What are the symptoms and management options for a patient with ostomy prolapse?

Symptoms of Ostomy Prolapse

Ostomy prolapse presents as visible elongation of the intestinal portion of the stoma protruding through the abdominal wall, which may be accompanied by difficulty with appliance fitting, leakage, and in acute cases with ischemia, pain with purple/black discoloration requiring emergency surgery. 1

Clinical Presentation

Non-Emergent Symptoms

• Visible protrusion of bowel through the stoma opening, ranging from several centimeters to 20 cm in length 1, 2, 3
• Difficulty maintaining appliance seal due to changing stoma size and shape, leading to frequent leakage 1, 2
• Peristomal skin breakdown from chronic effluent exposure secondary to poor appliance fit 1, 4
• Marked redness, swelling, and erosion of the prolapsed bowel segment 3
• Irritable stoma causing discomfort and difficulty with routine stoma care 3

Emergency Symptoms Requiring Immediate Surgical Intervention

• Pain associated with incarceration of the prolapsed segment 1
• Obstipation (inability to pass stool) indicating bowel obstruction 1
• Purple or black discoloration of the stoma indicating ischemia and tissue necrosis 1, 5
• These findings represent a surgical emergency and cannot be managed conservatively 1

Epidemiology and Risk Factors

• Occurs in 5% to 10% of ostomates 1
• Loop stomas have significantly higher prolapse rates than end stomas 1, 2
• Transverse colostomies carry particularly high risk and should be avoided when possible 1
• Increased intra-abdominal pressure, redundant or mobile colon, and excessive fascial opening at creation increase risk 2

Management Algorithm

Immediate Assessment

First, determine if ischemia is present by examining stoma color—purple/black discoloration mandates emergency surgery without delay 1, 5

Non-Ischemic Prolapse: Conservative Management

If the stoma remains pink and viable:

1. Position the patient in a relaxed, supine position 1
2. Apply gentle manual pressure to squeeze the prolapsed bowel back into the abdomen 1
3. If manual reduction fails, apply granulated sugar directly to the stoma and leave in place for 20 minutes to reduce edema through osmotic effect, then reattempt reduction 1
4. Optimize appliance fit with convex pouching systems and ostomy belts to manage the prolapse conservatively 6, 2

Indications for Surgical Repair

Surgery is warranted when: 2

• Conservative management fails to maintain reduction
• Persistent leakage causes significant financial burden from frequent appliance changes
• Prolapse affects normal bowel function
• Recurrent incarceration episodes occur

Surgical Options

• Stoma reversal is the definitive solution if the ostomy was intended as temporary fecal diversion 2
• Local revision techniques include stapling procedures that can be performed under local anesthesia in day surgery settings 3, 7, 8
• Avoid relocating the stoma to a new abdominal site, as this creates significant risk of complications at the new location 1, 6

Critical Pitfalls to Avoid

• Never dismiss purple or dark stoma discoloration as normal variation—this represents ischemia requiring emergency surgical consultation 5
• Do not delay surgical evaluation when ischemic changes are present, as this can lead to bowel necrosis and sepsis 1
• Avoid excessive observation of incarcerated prolapse hoping for spontaneous reduction, as this increases morbidity and mortality 1