and tender tongue with scant and moist coating, and deep, thin pulse. It is mainly characterized by kidney symptoms (soreness and weakness of the waist and knees, impotence, diarrhea before dawn, frequent urination) combined with yang deficiency manifestations (general fear of cold, etc.). For those with kidney yang deficiency, in addition to tonifying qi, lifting, and consolidating, treatment should emphasize warming and tonifying kidney yang. The prescription uses Cassia Bark, Aconite and Rehmannia Pill plus Tangshen, Astragalus Root, Cimicifuga Rhizome, Bupleurum, Chebula Fruit, and Chinese Gall.
3. Dampness-heat Accumulating in the Large Intestine︰Prolapse of the anus, redness, swelling, and pain, or thirst with dry stool, flushed face, red lips, red tongue texture, yellow coating, and wiry rapid pulse. This syndrome is often caused by habitual indulgence in rich and greasy food, leading to dampness-heat accumulation in the intestines and stomach, which presses downward on the anus; or chronic severe constipation; or long-standing hemorrhoids; or excessive alcohol consumption causing heat and dampness accumulation; or indulgence in food and drink followed by sexual activity while suppressing ejaculation, allowing desire-fire to descend and affect the large intestine, resulting in anal prolapse with pain and discomfort. The prolapsed anus appears bright red or may bleed, all signs of fiery heat. Symptoms such as thirst, red tongue texture, yellow coating, and wiry rapid pulse indicate systemic excess heat or dampness-heat manifestations. Dampness-heat accumulation in the large intestine leads to rectal prolapse, and treatment focuses on clearing heat and draining dampness, as well as dispersing fire and promoting bowel movements. The recommended formula is Yue Ying Jian.

Sinking of middle qi and kidney yang deficiency prolapse of rectum: Commonly seen in the elderly with insufficient original qi, or women with excessive childbirth, where the original qi is severely damaged during delivery and cannot be retained; or chronic diarrhea and prolonged dysentery leading to the decline of both spleen and kidney, causing the qi of the large intestine to be unstable; or chronic cough disease damaging lung qi, leading to qi deficiency and inability to control the anus; or children with insufficient qi and blood, prone to crying, which depletes healthy qi, etc. All these can lead to lung-spleen qi deficiency, sinking of original qi, and inability to retain, resulting in the anus being unable to hold and prolapsing, as mentioned in Leizheng Zhicai "Prolapse of Rectum": "Prolapse of rectum is a symptom of sinking original qi, only qi deficiency cannot hold it firmly, so it is common in postpartum women, those with prolonged dysentery, those who exert too much effort, the elderly with declining health, and children with insufficient qi and blood." In severe cases, women may also experience prolapse of the anterior anus.

Dampness-heat accumulation in the large intestine and spleen qi deficiency without heat sinking and kidney yang deficiency prolapse of rectum are not difficult to differentiate: deficiency pattern prolapse of rectum, the prolapsed anus shows no redness, swelling, heat, or pain, and the whole body exhibits signs of interior deficiency cold or insufficient middle qi; dampness-heat prolapse of rectum, the person is usually robust; deficiency pattern individuals are often physically weak. From the perspective of chronic diarrhea or dry stool, it can also assist in differentiation: excess pattern, the stool is dry and accumulated, often due to dry stool not passing, straining to defecate causing the anus to prolapse; deficiency pattern is mostly due to chronic diarrhea, prolonged dysentery, postpartum, or no dry stool accumulation at all, only due to sinking of middle qi, relaxation of anal muscles, or kidney yang deficiency, leading to the anus not being firmly closed and prolapsing.

bubble_chart Documentation

1. Zhubing Yuanhou Lun-Anal Prolapse Condition: "The anus serves as the gateway to the large intestine. When the large intestine is weakened by cold-induced diarrhea, and forceful straining occurs, the downward surge of qi causes the anus to prolapse, hence termed anal prolapse."
2. Yixue Zhengzhuan-Hemorrhoids and Fistulas - Anal Prolapse Syndrome: "This condition stems from deficiency of qi and blood combined with heat. For qi deficiency, use Ginseng、Astragalus Root、Cimicifuga Rhizome、Sichuan Lovage Rhizome. For blood deficiency, employ Four Ingredients Decoction, and for heat, add Phelloendron Bark. Externally, apply powdered Chinese Gall to support and elevate the prolapse. If not retracted in one attempt, persist through five to seven applications for certain success."
3. Linzheng Zhinan Yi'an-Anal Prolapse: "Cases may arise from alcohol-dampness injuring the spleen or excessive sexual desire damaging the kidneys, leading to prolapse. Some occur due to congenital kidney qi deficiency with unsecured {|Guanmen|}, others from downward-descending damp-heat. Moreover, as the anus serves the large intestine, exposure to either cold or heat in the large intestine can cause prolapse. The elderly with declined qi-blood and children with underdeveloped qi-blood are particularly susceptible to anal prolapse."