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Necrotizing paraproctitis
Last reviewed: 07.07.2025
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The allocation of this pathology into a separate group is due to both the extent and severity of the infection of the fatty tissue, muscles and fascia in the rectum and perineum, and the specifics of treatment. The disease necrotic paraproctitis is characterized by rapid generalization of infection, development of multiple organ dysfunction and requires necrectomy and intensive care. Severe soft tissue lesions can be caused by both individual microorganisms and associations of aerobes, anaerobes and facultative anaerobes.
Anaerobic clostridial paraproctitis
Anaerobic clostridial necrotic paraproctitis is the most severe form. The causative agents of the disease are Cl. petfringens, Cl. novyi, Cl. septicum and Cl. histotyticum.
The incubation period of the disease is very short, sometimes it is only 3-6 hours, less often 1-2 days. The onset of gas infection is manifested by the fact that the patient, against the background of relative well-being, develops inexplicable anxiety, the pulse rate increases rapidly, blood pressure decreases, and a gray-blue coloration of the face is often visible. At the same time, severe pressing pain in the perineum occurs, often simply unbearable. The most severe pain can be explained by tissue ischemia.
Clostridia produce toxins that cause hemolysis, destruction of cells and intermediate substances, and disrupt blood circulation. Depending on the type of pathogen, tissue edema or gas formation may predominate; in some cases, muscle and other tissues rapidly disintegrate, turning into an amorphous mass, leading to putrefaction. Due to gas and edema, intra-tissue pressure increases, leading to partial or complete compression of first venous and then arterial vessels.
When examining the perineum, hyperemia characteristic of inflammatory processes is not detected; due to tissue edema, the skin becomes white and shiny, later, due to hemolytic processes, it first becomes brownish and then black-gray. Crepitation is felt on palpation - "cracking" of gas bubbles in the tissues. Hyperemia and local increase in temperature are absent, the lymph nodes usually do not enlarge. When punctured, instead of pus, a cloudy yellow-brown liquid with an unpleasant sweetish-putrid odor is detected; when cutting the tissue, a liquid containing gas bubbles flows out. The muscles are flabby and disintegrate as necrosis increases. The fascial partitions are also affected.
Severe pain, severe general condition, absence of signs of banal inflammation (hyperemia, pus), tissue swelling, change in skin color and appearance should suggest the possibility of gas infection. If crepitus appears, the diagnosis is certain. Radiographs show characteristic "feathery" due to muscle stratification under the influence of gas. Clostridial infection is confirmed bacterioscopically and bacteriologically. A smear from the wound (from the surface of the muscles) is stained with methylene blue solution; the presence of gas gangrene is indicated by "clumsy" sticks (like matches scattered from a matchbox), myolysis, gas bubbles and absence of leukocytes. A piece of muscle should be taken from the wound for bacteriological confirmation of the diagnosis.
Anaerobic non-clostridial necrotic paraproctitis
Anaerobic non-clostridial necrotic paraproctitis is caused by non-spore-forming anaerobes - bacteroides and fusobacteria. Predisposing factors for the development of non-clostridial infection are necrotic or poorly blood-supplied tissues, local decrease in the activity of oxidative processes, weakening of the immune system, tissue acidosis and selection of anaerobes due to the use of antibiotics.
In non-clostridial infections, inflammation may occur in the cellulose (cellulitis), muscles (myositis), fascia (fasciitis). Tissue edema and necrosis are observed, sometimes with the formation of gas bubbles. There is no hyperemia or pus. When tissue is cut, detritus and a turbid liquid with a strong odor (the so-called colibacillary) are found, caused by the presence of bacteroids. Development is accompanied by fever, chills, and a severe general condition due to toxemia.
The diagnosis is usually made based on clinical signs. Bacteriological confirmation of the diagnosis is not always possible. Difficulties arise already at the moment of taking the material for research - it must be carried out in the complete absence of oxygen. The same requirements should be observed during transportation and processing of the smear. Growing microorganisms requires considerable costs and lasts 4-6 days.
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Putrefactive necrotic paraproctitis
Another severe form, identified as putrefactive necrotic paraproctitis, is caused by an association of non-spore-forming anaerobes (bacteroides, fusobacteriaceae, peptococci), E. coli and Proteus. Putrefactive necrotic paraproctitis often occurs against the background of diabetes mellitus, decreased immunity due to malnutrition, hypothermia and severe vascular diseases.
The process affects the pararectal tissue and can then spread to other areas (anterior abdominal wall, lumbar region). Very often in men, tissue necrosis spreads to the scrotum and even the penis. This process is known as Fournier's gangrene. Fat tissue and skin become necrotic, releasing a foul-smelling fluid, sometimes with gas bubbles ("swamp" gas). The putrefactive process causes severe intoxication.
How is necrotic paraproctitis treated?
Treatment of necrotic paraproctitis should be started immediately. It includes emergency surgery, intensive infusion and antibacterial therapy, correction of organ dysfunctions.
Surgical intervention involves wide opening of the affected cellular spaces with mandatory excision of devitalized tissues until the wound edges begin to bleed, washing and drainage of the cavities. During subsequent dressings, it is often necessary to excise newly identified nonviable tissues, which results in the formation of large and deep tissue defects. Surgery for a disease such as necrotic paraproctitis does not involve searching for and excising the affected crypt. Therapy requires creating wide access of oxygen to the foci of infection, which is ensured by open wound management and treatment in a pressure chamber. The principles of antibacterial and intensive therapy, as well as methods for correcting organ dysfunctions in sepsis are reflected in separate chapters of this manual.
What is the prognosis for necrotic paraproctitis?
Delay in surgical intervention and inadequate intensive and antibacterial therapy make the prognosis extremely unfavorable.