International Journal of Colorectal Disease

, Volume 28, Issue 2, pp 261–266

Chronic radiation-induced proctitis: the 4 % formalin application as non-surgical treatment

  • Daniele Pironi
  • Alessandra Panarese
  • Maurizio Vendettuoli
  • Stefano Pontone
  • Salvatore Candioli
  • Annarita Manigrasso
  • Flaminia De Cristofaro
  • Angelo Filippini
Original Article



Radiation proctitis is a known complication following radiation therapy for pelvic malignancy. The majority of cases are treated nonsurgically. Rectal instillation of formalin solution has been described as a successful treatment for chronic radiation-induced hemorrhagic proctitis resistant to medical treatment. We present our results in patients undergoing treatment with application of 4 % formalin for radiation-induced injury to the rectum.


All patients were treated under anesthesia by direct application of 4 % formalin solution to the affected rectal areas. Patient gender, initial malignancy, grade of proctitis, need for blood transfusion, previous therapy, number of applications and response to treatment with formalin, complications, and length of follow-up were reviewed.


A total of 15 patients with a mean age of 68.9 (range, 48–77) years were followed for 31.3 (range, 18–51) months. The mean interval from the conclusion of radiotherapy and the onset of symptoms was 6.9 months. The mean duration of hemorrhagic proctitis before formalin application was 7.9 months. Ten patients had only one formalin application and five patients required a second application because of the persistent bleeding. Thirteen patients (87 %) had complete cessation of bleeding. No complications related to the formalin treatment were observed.


According to a revision of the literature and our experience, despite the small number of patients in our trial, we can state that the application of 4 % formalin solution is an effective, safe, and well-tolerated treatment for chronic radiation-induced hemorrhagic proctitis with minimal discomfort and no severe complications.


Formalin Proctitis Chronic radiation-induced proctitis Hemorrhagic proctitis 


  1. 1.
    Haas EM, Bailey HR, Farragher I (2007) Application of 10 percent formalin for the treatment of radiation-induced hemorrhagic proctitis. Dis Colon Rectum 50(2):213–217PubMedCrossRefGoogle Scholar
  2. 2.
    Hong JJ, Park W, Ehrenpreis ED (2001) Review article: current therapeutic options for radiation proctopathy. Aliment Pharmacol Ther 15(9):1253–1262, ReviewPubMedCrossRefGoogle Scholar
  3. 3.
    Lee SI, Park YA, Sohn SK (2007) Formalin application for the treatment of radiation-induced hemorrhagic proctitis. Yonsei Med J 48(1):97–100PubMedCrossRefGoogle Scholar
  4. 4.
    de Parades V, Etienney I, Bauer P, Bourguignon J, Meary N, Mory B, Sultan S, Taouk M, Thomas C, Atienza P (2005) Formalin application in the treatment of chronic radiation-induced hemorrhagic proctitis—an effective but not risk-free procedure: a prospective study of 33 patients. Dis Colon Rectum 48(8):1535–1541PubMedCrossRefGoogle Scholar
  5. 5.
    Wong MT, Lim JF, Ho KS, Ooi BS, Tang CL, Eu KW (2010) Radiation proctitis: a decade's experience. Singapore Med J 51(4):315–319PubMedGoogle Scholar
  6. 6.
    Konishi T, Watanabe T, Nagawa H (2006) Formalin application in the treatment of chronic radiation-induced hemorrhagic proctitis induces acute deterioration of mucosal blood flow. Dis Colon Rectum 49(4):530–531PubMedCrossRefGoogle Scholar
  7. 7.
    Parikh S, Hughes C, Salvati EP, Eisenstat T, Oliver G, Chinn B, Notaro J (2003) Treatment of hemorrhagic radiation proctitis with 4 percent formalin. Dis Colon Rectum 46(5):596–600PubMedCrossRefGoogle Scholar
  8. 8.
    Do NL, Nagle D, Poylin VY (2011) Radiation proctitis: current strategies in management. Gastroenterol Res Pract 2011:917941, Epub 2011 Nov 17PubMedGoogle Scholar
  9. 9.
    Hayne D, Vaizey CJ, Boulos PB (2001) Anorectal injury following pelvic radiotherapy. Br J Surg 88(8):1037–1048PubMedCrossRefGoogle Scholar
  10. 10.
    Alfadhli AA, Alazmi WM, Ponich T, Howard JM, Prokopiw I, Alaqeel A, Gregor JC (2008) Efficacy of argon plasma coagulation compared to topical formalin application for chronic radiation proctopathy. Can J Gastroenterol 22(2):129–132PubMedGoogle Scholar
  11. 11.
    Denton AS, Andreyev HJ, Forbes A, Maher EJ (2002) Systematic review for non-surgical interventions for the management of late radiation proctitis. Br J Cancer 87(2):134–143, ReviewPubMedCrossRefGoogle Scholar
  12. 12.
    Brown RB (1969) A method of management of inoperable carcinoma of the bladder. Med J Aust 1(1):23–24PubMedGoogle Scholar
  13. 13.
    Rubinstein E, Ibsen T, Rasmussen RB, Reimer E, Sørensen BL (1986) Formalin treatment of radiation-induced hemorrhagic proctitis. Am J Gastroenterol 81(1):44–45PubMedGoogle Scholar
  14. 14.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240(2):205–213PubMedCrossRefGoogle Scholar
  15. 15.
    Hernández Sánchez A, Vicente Sánchez MD, Arteta Jiménez M (2011) Formalin for haemorrhagic radiation-induced proctitis. Int J Colorectal Dis 39(2):196–199Google Scholar
  16. 16.
    Johnston MJ, Robertson GM, Frizelle FA (2003) Management of late complications of pelvic radiation in the rectum and anus: a review. Dis Colon Rectum 46(2):247–259, ReviewPubMedCrossRefGoogle Scholar
  17. 17.
    Silva RA, Correia AJ, Dias LM, Viana HL, Viana RL (1999) Argon plasma coagulation therapy for hemorrhagic radiation proctosigmoiditis. Gastrointest Endosc 50(2):221–224PubMedCrossRefGoogle Scholar
  18. 18.
    Chattopadhyay G, Ray D, Chakravartty S, Mandal S (2010) Formalin instillation for uncontrolled radiation induced haemorrhagic proctitis. Trop Gastroenterol 31(4):291–294PubMedGoogle Scholar
  19. 19.
    Bem J, Bem S, Singh A (2000) Use of hyperbaric oxygen chamber in the management of radiation-related complications of the anorectal region: report of two cases and review of the literature. Dis Colon Rectum 43(10):1435–1438, ReviewPubMedCrossRefGoogle Scholar
  20. 20.
    Shrom SH, Donaldson MH, Duckett JW, Wein AJ (1977) Formalin treatment for intractable hemorrhagic cystitis: a review of the literature with 16 additional cases. Surg Forum 28:565–567PubMedGoogle Scholar
  21. 21.
    Seow-Choen F, Goh HS, Eu KW, Ho YH, Tay SK (1993) A simple and effective treatment for hemorrhagic radiation proctitis using formalin. Dis Colon Rectum 36(2):135–138PubMedCrossRefGoogle Scholar
  22. 22.
    Yegappan M, Ho YH, Nyam D, Leong A, Eu KW, Seow C (1998) The surgical management of colorectal complications from irradiation for carcinoma of the cervix. Ann Acad Med Singap 27(5):627–630PubMedGoogle Scholar
  23. 23.
    Saclarides TJ, King DG, Franklin JL, Doolas A (1996) Formalin instillation for refractory radiation-induced hemorrhagic proctitis. Report of 16 patients. Dis Colon Rectum 39(2):196–199PubMedCrossRefGoogle Scholar
  24. 24.
    Nelamangala Ramakrishnaiah VP, Javali TD, Dharanipragada K, Reddy KS, Krishnamachari S (2012) Formalin dab, the effective way of treating haemorrhagic radiation proctitis: a randomized trial from a tertiary care hospital in South India. Colorectal Dis 14(7):876–882. doi:10.1111/j.1463-1318.2012.03008.x PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • Daniele Pironi
    • 1
  • Alessandra Panarese
    • 1
  • Maurizio Vendettuoli
    • 1
  • Stefano Pontone
    • 1
  • Salvatore Candioli
    • 2
  • Annarita Manigrasso
    • 2
  • Flaminia De Cristofaro
    • 1
  • Angelo Filippini
    • 1
  1. 1.Department of Surgical Sciences“Sapienza” University of RomeRomeItaly
  2. 2.Surgical UnitS. Martino HospitalBellunoItaly

Personalised recommendations