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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