More than 100 different operations have been described for prolapse; therefore, it is not surprising to see rates of functional problems following prolapse repair to be widely variable. While several different mechanisms contribute to normal defecation, abdominal prolapse procedures risk dam­age to nerves controlling defecation, while perineal proce­dures remove the rectum with resultant loss of its intrinsic capacitance and reservoir. Additionally, some patients pre­operatively suffer severe alterations to anorectal physiology that may prove recalcitrant to surgical improvement. A pro­spective analysis of 86 patients over 36 months of follow­up after ventral rectopexy demonstrated improvement in continence in 68 % of patients. However, the authors noted that 50 % of patients remained incontinent postoperatively. Older patients with longer duration of prolapse and worse preoperative continence scores were more likely to be incon­tinent postoperatively [ 28 ]. Perineal operations remain a viable option for debilitated patients with rectal prolapse, but data on functional outcome are variable. In one study, 6-month follow-up after Altemeier procedure, i.e., perineal rectosigmoidectomy, revealed that 62 % of patients demon­strated improvement in continence, although 25 % remained incontinent [ 29 ]. In contrast, only 28 % of patients had improved continence after Altemeier procedure in long-term follow-up of 93 patients, and several had deterioration or de novo incontinence [ 30 ]. Prospective trials of perineal versus abdominal approaches to rectal prolapse are forthcoming and may improve the surgeon’s expectations for postopera­tive functional outcomes.