Formalin instillation for refractory radiation-induced hemorrhagic proctitis.

BACKGROUND AND OBJECTIVES: Radiation proctitis is a common complication after pelvic irradiation. One to five percent of these patients will develop intractable or massive hemorrhagic radiation proctitis that will require repeated hospital admissions and blood transfusions. We evaluated the benefits of instillation of 4% formalin in the management of refractory hemorrhagic radiation-induced proctitis.

METHODS: From January 1998 to May 1999, 20 female patients who failed with administration of topical steroids and/or mesalazine were treated with 500 ml of 4% formalin instilled into the rectum in 50-ml aliquots.

RESULTS: Median age was 58 years. Eighteen patients had cervical cancer and two, endometrial cancer. These patients received a mean of 7,500 rads to the pelvis. The symptoms began at a mean of 8 months after termination of radiotherapy. Median time of symptomatic rectal hemorrhage was 8 months. Median of blood units previously transfused was six (range: 2-11). Hemorrhage immediately ceased after the 4% formalin instillation in 17 patients. Three patients required formalin instillation repetition with success in one. Overall success was 90%. Median follow-up was 20 months. Five patients had moderate pelvic pain after instillation and one developed rectosigmoideal necrosis that required resection plus Hartmann procedure. Two patients developed rectovaginal fistula and required colostomy, and one thereafter, required abdominoperineal resection en bloc with the posterior wall of the vagina due to pelvis sepsis.

CONCLUSIONS: Rectal instillation of 4% formalin is a simple, inexpensive, and efficient treatment for refractory hemorrhagic radiation proctitis.