A stoma is a surgically created opening on the abdomen that allows waste to exit the body into an external pouch, bypassing a diseased or damaged section of the intestine or urinary tract. A stoma prolapse is a complication where the segment of bowel forming the stoma protrudes outward and telescopes excessively from the abdominal surface.
Recognizing the Signs of Prolapse
The most noticeable sign of a prolapsed stoma is a change in its size and length, appearing significantly longer than its typical resting state. The stoma may extend several centimeters from the abdomen, often described as a telescoping effect. This increase in size can cause the stoma to appear swollen or bulky, complicating the application and sealing of the ostomy appliance.
While the stoma is normally a healthy, moist, reddish-pink color, a prolapse can lead to color changes that signal a problem with blood flow. The tissue may become dark red, dusky, or purple, indicating reduced circulation and requiring immediate medical attention. The prolapse may be intermittent, appearing only when standing or straining, and reducing when lying down. A persistent or non-reducible prolapse that remains distended can lead to ulceration and bleeding on the surface of the exposed intestine.
Immediate Mechanical Triggers
Stoma prolapse is triggered by a sudden or sustained increase in intra-abdominal pressure (pressure within the abdominal cavity). This pressure pushes the mobile segment of the bowel out through the path of least resistance at the stoma site. Activities causing this pressure surge are the direct mechanical triggers for prolapse.
Straining during a bowel movement due to constipation, or during urination, is a common mechanical cause of excessive intra-abdominal pressure. Forceful expulsion of air, such as chronic coughing (associated with conditions like COPD) or aggressive sneezing, can transmit sufficient pressure to instigate a prolapse. For infants, sustained periods of crying can generate the necessary pressure to push the stoma outward.
Heavy lifting or excessive physical exertion places strain on the core muscles and abdominal wall, rapidly elevating internal pressure. If the fascial opening around the stoma is weakened or wider than ideal, this sudden pressure can force the bowel to protrude. The mechanism involves the mobile intestine being pushed into the space between the stoma and the abdominal wall, causing the segment to telescope.
Underlying Patient and Surgical Risk Factors
The predisposition to stoma prolapse is determined by individual patient characteristics and factors related to the surgical construction of the stoma. Patient factors contribute to a pre-existing weakness in the abdominal wall or poor tissue integrity. Obesity, particularly weight gain after surgery, increases the risk because the excess weight puts continuous strain on the abdominal musculature and increases basal intra-abdominal pressure.
Advanced age and chronic conditions that compromise tissue healing, such as malnutrition or inflammatory diseases, can lead to a general weakness of the abdominal fascia (the connective tissue layer supporting the stoma). Pre-existing abdominal wall weakness, common in infants and older adults, offers less resistance to internal pressure. These systemic factors create a susceptible environment for prolapse to occur under stress.
Surgical factors play a role in determining long-term risk; for instance, the type of ostomy influences the likelihood of prolapse. Loop stomas, which bring a loop of bowel out onto the abdomen, are more susceptible to prolapse than end stomas. This is often due to the mobility of the loop and how the bowel is secured. If the fascial opening created by the surgeon is too wide or if the stoma is constructed outside of the rectus abdominis muscle, it provides an inadequate seal and an easier route for the intestine to protrude.
Necessary Management and Intervention
Upon recognizing a stoma prolapse, the most important action is to contact a healthcare provider, such as a Wound, Ostomy, and Continence (WOC) nurse or a surgeon, for guidance. The primary concern is assessing the viability of the stoma tissue by checking its color to ensure adequate blood supply. Any change to a dark or purple color, severe pain, or a complete lack of output requires immediate emergency medical evaluation.
For a non-urgent prolapse where the tissue color remains healthy, temporary management focuses on reducing swelling and encouraging the bowel to slide back into the abdomen. Lying down flat or in a slight Trendelenburg position can help by reducing intra-abdominal pressure and relaxing the core muscles. Gentle, continuous pressure applied with a clean hand to the prolapsed tissue can assist in manual reduction.
If swelling prevents the stoma from reducing, a temporary technique may involve applying granulated table sugar or a cold compress to the exposed tissue. Sugar works osmotically to draw fluid out of the swollen tissue, while a cold compress reduces edema; these should only be used under the direction of a healthcare professional. If conservative measures fail, or if complications like obstruction or strangulation occur, definitive treatment requires a surgical revision to either fix the stoma in its current location or relocate it entirely.