Proctoptosis, also commonly known as "prolapse of rectum," is a
pathological phenomenon of displacement and prolapse of the
rectum and anal canal or even a part of the sigmoid colon, most
commonly seen in children, old people, multiparae and weak
youngsters and the middle aged.
Main
Points of Diagnosis
1. Most of the patients have a long history of
diarrhea.
2. There are two kinds of prolapses. If there is only prolapse
of the mucosa and the prolapsed part only protrudes a bit
outside with radial plicae, it is called partial prolapse or
incomplete prolapse. If the prolapse happens to be of the whole
layer of rectum wall or the prolapsed part is rather long with
circular folds, it is known as complete prolapse.
3. First, measure the length and the thickness of the prolapsed
part. Next, palpate the prolapsed lump to see whether there is a
reflected groove or not. After that, determine the size of the
"concentric circles" on the top part of the prolapsed lump.
Through digital examination with repetition tests make sure of
the sphincter strength and so on.
Differentiation and Treatment of Common Syndromes
1. Internal Treatment
Medication for treating proctoptosis is the main method in TCM.
This treatment can eliminate the main manifestations of the
disease and restore the anus.
Therapeutic Principle: Invigorating and elevating qi and
inducing astringency.
Recipe 1: Modified Decoction of Reinforcing Middle and
Replenishing qi. Among the ingredients, astragalus root, pilose
asiabell root and cimicifuga rhizome are used in larger amounts.
Recipe 2: Decoction of Bitter Orange for Proctoptosis. Its
ingredients are:
bitter orange
astragalus root
asiabel root
cimicifuga rhizome
licorice root
All the above herbs are to be decocted in water for oral
administration. Although the use of the above recipes can bring
about some results, as a whole, the progress of the internal
treatment for this kind of disease is very slow and We can't
obtain satisfactory curative effect especially in severe cases
and complete prolapse cases. The disease can be cured but will
recur again. Therefore, attention should also be paid to
regulating the bowel movement so as not to cause constipation or
diarrhea.
2. External Treatment
1) Fumigating and Washing: The main drugs commonly used in this
treatment are : pomegranate rind , Chinese gall, dried alum,
black plum, bitter orange flavescent sophora root and so on.
All the these herbs are to be decocted in water for fumigating
and washing, 1-2 times a day.
2) Topical Application: There are many recipes for this
treatment, with the main function of inducing astringency, The
drugs commonly used are: red halloysite Chinese gall, black
plum, chebula fruit, calcined dragon's bone spirodela head of
fresh water turtle and so forth. They are ground into powder and
sprinkled to the affected part or mixed with water or oil to be
spread onto it. Or use turtle blood for application.
3) Hot Compress: This method is simple and easy to be used,
mostly to treat prolapse of rectum in children. At present, a
piece of heated brick wrapped with a piece of cloth is used for
application onto the local affected part, several times a day,
about half an hour each time.
4) Block Therapy: Inject novocaine solution into the perianal or
sacro-anterior part for blocking so as to cut off the vicious
circle of the affected part and arrest the prolapse. Generally
about 60-100 ml of 0.25-0.5 percent novocaine solution is given
to adults for each time, once every week until prolapse does not
occur (appropriate amount for children).
5) Cauteriztion Therapy: In this method certain devices are
required to scorch the prolapse mucosa. After the burning
process the eschar will fallen off wit a scar formed so as to
have this area stuck and fixed. It is suitable for the prolapse
of the mucosa. High frequency cautery device or carbon dioxide
laser can be use for this purpose.
Manipulation: After routine sterilization and local anesthesia,
relax the sphincter or expand the anus so as to enable the
mucosa to be pulled out easily. Then use a clamp to fix the
mucosa onto both sides of the area ready to be burned. Wipe the
surface of the mucosa until it is dry from the external to the
internal part to make 4-6 radial threadlike burned streaks
between the top of the prloapsed mucosa and dentate line, the
depth of the streaks should reach the lower layers of the
mucosa. The scorching should not stop until the tissues of this
area has become black. Be careful not to burn too deep. When the
operation is completed, remove the tissue clamp, and replace the
mucosa back t its original place, Then put a piece of small
Vaseline gauze into the anus or insert some Nine Magnificent
Paste onto the wounded area. After the operation, change the
dressing once a day until the wound is healed.
6) Ligation Therapy: This method is effective for the prolapse
of mucosa. The ligation can be done on the mucosa in the right
anterior, right posterior and the left lateral areas. The
manipulation of the ligation is similar to that of the ligation
for internal hemorrhoid.
7) Injection Therapy: This method is rather simple in operation,
less painful, safe and easy to popularize. The recipes adoptable
for this treatment are of may kinds. It can be classified into
sclerosing agent, astringents and smooth muscle stimulants. The
route of medication is either submucosal or perirectal
injection.
(1) The Submucosu Injection: This method is to inject directly
into the submucosal layer, such as point injection, an
cylindrical injection and so forth This method is suitable for
the prolapse of the mucosa or mild cases of the prolapse of the
whole layer.
Manipulation: Generally, it is necessary to let the rectum canal
prolapse out of the anus. After the sterilization of the
mucosea, use a thin needle to puncture through the mucosa, and
inject the medical solution directly into the submucosal layer.
The injection should be done form the distal part to the
proximal part and from one point to the other individually. The
amount of the medical solution used varies with different
medicines. If 5% sodium morrhuate injection is used, then 0.5 ml
of the solution will be sufficient for each point. The injected
points should be encircled around the rectum in a wheel shape.
In each wheel 4-6 points should be injected. When the injection
starts from the distal part to the proximal part, the wheel
points alternately arranged but they are not parallel with each
other. After the injection, replace the rectum canal back to the
anus. Another method is to expand the anus with an anoscope
without letting the rectum prolapse out of the anus. Then inject
the solution into the submucous layer in the way mentioned
above. This injection is commonly known as the punctuate
submucosal injection. In recent years, doctors in Chongqing City
have used a method of giving the injection directly into the
submucous part by using and keeping a long syringe needle
parallel with the longitudinal axis of rectal canal and then
puncture a few points. The medical solution given to these parts
is of a large amount, thus, the injected part will soon bulge up
and take on a longitudinal patchy shape. Therefore, the medical
solution can be spread more extensively than that injected in a
punctuate way and has better results. When the injection is
completed, spread some Nine Magnificent Paste onto the affected
part and have it bandaged and fixed. After the injection, it is
not necessary to change the dressing.
(2) The Perirectal Injection of Alum Solution
1. Indication: This method is mainly suitable for the complete
layer prolapse of the rectum.
2. The preparation for the solution: Use pure alum also called
alum regent (potassium aluminium sulfate) Be sure not to use
ordinary alum. Since there are a lot of impurities in the
compound, the injection may have some side effects The usual
concentration is 6-10% of the alum solution and 7% is the most
common. To prepare the solution some stabilizing agents such as
sodium citrate amount of novocaine. the bottle must be sealed as
required and must be sterilized with high pressure. The alum
solution can stand high pressure but it can not stand a high
pressure for a long time. Usually, 15 lbs in 15 minutes is often
used. If there is sediment in the solution due to high pressure,
it should not be used.
3. The devices and utensils: The preparation and sterilization
should follow the same requirement as in general surgery.
Prepare an emptied syringe with a 8 cm long needle for block
therapy, used in alum injection. If the gauze roller is needed
to fill in the canal, then prepare a 8-10 cm long rubber tube
and a large vaseline gauze roller for pressing.
4. The injection method: the patient takes a knee chest position
with buttocks high. After routine sterilization and local
infiltration anesthesia, use the right hand or the left hand to
puncture syringe needle filled with alum solution into the
prolapse part, about 1-2 cm apart from the left, right, middle
position of the anal margin. First of all the puncture needle
should be parallel to the anal canal, then after the needle
passes through the anal ring, it should be slanted to external
passes through the anal ring, it should be slanted to eternal
side, while the needle is passing through, the forefinger of the
other hand inserts into the anus working as a guide. If the
needle is far from the mucosa of the rectum and fail to reach
it, the needle should have another try. There should be only a
distance of thin membrane between the right site and the needle,
which makes it easily touchable. Generally speaking, the
puncture needle should go as deeply as 4-7 cm, then 2/5 of the
liquid medicine is slowly injected, if there is no returned
blood in the syringe, the operator will continue the injection
and withdraw the needle outwards until the liquid medicine is
used up. Be careful not to inject the liquid into the sphincter,
otherwise it will cause pain and also reduce the effectiveness
of the injection. If the site of the puncture is too far away
from the anal margin and the needle is far from the mucosa, then
the function of fixation will not be so effective. If the
puncture site is too close to the anal margin then the needle
will go through the mucosa of the rectum. Usually, the injection
is only to be given to the left and the right middle sites. When
necessary two sites of the right anterior and the middle
posterior are to be added. In serious cases apart from the above
mentioned points injection can also be given to the right
posterior, left anterior and posterior. Bat the puncture needle
should not go through the middle anterior site. In most cases,
we apply the principle: one injection for one point. Therefore,
there are many punctured points. In mild cases, it is only
necessary to do the injection on the left, right and middle
site. In severe cases, we may puncture into one point and give
the medical solution to many places, which is called a
fan-shaped injection. The amount of medical solution to be used
depends on its concentration. If 7 percent solution is used, the
20-60 ml are used for an adult, 20-30 ml being a little lower
than the standard while 60 ml, a little higher than the usual
dose. In some cases, the amount given to some individual
patients even reached up to 80 ml and 100 ml ,without bad
reaction. Massage the injected part after the injection. When
the amount of liquid medicine is excessive, this area will be
swollen. It is necessary to do the massage until the elevated
part becomes flat so as to let a larger area be infiltrated with
the medical solution. Finally, put a piece of hard rubber tube
wrapped by Vaseline gauze into the anus to fix it by pressing.
The thickness of the gauze roller depends on the size of the
anal and rectal canal and also the degrees of tightness of the
anus. Generally, for adults, the diameter of the roller will be
3-4cm, and a little thinner for children. In order to avoid
difficulties in removing the roller, use a piece of silk thread
to sew it onto one end of the rubber tube before it is inserted,
then leave part of the thread outside and tie it to the dressing
material. Generally, one injection is sufficient, or twice if
necessary.
5. Points for attention in manipulation: The injection should be
given under strict aseptic manipulation while puncturing. It is
better not to do the puncture in the anterior site. Before the
infection, make sure that there is no returned blood. The liquid
medicine should be given slowly into the affected parts and its
amount should be sufficient.
6. The treatments before and after the injection: The day before
the injection, the patient should have soft diet and have to
limit the meals on the day of the injection. If necessary, the
bowel movement should be put under control in two days. before
the injection use enema to clean the intestine twice. Usually,
the night before the injection the patient should have 800 ml of
salt solution enema and should be given 3-5 hours prior to the
injection, 500 ml of salt solution enema. After the injection
the patient is advised to lie in bed for 1-2 days. If there is
any systemic or local discomfort, he must be treated in time.
The use of the pressed gause roller for fixation is effective
for the curative effect, thus it should be recommended as a
route treatment after injection. Generally, the gauze roller
should stay in the site for 24-48 hours, and in some cases it
lasts for even more than 60 hours. If the time of retaining the
gauze roller in the anus is too short, the effectiveness of the
whole treatment will be reduced. When the pressing is completed,
the gauze roller is removed. It is necessary to observe the
contraction of the anus and judge the effectiveness of the
treatment. If the contraction of the anus is fast and when it
stops con tract, the anus is not easy pulled apart, it shows
that the injection is successful and the fixation is also firm.
If the contraction the anus is easy to be pulled apart, this
shows that the fixation is not firm enough but is still does not
prove that the injection is a failure. For those whose anus is
extremely loose, and remains open the packing material is
removed, it shows that the tension of the sphincter has
increased. This phenomenon known as the sign of the fixation
should be observed right after the filling material is removed.
After that, use 60-100 ml of 50 percent glycerin or castor oil
as enema to promote bowel movements. Remind the patient not to
squat or use too much strain during bowel movement. The patient
may stand up and take a bowing position for the fecal excretion.
The aluminjection works for the fixation of the rectal canal but
is not obviously effective for the improvement of the strength
of the sphincter. Therefore, it is necessary to take other
measures to have an integrated treatment. For example, treating
the patients with appropriate drugs according to the different
constitution and regulating the bowel movement to avoid
constipation or diarrhea. Local hot compress anal contraction
and other subsidiary exercises may assist the contraction of the
anus. If necessary, use acupuncture to enhance the contraction
of the anus or take an operation for the tightening of the
sphincter. If there is still mucosa that turns out of the anus,
then mucosa ligation may be applied.
The alum injection therapy for the treatment of proctoptosis is
an outstanding achievement is the field of rectum and anus in
China. It is an effective method for adults in complete prolapse
cases. Compared with the operation of the abdomen, it had may
advantages. But there are different understandings in the
evaluation of the effectiveness of this therapy. Some consider
that the injection therapy including alum injection can not be
successful in treating complete proctoptosis of adults cases.
But according to some of the clinical applications, if the
injection is done once with a large amount of liquid medicine,
the result will be much better than that of dividing the
injection into may times and each time with a smaller amount
liquid medicine. Therefore, if a sufficient amount is given to
the affected part, it can obtain a satisfactory therapecctic
result. So, it is proved by clinical practice that this method
is possible to cure completely proctoptosis cases. But the
result may vary with the different methods used.
8) Operation Therapy
(1) Operation for the Contraction of the External Sphincter:
This operation can be carried out only by tightening the
external sphincter or combined with saturation of the
anococcygeal groove.
Manipulation: After routine sterilization and local anesthesia
or lumbar anesthesia, make a radial incision 1 cm away from one
side or both sides, mostly the left, right, middle site of the
anal margin, then make skin incision, separate the subcutaneous
tissues, to expose external sphincter, and then insert blood
vessel forceps vertically into muscle bundle to have it
separated. Pick out the separated muscle bundle and then use a
piece of thin silk thread or catgut to do the penetration
suturation and ligation on the base part, so as to shorten 1/3
of the original length. The tissue on top the ligating thread
should be cut off or buried under the subcutaneous tissue. The
incision will be sutured or non-sutured. The operation is
completed with bandage and fixation. If it is an open incision,
after the operation, change the dressing until the wound is
healed. If it is an operation combined with the suturation of
the anococcygeal groove, sterilization and anesthesia should be
applied. Make a "A"-shaped incision 2 cm posterior to the anus,
the incision usually will be a little longer, cut the skin and
the subcutanteous tissues, separate the skin flap to the anal
margin. Then expose the anococcygeal ligament and the external
sphincter. The method of separation, the suturation and ligation
are the same as mentioned above. Or instead of separation, only
penetrate the thread into the sphincter from both sides of the
edges of wound, tighten it and make two stitches onto it. After
tightening the anococcygeal wound, do the saturation, When the
skin flap is removed, the remaining part will be like a triangle
in shape. Then, suture together the skin of the posterior part
after apposition. When the operation is completed, the anus will
be able to close with strength. In digital examination there is
a tightening sensation. After the operation, use a wedge-shaped
gauze for compressing and have it bandaged and fixed.
(2) The Embedding of the Dermis and Plastic Operation of the
Sphincter: It is to let the vital skin flap with peduncle to be
embedded under the perianal part. Then, after the operation, the
function of the sphincter will be strength ended. Its
manipulations are done in three steps:
1. After routine sterilization and lumbar anesthesia, make a
sword-like incision, narrow in the front and wide in the back,
10 cm away from the left posterior or the right posterior of the
anal margin. This incision should be cut about 1 cm away from
the anal margin, then separate the skin flap to let it be free,
strip off the epidermis and the fat layer t make a skin flap
with a peduncle 8 cm long, 1 cm wide and about 0.2 cm thick.
Then at the anterior middle position make another longitudinal
incision is 1.5 cm in length. Insert a pair of curved blood
vessel forceps from this part, pass through one side of the anus
and penetrate out from the skin flap part, clamp the distal part
of the skin flap and pull it to the site of anterior middle
incision. Insert another pair of blood vessel forceps from the
other side of the skin flap through to the site of the middle
anterior incision, clamp the skin flap and pull it to encircle
around to the another side of the anus. Then let it come out
from the base of the skin flap and tighten it. After that use
catgut or silk thread to suture the free part of skin flap. Use
a piece of silk thread to do the interrupted suturation on the
incision of the skin flap. The middle anterior incision can be
sutured or non-sutured. To enforce the operation can be
supplemented by cutting from the other anal side a skin flap and
replanting it underneath the perianal skin.
2. Make an incision 5 cm from the side of the left posterior and
right posterior of the anal margin towards the anus and the free
skin flap will be one half of the size as recommended in Method
1 while its thickness and width are the same as required in
method ¢Ù. After that, make a longitudinal incision of the same
length at the anterior middle position. Then follow the same
method to use blood vessel forceps and cut them off out from the
middle anterior incision and then tighten them. Use silk thread
to suture the two skin flaps tightly. Cut off the remaining part
and use catgut or silk thread to suture the skin flap suturation
part with the underneath tissues so as to fasten them. The
incision of the ski flap is sutured interruptly. The treatment
of the incision at the anterior middle site is the same as
mentioned above.
On the whole, this method is similar to the method ¢Ù. The only
difference lies in the fact that the skin flap is a little
shorter and it is cut and pulled out from both sides of the
anus, and the free skin flaps don't have to go around the
perianal part, they only follow along the same side and are
sutured and fixed at the anterior middle part. Thus the skin
underneath the middle posterior site of the anal margin is not
connected with any skin flaps. So it is necessary to cut the
skin flaps from the left posterior and right posterior part of
the anus and have them sutured and fixed at the middle anterior
site. This is aimed at strengthening the contractility of the
anterior part of the anus.
¢Û Make an incision 5 cm away from the left, right, middle
sites of the anus. Use the same method to cut two sword-like
skin flaps, and the length of each is half as recommended by
method ¢Ù while the width and thickness are the same as required
in method ¢Ù. Use curved blood vessel forceps to clamp the skin
flaps one after the other, then whirl each around half of the
ring of the anus and pull them out from the opposite side of
the anus and pull them out from the opposite side of the
incision, and then tighten them up. Then have each of the skin
flaps sutured and fixed them with the pedicle part of the
opposite skin flap. After that cut the remaining part and fix
the sutured area to the underneath tissues by suture. The
suturation of the incision of the skin flap should be done with
a space apart from each other.
This method is basically similar to the former two. The
difference is that the site of the resection and the removal of
the skin flap is at the left, right, middle position. The two
skin flaps underneath the perianal part are connected together.
The manipulation of the above three methods should be carried
out under strict aseptic manipulation to avoid possible
infection.
(3) Anal Ligation: Use a piece of metallic or non-metallic
thread-like or ribbon-like material to ligate around the
perianal subcutaneous part. The enhancement of the contractility
of the anus is not very effective.
Metallic Thread Ligation for the Anus: Use a piece of stainless
steel thread for the ligation to tie around the perianal
subcutaneous part. The tightening is done in a wheel-whirl-ing
way (like whirling around a wheel). The tightening should be
appropriate so that the forefinger can go through the anus. In
the case of a child, the passage can hold the tip of the little
finger. Since the tied part constitutes a foreign body
stimulation, the connective tissues will gradually become
hyperplastic proliferation, which is helpful for the anus to
contract. The metallic thread used can be removed in a few
months or may not be taken off at all. In some cases, catguts or
thick silk threads can also be used instead.
Rubber Tube Ligation for the Anus: Apiece of soft and elastic
rubber tube for ligation is tied around the perianal
subcutaneous part. This method is as the same as the metallic
thread ligation of the anus. The rubber tube is to be removed in
2-3 months. This method can not only assist the anus to contract
in a short while, but also stimulate the tissues to form scars.
But it is more painful and easier to induce infection.
Fascia Ligation and Other Methods for the Anus: Remove some
fasciae from the thigh, or take silk or nylon threads to make
then into a net or a ribbon, then ligate them around the
perianal part to tighten the anus. The manipulation is similar
to the previous method, but it should be done under aseptic
technique. It is more effective than threads in contracting the
anus. But other operative methods are less commonly used in
China due to their serious injuries.
3. Acupuncture Therapy: Acupoints: Baihui (Du 20), Zusanli (St
36), Changqiang (Du 1), Chengshan (UB 57), Huanmen (The left,
right, middle position of the anus and dorso-ventral boundary)
and so on. Moderate stimulation, retaining the needle for 3-5
minutes, puncture every other day. Usually, the whole course of
treatment will be 10-15 times. The pricking method will be the
same as that for the treatment of hemorrhoid. At the same time,
moxibustion should also be adopted on the points Baihui (Du 20),
Zusanli (St 36), zhongwan (Ren 12), Changqian (Du 1).
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