Chronic Perianal Pain

Original Editor - Adu Omotoyosi Johnson Top Contributors - Adu Omotoyosi Johnson and Kim Jackson

Introduction

Chronic or frequently recurring pain in the anal canal or rectum of at least 20- minute duration.[1] It is also known as chronic proctalgia. The following are considered to be synonymous with chronic perianal pain, they are; levator ani syndrome, chronic idiopathic perianal pain. Thiele, who was one of the earliest researchers to investigate this pain syndrome referred to it as coccygodynia, but he acknowledged that the pain is not in the coccyx.[2]

Aetiology

Idiopathic; it is largely of unknown origin

Epidemilogy

Chronic perianal pain is a prevalent symptom that affects approximately 6.6% population.[3]

Clinical Presentation

Patients often describe this condition as dull ache or pressure sensation in the rectum that is usually aggravated by prolonged sitting and relieved by standing or lying [1][4]

The pain rarely occurs at night but it severity increases throughout the day, it may be precipitated by long distance car travelling, sexual intercourse, stress and even defecation [5][6]

Pathophysiology/Causes

  • The pathophysiological basis for chronic proctalgia has previously been assumed to be tension, spasm or inflammation of the striated pelvic floor muscles[7][8][9]
  • Inflammation of the levator ani muscle has also been suggested as a cause of chronic proctalgia, Retrospective studies has also shown that many patients reported prior pelvic surgery, anal surgery as significant in the development of their pain syndrome [5][10]
  • Childbirth can also be a precipitating factor[11]
  • Anxiety disorders, depression and stress[6][12]

Diagnostic Assessment

Diagnosis of chronic proctalgia relies on clinical symptoms of recurring pain in d rectum lasting 20 minutes or more.[3] digital rectal examination is also performed so as to ascertain whether the patients reports tenderness when the levator ani muscle is pulled as this is a strong prediction as to whether the patient will likely benefit from treatments directed at relaxing pelvic floor muscles

Differential Diagnosis

  • Anal fissures
  • Pudendal neuralgia
  • Levator ani syndrome and proctalgia fugax
  • Anorectal abscesses
  • Viral/bacterial infections in the rectum area
  • Hemorrhoids
  • Rectal foreign body

Medical Management

The first line of treatment most commonly provided is reassurance that pain is benign and is not suggestive of malignanacy[13]

Diazepam; a study revealed that hot sitz baths and or diazepam were effective for relieving pain in 68% of 316 chronic proctalgia patients[14]

Physiotherapy Management

The goal of physiotherapy in this case is to relieve pain

  • Puborectalis muscle massge; this should be performed up to like 50 times depending on well the patient can tolerate it. Some claim that it may not be effective if the patient is not uncomfortable while being performed[10]
  • Electro galvanic muscle stimulation has been used traditionally by Physiatrists to treat muscle spasticity especially when conservative therapy seems not to be effective.
  • Biofeedback training to teach pelvic floor muscle relaxation.

Resources

References

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  2. Thiele Gh. Coccygodynia: cause and treatment. Dis Colon Rectum. 1963;6:422–436. [PubMed] [Google Scholar]
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  8. Gilliland R, Heymen JS, Altomare DF, Vickers D, Wexner SD (1997) Biofeedback for intractable rectal pain: outcome and predictors of success. Dis Colon Rectum 40: 190-196.
  9. Park DH, Yoon SG, Kim KU, Hwang DY, Kim HS, et al. (2005) Comparison study between electrogalvanic stimulation and local injection therapy in levatorani syndrome. Int J Colorectal Dis 20: 272-276.
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