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 ?.
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 ?. 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.
? 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 ? while the width and thickness are the same as required
in method ?. 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).
Dr. Ming's TCM Medical Center,
Hua
Xi Xiao Yuan, Hutian Developing Area,
Huaihua city, Hunan province
China