What to do if an ostomy (ostomy, a surgically created opening in the body) is attached but prolapsing (protruding)?

Management of Prolapsing Ostomy

For a prolapsing ostomy, immediate management involves gentle manual reduction with the patient in a relaxed position, and if this fails, applying sugar directly to the stoma for 20 minutes to reduce edema before attempting reduction again. 1

Understanding Stomal Prolapse

Stomal prolapse refers to the elongation of the intestinal portion of the stoma, as opposed to a parastomal hernia which is a bulge in the surrounding skin and soft tissue. Prolapse occurs in approximately 5-10% of ostomy patients 1. This condition can cause significant physical and psychological distress for patients.

Assessment Algorithm

1. Evaluate for signs of complications:

   • Check for pain, obstipation, or purple/black discoloration of the stoma (signs of ischemia)
   • Assess for signs of obstruction
   • Determine if the prolapse is reducible

2. If no signs of ischemia or obstruction:

   • Proceed with reduction attempts

3. If signs of ischemia present (pain, purple/black discoloration):

   • This is a surgical emergency requiring immediate intervention 1

Management Approach

For Reducible Prolapse Without Ischemia:

1. Position the patient properly:

   • Place patient in a relaxed position (Trendelenburg position is optimal)
   • Ensure adequate analgesia or mild sedation is provided 1

2. Attempt manual reduction:

   • Gently squeeze the ostomy back into the abdomen 1
   • Apply gentle, continuous pressure

3. If initial reduction fails:

   • Apply a cup of sugar directly to the stoma
   • Leave in place for 20 minutes to reduce edema
   • Then attempt reduction again 1

4. Alternative methods to reduce edema before manual reduction:

   • Topical application of hypertonic solutions
   • Submucosal infiltration of hyaluronidase
   • Elastic compression wrap 1, 2

For Irreducible Prolapse or Signs of Ischemia:

1. Surgical intervention is required:

   • Acute prolapse with incarceration and ischemia requires emergency surgery 1
   • Do not delay surgical treatment when non-operative management fails 2

2. Surgical options include:

   • Perineal procedures (preferred for elderly or high-risk patients):
     • Anal encirclement (Thiersch procedure)
     • Mucosal sleeve resection (Delorme's procedure)
     • Perineal proctosigmoidectomy (Altemeier's procedure) 1, 2
   • Abdominal approaches (for lower-risk patients):
     • Suture rectopexy
     • Mesh rectopexy
     • Resection rectopexy 1

Prevention and Long-Term Management

1. Address underlying causes:

   • Manage constipation and avoid straining
   • Consider stool softeners

2. Pouching system adjustments:

   • May need to adjust the appliance to accommodate the prolapse
   • Ensure proper fit to prevent leakage

3. Follow-up care:

   • Regular assessment by wound ostomy and continence (WOC) nurse
   • Monitor for other complications such as parastomal hernia or skin issues

Important Caveats

• Do not delay surgical treatment when non-operative management fails, as this increases risk of ischemia and perforation 2
• Ensure adequate analgesia during reduction attempts, as pain can cause sphincter spasm and hinder reduction 2
• Recognize that rectal prolapse may coexist with other pelvic floor disorders, particularly in elderly women 2
• The psychological impact of ostomy complications should not be overlooked; appropriate support and education should be provided 3

By following this systematic approach to managing ostomy prolapse, healthcare providers can effectively address this complication while minimizing the risk of serious adverse outcomes such as ischemia or perforation.