From Boomtown To Bust, The Story Of The Total Failure Of Corrupt San Francisco

SAN_FRANCISCOS_CORRUPTION_CULTURE

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A variety of social problems and political corruption have cast a shadow over the once-gleaming City by the Bay

REVEALED: San Fran venture capitalist’s wife – who’s spearheaded campaign to shut down neighborhood pickleball court – has PRIVATE one in backyard of $36m mansion

Holly Peterson is being called a hypocrite after launching a petition to shut down pickleball courts in her neighborhood only for it to be revealed she had one in her own backyard.

San Francisco’s drug-addicted and homeless population is among the nation’s highest

Illustrated / Getty Images

JUSTIN KLAWANS

San Francisco is a city of two realities. The Bay Area is arguably the tech capital of the world, and the Silicon Valley region has “both the largest tech talent pool and the highest number of tech roles of any U.S. market,” according to TheRealDeal. San Francisco also remains a global leader in arts, culture and education, with its greater metropolitan area containing colleges like Stanford and UC Berkeley. 

It’s also among the wealthiest cities in the world. It has more than 285,000 millionaires, per a 2023 report from Henley and Partners, and also has 63 billionaires — more than any other city on the planet. The Bay Area is also known for its high cost of living and consistently ranks among the 10 most expensive cities in the world, according to The Economist Intelligence Unit. Data released at the end of 2022 showed that San Francisco’s “housing costs were 113% higher and utility costs were 67.5% higher … than the national average,” SFGate reported. The average rent for a one-bedroom apartment in San Francisco is $3,000, among the highest in the country, according to Zumper.

Heading into downtown, though, displays a much less glamorous version of the city. San Francisco has been grappling with several societal ills for years, including a widespread drug addiction crisis. In 2019, the city had “more drug addicts than it [had] students enrolled in its public high schools,” the San Francisco Chronicle reported, by a margin of more than 8,000 people.

While the city’s rate of violent crime is lower than the national average, San Francisco has high rates of property crimes like theft and burglary. Combined with the ongoing drug crisis, this has led to a large homeless population in the city. A mid-2022 report showed that 20,000 people were expected to experience homelessness in San Francisco that year, per the San Francisco Chronicle, and “for every one person housed by a city program, four more will become unhoused.” But San Francisco has had a long history of ups and downs. So how did the Bay Area get here, and is there still a way for the city to recover? Or is San Francisco destined for failure?

Why is it an epicenter of drugs and homelessness?

The influx of fentanyl is causing many of the problems, just as it is in cities across the United States. The drug has become almost ubiquitous in San Francisco. This past June, the California Highway Patrol “seized enough fentanyl in San Francisco to potentially kill over 2.1 million people,” according to the Office of the Governor. Given the city’s population of just over 800,000, this would be enough to kill everyone in San Francisco nearly three times over. 

At least 268 people in San Francisco died from fentanyl overdoses in the first four months of 2023, per the city’s chief medical examiner. Many additional overdose deaths were attributed to heroin, methamphetamines, medicinal opioids and cocaine. 

As a result of this fentanyl surge, users smoking drugs in public has become a common sight. However, unlike many other major cities, San Francisco “largely does not prosecute public drug use,” The San Francisco Standard reported. While drug possession remains a misdemeanor crime, experts told the Standard that the city’s “harm reduction” approach was the “result of a growing sentiment that … the government should take a public health approach that focuses on mitigating the harmful consequences of drug use.”

These drug issues have contributed to the city’s growing homelessness epidemic. California itself is home to half of the American homeless population, per McKinsey and Company, and “on any given night, 38,000 individuals in the Bay Area are homeless.” Drugs don’t appear to be the root cause of the city’s homelessness, though. A recent comprehensive study by ASR on the matter found that the problem was the result of a “severe shortage in affordable housing, a widening gap between rising housing costs and stagnant wages, and an insufficient safety net for individuals with disabling conditions.”

While 12% of respondents to the study said drug and alcohol abuse was the cause of their homelessness, this was only the third-most cited reason. Fourteen percent reported eviction as the culprit, and another 21% — more than a fifth of respondents — said they were homeless because they lost their jobs.

What role does wealth disparity play?

Not only is the cost of living increasing in the city, but the gap is widening, which researchers say is significantly contributing to the overall rise in poverty. If Silicon Valley were its own nation, it would be a “politically unstable country with extreme wealth inequalities,” according to a 2023 study from San Jose State University. The study added that “African American, Latinx, Indigenous and various Asian American communities continue to receive considerably less of the economic, political, education and social rewards” afforded to other races in San Francisco. A poll from the Chronicle found that even the city’s wealthiest individuals feel the gap between rich and poor is a major problem. Among 1,653 people sampled, 75% of those who made over $200,000 per year said the wealth gap was a “problem that should be made smaller.” Those who made between $50,000 and $100,000 were the likeliest to believe that the wealth gap was a problem, at 80%.

This is a notable statistic because these are people “who traditionally would have been able to afford homes but are not able to because of the city’s high cost of living,” Jacob Denney, of the San Francisco Planning and Urban Research Association, told the Chronicle. “People who are making $53,000 a year effectively are barely able to survive here,” Denney concluded. 

How can the city’s problems be fixed?

One solution: Build homes. “Build lots of homes everywhere in the Bay Area. Fill in all the empty lots and surface parking with places to live. Convert commercial buildings to residential ones,” Adam Rogers wrote for Insider. This could potentially be compounded by unused office space scattered throughout downtown post-Covid. 

While the city is already working on these initiatives, Rogers argued against zoning laws that prevent homeless people from being housed. “Fix the zoning issues that privilege big single-family homes and make multiplexes illegal. Get rid of rules that require every living unit to include parking for cars. Turn first floors into small retail spaces that local businesses can afford,” he said. 

And despite cooled-off criminalization against drug addicts, police have begun arresting open-air users. While this has been panned by some critics as the “wrong approach to deal with addiction and could even increase overdose deaths,” CBS News reported, the user’s risk “depends entirely on what you do after the arrest,” Stanford addiction researcher Keith Humphreys told the outlet. He added that these arrests should be coupled with “immediate enrollment in good medication” so people don’t suffer from withdrawals. 

While San Francisco undoubtedly has its downfalls, “its problems aren’t all that different from other major metros,” Vox reported. Rather, the city has received large amounts of negative press coverage because it “occupies a unique space in the identity of the U.S.” 

“San Francisco’s always had this mythology of being this future-forward, progressive city, but the rights of the disenfranchised have historically always been undercut and challenged by the cronyism and corruption at San Francisco City Hall.”

Popular vegan restaurant in San Francisco is forced to close after 13 years because doom-laden crime hotspot has made it ‘impossible’ to run the business

Gracias Madre boasts clients including the Duchess of Sussex, Natalie Portman and Liam Hemsworth at its branch in West Hollywood. But it shares its neighborhood in the Golden Gate city with an open-air drugs market and hundreds of homeless people. ‘The condition of life in San Francisco has deteriorated and made running a small business nearly impossible,’ a note left for customers on the door read. ‘We’ve got regular clients and customers that kept on saying it just seems too dangerous to come down here at night,’ manager Joseph Donohue told CBS, ‘and I don’t blame them.’

Shocking moment car is hit in smash-and-grab near San Francisco’s iconic Painted Ladies before thieves make getaway right in front of police – the same week top cop vowed to crack down on daylight robbers

San Francisco’s increasing crime has been memorialized in a video of a brazen thief seen stealing a car and speeding off in full view of a cop car in broad daylight. The incident happened Monday along the eastern side of Alamo Square Park, on what perhaps is the city’s most iconic street, the Painted Ladies. Also called ‘postcard row’, the sloped street is home to several affluent residences made famous in shows like Full House, and boasts a decidedly different look from the city’s crime-ridden Downtown, drawing thousands of tourists each year.

California Highway Patrol Policing Open Air Drug Use in San Francisco’s Tenderloin District

FILE - People sleep near discarded clothing and used needles on a street in the Tenderloin neighborhood in San Francisco, on July 25, 2019. London Breed, the mayor of San Francisco, declared a state of emergency in the Tenderloin district Friday, Dec. 17, 2021, in an effort to reduce overdose …
AP Photo/Janie Har, File

California Gov. Gavin Newsom is pulling officers from the California highway patrol to San Francisco’s Tenderloin district as part of a multi-agency initiative to crack down on open air drug dealings and drug use.

Since May 30, highway patrol officers have made 100 drug related arrests, CNN reported.  In one instance, a highway patrol officer arrested a drug dealer allegedly selling 33 grams of fentanyl which had the potential to kill 16,500 people.

Local authorities have apprehended 300 suspected drug dealers since the protocol changes.

Gov. Newsom’s office announced that California highway patrol officers have seized enough fentanyl to kill 2.1 million — three times the population of San Francisco — since deploying officers to the Tenderloin district since May 1.

Additionally, in the first six weeks of the operation, the CHP seized over 957 grams of methamphetamine, 319 grams of cocaine, and 31 grams of heroin and made 92 felony and misdemeanor arrests – including on charges related to possession of fentanyl, illegal firearm possession, driving under the influence, and domestic violence.

However, many of those arrested on drug dealing and drug use charges are released back onto the streets as soon as their case is filed, according to district attorney Brooke Jenkins, who was elected in 2022. Her office has filed 1,000 drug dealing cases, and she said they have put in motion to detain 200 of the most serious offenders awaiting trial. However, the judges only remanded 17 of those charged, leaving the rest to return to the streets.

“I’m not going to take the blame when my prosecutors are going in and arguing that these people have to remain in custody,” Jenkins told CNN. “The judges are not doing their part and that has to be revealed.”

RELATED: San Francisco Man Saves Stranger from Apparent Fentanyl Overdose 

@RawRicci415 / Twitter

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While overall crime is down by 1 percent when compared to the same period ending in 2022, drug offenses have climbed by 36 percent, the San Francisco Standard reported.

While authorities are releasing most of those charged with drug dealing and drug use; the prison population reached 1,000 for the first time in years last month. Now officials are discussing whether to reopen a jail closed three years ago for being “seismically unsafe, outdated and in disrepair.”

Some have called the arrests made for open drug use simply putting a Band-Aid on the epidemic.

“We can’t fill the jails with people to fuel the political agendas of a few politicians,” Diana Block, a member of the No New SF Jails Coalition told the Standard. “We refuse to turn back the progress that we in San Francisco have fought for for years.”

San Francisco is now the home of the most aggressively irritating douchebags in America. It didn’t used to be this way. SF used to be a cool place to live. Now, it’s just a breeding ground for …
Contents 1 How My Love for San Francisco Soured 2 5 Reasons I Hate San Francisco 2.1 San Francisco has a major homeless problem 2.2 It also has a major douche-bro problem 2.3 San Franciscans are in denial of their city’s problems 2.4 It’s getting worse, not better 2.5 There’s no end in sight 3 Should You Give San Francisco a Chance?
Many additional overdose deaths were attributed to heroin, methamphetamines, medicinal opioids and cocaine. As a result of this fentanyl surge, users smoking drugs in public has become a common…

Salesforce CEO threatens to pull annual Dreamforce conference from firm’s hometown of San Francisco if any of its 40,000 attendees fall victim to soaring crime in city

Marc Benioff, the CEO of software giant Salesforce, told The San Francisco Chronicle that he would consider relocating their massive annual conference if there was trouble this year.

Answer (1 of 48): Leading question with a questionable assumption at its heart but I will take it on anyway. Starting with the obvious — the title “most disgusting city in America” is an opinion, not an official thing. I was just in New Orleans, and looking at the debauchery and vomit and meande…
San Francisco is in a sinkhole that’s growing bigger by the day,” Clancy, who is based in New York, told Insider. “Store closings, crime, and other quality-of-life issues are leading to an…
Ideas How San Francisco Became a Failed City And how it could recover By Nellie Bowles Photographs by Austin Leong June 8, 2022 Saved Stories S an Francisco was conquered by the United States in…
As San Franciscans have left, San Francisco’s downtown has suffered the most, as many tech workers and their employers have decided that they collectively are better off reducing or eliminating their office space footprint in the downtown area. The office vacancy rate in the city is 27 percent, up from just 4 percent in 2019.
As part of the SFNext project to help San Francisco residents solve some of the city’s problems, we polled more than 1,650 people to measure attitudes on what’s working, what isn’t, performance of…
It’s usually some “the Bay Area is over” screed that gets social traction. You know the genre — the tech industry is leaving/the city is dying/costs are up/quality of life is down/the Bay Area has…
By: Lee Ohanian San Franciscans face about a 1-in-16 chance each year of being a victim of property or violent crime, which makes the city more dangerous than 98 percent of US cities, both small and large.

San Francisco’s once-trendy downtown area has descended into a drug-addled hellscape — where addicts regularly overdose in city-funded “dens of death.”

Historic hotels in the Tenderloin neighborhood — which used to be the City by the Bay’s premier entertainment district — are now the face of the progressive California city’s deterioration.

Around 20,000 rooms in about 500 hotels have been converted from coveted tourist destinations into roach- and vermin-infested “Single-Room Occupancy” (SRO) housing for vagrants.

Many of the century-old buildings are now overrun with drug-addled “zombies” high on fentanyl and the flesh-eating animal tranquilizer dubbed “tranq,” residents told The Post during a tour on Tuesday.

“It’s like living in a prison, but worse,” Robert Blackburn said of his squalid room in one of Tenderloin’s SROs.

The neighborhood, located just 2 miles south of tourist hotspot Fisherman’s Wharf, was “once one of San Francisco’s fashionable neighborhoods, home to Bonanza Kings, politicians and millionaire merchants,” according to the San Francisco Chronicle.

Now, Blackburn says he sees overdoses “all the time” as drug dealers run the corners just steps from the squalid hotels.

“I’ve had human feces come up and out of my shower,” Blackburn told The Post. “I try my best to keep my room clean, but there’s been mice [and] lots of roaches in other rooms.”

The Cambridge is one of the SRO (Single room occupancy) buildings trying to help the homeless in the Tenderloin District of San Francisco, California as seen on Tuesday, August 29, 2023. The city of San Francisco has come under a lot of attack for how it is handling the homeless, drug and retail fallout in Downtown San Francisco.
The Cambridge, one of the SRO (Single room occupancy) buildings in the Tenderloin District of San Francisco.
David G. McIntyre
Robert Blackburn is a former pimp and is trying to stop his drug use who is also homeless in the Tenderloin District of San Francisco, California as seen on Tuesday, August 29, 2023.
Robert Blackburn said his SRO is “like living in a prison, but worse.”
David G. McIntyre

Longtime Tenderloin resident JJ Smith, who lives near four of the city-funded buildings, said that “once they put these people in these SROs, it’s like they are stuck.”

“The biggest issue is there are too many deaths in and out of there. On a daily basis, I see five overdoses, at least one or two of them end up dead,” he said.

“The only way they leave there is in a coroner’s bag.”

Smith estimates that he’s personally helped revive at least 50 SRO residents in the past year, sharing graphic video of one such harrowing scene from June.

The shocking video shows the woman unconscious on the ground of the filthy room as Smith passes Narcan to the boyfriend to try to revive her.

JJ Smith, a long time resident of the Tenderloin District, seen checking on a homeless man in the Tenderloin District of San Francisco, California on Tuesday, August 29, 2023.
JJ Smith, a longtime resident of the Tenderloin District, checks on a homeless man.
David G. McIntyre

He squirts the Narcan — a drug used to reverse overdoses — into the woman’s nostrils, but she doesn’t move.

“Wake up, girl,” the boyfriend says. “Come on, baby girl! Don’t die on us!”

Smith repeatedly calls out her name, while her boyfriend shakes her repeatedly in a desperate effort to wake her up.

“She survived that time, but she died about a month later inside the SRO,” Smith told The Post.

“I saw her body be wheeled out by the coroner. She overdosed and died because no one was there to help her that time.”

A homeless encampment on the street as tour participants on the Celebrate Tenderloin Tour walk through the Tenderloin District in San Francisco, California on Saturday, August 26, 2023. TThe advertised âDoom Loop Tourâ was a no show and was supposed to start at City Hall, and cover various downtrodden areas of Downtown San Francisco.
Even with the SROs, San Fran’s streets are littered with homeless encampments.
David G. McIntyre

The city runs nearly 20,000 rooms in about 500 SRO hotels, according to San Francisco’s Department of Building Inspections 2021-22 stats. The rooms are typically 8 by 10 feet and the residents share a common bathroom on each floor.

Many of the residents in the city’s hundreds of SROs are vagrants who first lived in encampments or one of the homeless shelters before securing a room. Some are recovering addicts, but many “fall off the wagon” and start using drugs again while living in the SRO, which is against the rules each resident must follow.

Blackburn, a recovering heroin addict who is now taking methadone, said the SRO desk managers who man the doors and check on residents “don’t do much” to push them into seeking treatment and counseling.

“They don’t push it because they can’t control us, and really, it’s not their job,” Blackburn said.

Discarded syringes with needles lay in a street gutter in the Tenderloin District of San Francisco, California as seen on Tuesday, August 29, 2023. The city of San Francisco has come under a lot of attack for how it is handling the homeless, drug and retail fallout in Downtown San Francisco.
The once ritzy area now has discarded syringes lying in the street.
David G. McIntyre

The SROs were not meant to be used as permanent housing, but many of the recovering and still-struggling addicts stay in the roach- and mice-infested rooms for years.

“We need help,” Blackburn said. “We keep asking, but our voices aren’t being heard.”

Block after block in the Tenderloin district, drug dealers can be seen handing balled-up foil to addicts on the street.

Business owners said they are frustrated with the amount of homelessness and drug overdoses happening right in front of their doors.

Residents and business leaders alike said the blight surrounding Tenderloin and other areas in downtown have contributed to the city’s “doom loop” and flagship businesses like Nordstroms and Whole Foods to leave the area.

“A lot of people just don’t want to come down to this neighborhood anymore,” said Tommy, who owns a Vietnamese and Chinese restaurant on Larkin Street.

“We had the grand opening 10 days right before the [COVID-19] pandemic, but business is so slow. People see the street conditions, the homeless. I hope this neighborhood will get better.”

Tommy, the owner of the Bar Kin Vietnamese restaurant in the Tenderloin District of San Francisco, California on Tuesday, August 29, 2023. The restaurant opened in 2019, and has been loosing money due to various social issues in the Tenderloin Distinct. The city of San Francisco has come under a lot of attack for how it is handling the homeless, drug and retail fallout in Downtown San Francisco.
Tommy says his new restaurant has suffered from people being scared off by nearby homeless people and addicts.
David G. McIntyre
A San Francisco Police Car is surrounded by litter in the street of the Tenderloin District in San Francisco, California on Tuesday, August 29, 2023. The city of San Francisco has come under a lot of attack for how it is handling the homeless, drug and retail fallout in Downtown San Francisco.
The once fashionable neighborhood is now full of litter and crime.
David G. McIntyre

Workers from local non-profits paid by the city come to the Tenderloin to power wash the streets where families and young students walk daily. But right after the sidewalks dry up, the homeless addicts go right back to squatting on the street.

On Monday night, a homeless man allegedly holding a knife and threatening residents at the 300 block of Jones Street was shot by San Francisco Police. The unidentified man was rushed to a local hospital with life-threatening injuries, police officials said.

The next morning, a group of homeless men sat a few blocks away from where the shooting occurred and hot-wired one of the city’s electric poles, which they used to operate a TV in one of their tents.

“If they are smart enough to do that, I want to get them into some program because they can get a job where they can actually use that skill,” said one former city worker who wanted to remain anonymous.

JJ Smith, a long time resident of the Tenderloin District, seen in front of the Hotel Jefferson that is now a SRO (single resident occupancy) building trying to help the homeless in the Tenderloin District of San Francisco, California as seen on Tuesday, August 29, 2023. The city of San Francisco has come under a lot of attack for how it is handling the homeless, drug and retail fallout in Downtown San Francisco.
JJ Smith, a longtime Tenderloin resident, says he regularly sees people overdosing.
David G. McIntyre

City leaders said their hands are tied because of an injunction banning San Francisco Police from clearing most homeless encampments.

A judge ordered the injunction while a lawsuit filed by the Coalition on Homeless — which claims the city has violated state and federal laws on homeless individuals’ rights — is ongoing.

“It is not humane to let people live on our streets in tents,” said Mayor London Breed last week. “We want a reversal of this injunction that makes it impossible to do our jobs.”

Meanwhile, residents of the once-fashionable district say that while there are services available to them provided by non-profits and paid by the city, nothing is being done to push them into drug rehabilitation treatments — and they are ultimately left behind.

Overdoses from fentanyl claimed 62 lives out of 71 total deaths from drug overdoses last month, according to statistics released by the Medical Examiner’s Office. The grim figure now places San Francisco on track to break a 2020 record for the total number of overdoses, when 712 people died.

Ex-workers suing secretive elite club Bohemian Grove say camps were like college frat parties but with ‘more money and better alcohol’ and ‘public urination among the redwood trees’

NEW Members of the Bohemian Grove social club are said to get blackout drunk and urinate publicly, according to the claims of a former employee who is suing the organization.

Mill Valley, California Has An Anal Epidemic

Tam High school girls and divorcees in rustic Mill Valley, California, just north of San Francisco, have flooded regional medical centers with a surprising issue: Prolapsed Anus’s!

High School girls and Cougars have been ‘takin’ it up the poop hole more than usual’ according to a local medical office.

rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body.[2] However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.[3][4]

Rectal prolapse may occur without any symptoms, but depending upon the nature of the prolapse there may be mucous discharge (mucus coming from the anus), rectal bleeding, degrees of fecal incontinence and obstructed defecation symptoms.[5]

Rectal prolapse is generally more common in elderly women, although it may occur at any age and in either sex. It is very rarely life-threatening, but the symptoms can be debilitating if left untreated.[5] Most external prolapse cases can be treated successfully, often with a surgical procedure. Internal prolapses are traditionally harder to treat and surgery may not be suitable for many patients.

Classification[edit]

. Internal rectal intussusception. B. External (complete) rectal prolapse

The different kinds of rectal prolapse can be difficult to grasp, as different definitions are used and some recognize some subtypes and others do not. Essentially, rectal prolapses may be:[citation needed]

  • full thickness (complete), where all the layers of the rectal wall prolapse, or involve the mucosal layer only (partial)
  • external if they protrude from the anus and are visible externally, or internal if they do not
  • circumferential, where the whole circumference of the rectal wall prolapse, or segmental if only parts of the circumference of the rectal wall prolapse
  • present at rest, or occurring during straining.

External (complete) rectal prolapse (rectal procidentia, full thickness rectal prolapse, external rectal prolapse) is a full thickness, circumferential, true intussusception of the rectal wall which protrudes from the anus and is visible externally.[6][7]

Internal rectal intussusception (occult rectal prolapse, internal procidentia) can be defined as a funnel shaped infolding of the upper rectal (or lower sigmoid) wall that can occur during defecation.[8] This infolding is perhaps best visualised as folding a sock inside out,[9] creating “a tube within a tube”.[10] Another definition is “where the rectum collapses but does not exit the anus”.[11] Many sources differentiate between internal rectal intussusception and mucosal prolapse, implying that the former is a full thickness prolapse of rectal wall. However, a publication by the American Society of Colon and Rectal Surgeons stated that internal rectal intussusception involved the mucosal and submucosal layers separating from the underlying muscularis mucosa layer attachments, resulting in the separated portion of rectal lining “sliding” down.[5] This may signify that authors use the terms internal rectal prolapse and internal mucosal prolapse to describe the same phenomena.

Mucosal prolapse (partial rectal mucosal prolapse)[12] refers to prolapse of the loosening of the submucosal attachments to the muscularis propria of the distal rectummucosal layer of the rectal wall. Most sources define mucosal prolapse as an external, segmental prolapse which is easily confused with prolapsed (3rd or 4th degree) hemorrhoids (piles).[9] However, both internal mucosal prolapse (see below) and circumferential mucosal prolapse are described by some.[12] Others do not consider mucosal prolapse a true form of rectal prolapse.[13]

Internal mucosal prolapse (rectal internal mucosal prolapse, RIMP) refers to prolapse of the mucosal layer of the rectal wall which does not protrude externally. There is some controversy surrounding this condition as to its relationship with hemorrhoidal disease, or whether it is a separate entity.[14] The term “mucosal hemorrhoidal prolapse” is also used.[15]

Solitary rectal ulcer syndrome (SRUS, solitary rectal ulcer, SRU) occurs with internal rectal intussusception and is part of the spectrum of rectal prolapse conditions.[5] It describes ulceration of the rectal lining caused by repeated frictional damage as the internal intussusception is forced into the anal canal during straining. SRUS can be considered a consequence of internal intussusception, which can be demonstrated in 94% of cases.

Mucosal prolapse syndrome (MPS) is recognized by some. It includes solitary rectal ulcer syndrome, rectal prolapse, proctitis cystica profunda, and inflammatory polyps.[16][17] It is classified as a chronic benign inflammatory disorder.

Rectal prolapse and internal rectal intussusception has been classified according to the size of the prolapsed section of rectum, a function of rectal mobility from the sacrum and infolding of the rectum. This classification also takes into account sphincter relaxation:[18]

  • Grade I: nonrelaxation of the sphincter mechanism (anismus)
  • Grade II: mild intussusception
  • Grade III: moderate intussusception
  • Grade IV: severe intussusception
  • Grade V: rectal prolapse

Rectal internal mucosal prolapse has been graded according to the level of descent of the intussusceptum, which was predictive of symptom severity:[19]

  • first degree prolapse is detectable below the anorectal ring on straining
  • second degree when it reached the dentate line
  • third degree when it reached the anal verge


B. Recto-rectal intussusception
C. Recto-anal intussusception

The most widely used classification of internal rectal prolapse is according to the height on the rectal/sigmoid wall from which they originate and by whether the intussusceptum remains within the rectum or extends into the anal canal. The height of intussusception from the anal canal is usually estimated by defecography.[10]

Recto-rectal (high) intussusception (intra-rectal intussusception) is where the intussusception starts in the rectum, does not protrude into the anal canal, but stays within the rectum. (i.e. the intussusceptum originates in the rectum and does not extend into the anal canal. The intussuscipiens includes rectal lumen distal to the intussusceptum only). These are usually intussusceptions that originate in the upper rectum or lower sigmoid.[10]

Recto-anal (low) intussusception (intra-anal intussusception) is where the intussusception starts in the rectum and protrudes into the anal canal (i.e. the intussusceptum originates in the rectum, and the intussuscipiens includes part of the anal canal)

An Anatomico-Functional Classification of internal rectal intussusception has been described,[10] with the argument that other factors apart from the height of intussusception above the anal canal appear to be important to predict symptomology. The parameters of this classification are anatomic descent, diameter of intussuscepted bowel, associated rectal hyposensitivity and associated delayed colonic transit:

  • Type 1: Internal recto-rectal intussusception
    • Type 1W Wide lumen
    • Type 1N Narrowed lumen
  • Type 2: Internal recto-anal intussusception
    • Type 2W Wide Lumen
    • Type 2N Narrowed lumen
    • Type 2M Narrowed internal lumen with associated rectal hyposensitivity or early megarectum
  • Type 3: Internal-external recto-anal intussusception

Diagnosis[edit]

History[edit]

Patients may have associated gynecological conditions which may require multidisciplinary management.[5] History of constipation is important because some of the operations may worsen constipation. Fecal incontinence may also influence the choice of management.

Physical examination[edit]

Rectal prolapse may be confused easily with prolapsing hemorrhoids.[5] Mucosal prolapse also differs from prolapsing (3rd or 4th degree) hemorrhoids, where there is a segmental prolapse of the hemorrhoidal tissues at the 3, 7 and 11 o’clock positions.[12] Mucosal prolapse can be differentiated from a full thickness external rectal prolapse (a complete rectal prolapse) by the orientation of the folds (furrows) in the prolapsed section. In full thickness rectal prolapse, these folds run circumferential. In mucosal prolapse, these folds are radially.[9] The folds in mucosal prolapse are usually associated with internal hemorrhoids. Furthermore, in rectal prolapse, there is a sulcus present between the prolapsed bowel and the anal verge, whereas in hemorrhoidal disease there is no sulcus.[3] Prolapsed, incarcerated hemorrhoids are extremely painful, whereas as long as a rectal prolapse is not strangulated, it gives little pain and is easy to reduce.[5]

The prolapse may be obvious, or it may require straining and squatting to produce it.[5] The anus is usually patulous, (loose, open) and has reduced resting and squeeze pressures.[5] Sometimes it is necessary to observe the patient while they strain on a toilet to see the prolapse happen[20] (the perineum can be seen with a mirror or by placing an endoscope in the bowl of the toilet).[9] A phosphate enema may need to be used to induce straining.[3]

The perianal skin may be macerated (softening and whitening of skin that is kept constantly wet) and show excoriation.[9]

Proctoscopy/sigmoidoscopy/colonoscopy[edit]

These may reveal congestion and edema (swelling) of the distal rectal mucosa,[20] and in 10-15% of cases there may be a solitary rectal ulcer on the anterior rectal wall.[5] Localized inflammation or ulceration can be biopsied and may lead to a diagnosis of SRUS or colitis cystica profunda.[5] Rarely, a neoplasm (tumour) may form on the leading edge of the intussusceptum. In addition, patients are frequently elderly and therefore have increased incidence of colorectal cancer. Full length colonoscopy is usually carried out in adults prior to any surgical intervention.[5] These investigations may be used with contrast media (barium enema) which may show the associated mucosal abnormalities.[9]

Videodefecography[edit]

This investigation is used to diagnose internal intussusception, or demonstrate a suspected external prolapse that could not be produced during the examination.[3] It is usually not necessary with obvious external rectal prolapse.[9] Defecography may demonstrate associated conditions like cystocele, vaginal vault prolapse or enterocele.[5]

Colonic transit studies[edit]

Colonic transit studies may be used to rule out colonic inertia if there is a history of severe constipation.[3][5] Continent prolapse patients with slow transit constipation, and who are fit for surgery may benefit from subtotal colectomy with rectopexy.[5]

Anorectal manometry[edit]

This investigation objectively documents the functional status of the sphincters. However, the clinical significance of the findings are disputed by some.[9] It may be used to assess for pelvic floor dyssenergia,[5] (anismus is a contraindication for certain surgeries, e.g. STARR), and these patients may benefit from post-operative biofeedback therapy. Decreased squeeze and resting pressures are usually the findings, and this may predate the development of the prolapse.[5] Resting tone is usually preserved in patients with mucosal prolapse.[20] In patients with reduced resting pressure, levatorplasty may be combined with prolapse repair to further improve continence.[9]

Anal electromyography/pudendal nerve testing[edit]

It may be used to evaluate incontinence, but there is disagreement about what relevance the results may show, as rarely do they mandate a change of surgical plan.[5] There may be denervation of striated musculature on the electromyogram.[20] Increased nerve conduction periods (nerve damage), this may be significant in predicting post-operative incontinence.[5]

Complete rectal prolapse[edit]

Rectal prolapse is a “falling down” of the rectum so that it is visible externally. The appearance is of a reddened, proboscis-like object through the anal sphincters. Patients find the condition embarrassing.[9] The symptoms can be socially debilitating without treatment,[5] but it is rarely life-threatening.[9]

The true incidence of rectal prolapse is unknown, but it is thought to be uncommon. As most affected people are elderly, the condition is generally under-reported.[21] It may occur at any age, even in children,[22] but there is peak onset in the fourth and seventh decades.[3] Women over 50 are six times more likely to develop rectal prolapse than men. It is rare in men over 45 and in women under 20.[20] When males are affected, they tend to be young and report significant bowel function symptoms, especially obstructed defecation,[5] or have a predisposing disorder (e.g., congenital anal atresia).[9] When children are affected, they are usually under the age of 3.

35% of women with rectal prolapse have never had children,[5] suggesting that pregnancy and labour are not significant factors. Anatomical differences such as the wider pelvic outlet in females may explain the skewed gender distribution.[9]

Associated conditions, especially in younger patients include autism, developmental delay syndromes and psychiatric conditions requiring several medications.[5]

Signs and symptoms[edit]

Signs and symptoms include:

Initially, the mass may protrude through the anal canal only during defecation and straining, and spontaneously return afterwards. Later, the mass may have to be pushed back in following defecation. This may progress to a chronically prolapsed and severe condition, defined as spontaneous prolapse that is difficult to keep inside, and occurs with walking, prolonged standing,[5] coughing or sneezing (Valsalva maneuvers).[3] A chronically prolapsed rectal tissue may undergo pathological changes such as thickening, ulceration and bleeding.[5]

If the prolapse becomes trapped externally outside the anal sphincters, it may become strangulated and there is a risk of perforation.[20] This may require an urgent surgical operation if the prolapse cannot be manually reduced.[5] Applying granulated sugar on the exposed rectal tissue can reduce the edema (swelling) and facilitate this.[20]

Cause[edit]

Micrograph showing a rectal wall with changes seen in rectal prolapse. There is a marked increase of fibrous tissue in the submucosa and fibrous tissue +/- smooth muscle hyperplasia in the lamina propriaH&E stain

The precise cause is unknown,[3][9][8] and has been much debated.[5] In 1912 Moschcowitz proposed that rectal prolapse was a sliding hernia through a pelvic fascial defect.[9]

This theory was based on the observation that rectal prolapse patients have a mobile and unsupported pelvic floor, and a hernia sac of peritoneum from the Pouch of Douglas and rectal wall can be seen.[5] Other adjacent structures can sometimes be seen in addition to the rectal prolapse.[5] Although a pouch of Douglas hernia, originating in the cul de sac of Douglas, may protrude from the anus (via the anterior rectal wall),[20] this is a different situation from rectal prolapse.

Shortly after the invention of defecography, In 1968 Broden and Snellman used cinedefecography to show that rectal prolapse begins as a circumferential intussusception of the rectum,[3][9] which slowly increases over time.[20] The leading edge of the intussusceptum may be located at 6–8 cm or at 15–18 cm from the anal verge.[20] This proved an older theory from the 18th century by John Hunter and Albrecht von Haller that this condition is essentially a full-thickness rectal intussusception, beginning about 3 inches above the dentate line and protruding externally.[5]

Since most patients with rectal prolapse have a long history of constipation,[9] it is thought that prolonged, excessive and repetitive straining during defecation may predispose to rectal prolapse.[3][8][20][23][24][25] Since rectal prolapse itself causes functional obstruction, more straining may result from a small prolapse, with increasing damage to the anatomy.[8] This excessive straining may be due to predisposing pelvic floor dysfunction (e.g. obstructed defecation) and anatomical factors:[9][20]

  • Abnormally low descent of the peritoneum covering the anterior rectal wall
  • poor posterior rectal fixation, resulting in loss of posterior fixation of the rectum to the sacral curve[5]
  • loss of the normal horizontal position of the rectum[3] with lengthening (redundant rectosigmoid)[3][5] and downward displacement of the sigmoid and rectum
  • long rectal mesentery[3]
  • a deep cul-de-sac[3][5]
  • levator diastasis[3][5]
  • a patulous, weak anal sphincter[3][5]

Some authors question whether these abnormalities are the cause, or secondary to the prolapse.[3] Other predisposing factors/associated conditions include:

  • pregnancy[3] (although 35% of women who develop rectal prolapse are nulliparous)[3] (have never given birth)
  • previous surgery[3] (30-50% of females with the condition underwent previous gynecological surgery)[3]
  • pelvic neuropathies and neurological disease[20]
  • high gastrointestinal helminth loads (e.g. Whipworm)[26]
  • COPD[27]
  • cystic fibrosis [28]

The association with uterine prolapse (10-25%) and cystocele (35%) may suggest that there is some underlying abnormality of the pelvic floor that affects multiple pelvic organs.[3] Proximal bilateral pudendal neuropathy has been demonstrated in patients with rectal prolapse who have fecal incontinence.[5] This finding was shown to be absent in healthy subjects, and may be the cause of denervation-related atrophy of the external anal sphincter. Some authors suggest that pudendal nerve damage is the cause for pelvic floor and anal sphincter weakening, and may be the underlying cause of a spectrum of pelvic floor disorders.[5]

Sphincter function in rectal prolapse is almost always reduced.[3] This may be the result of direct sphincter injury by chronic stretching of the prolapsing rectum. Alternatively, the intussuscepting rectum may lead to chronic stimulation of the rectoanal inhibitory reflex (RAIR – contraction of the external anal sphincter in response to stool in the rectum). The RAIR was shown to be absent or blunted. Squeeze (maximum voluntary contraction) pressures may be affected as well as the resting tone. This is most likely a denervation injury to the external anal sphincter.[3]

The assumed mechanism of fecal incontinence in rectal prolapse is by the chronic stretch and trauma to the anal sphincters and the presence of a direct conduit (the intussusceptum) connecting rectum to the external environment which is not guarded by the sphincters.[5]

The assumed mechanism of obstructed defecation is by disruption to the rectum and anal canal’s ability to contract and fully evacuate rectal contents. The intussusceptum itself may mechanically obstruct the rectoanal lumen, creating a blockage that straining, anismus and colonic dysmotility exacerbate.

Author: swmof88