Functional Anorectal Pain

Original Editor - Adu Omotoyosi Johnson Top Contributors - Jacintha McGahan, Adu Omotoyosi Johnson and Kim Jackson

Introduction

A specialist convention in the area of gastroenterology devised a criteria, known as Rome criteria for diagnosing functional gastrointestinal disorders (FGIDs)[1]. The first version was released in 1990[2]. According to the most recent version of these criteria's, Rome IV, functional disorders affiliated with anorectal pain include proctalgia fugax, levtor ani syndrome and unspecified functional anorectal pain[3]. These three types of anorectal disorders are chiefly differentiated by the length of time pain is present and by the feature or lack of anorectal tenderness[4]. However, these pain disorders do coincide and show similitude with each other[4][5], for instance patients presenting with either levator ani syndrome or unspecified anorectal pain will have chronic pain or intermittent pain with a persistent duration[4].

Functional Anorectal Disorder Type Definitions

Levator Ani Syndrome

This syndrome has other names including levator spasm, puborectalis syndrome, and pelvic tension myalgia[3]. In this syndrome pain can be present for 30 minutes to being ceaseless. It's distinguishing attribute is on physical examination a hypertonic levator ani muscle and soreness on palpation of the pelvic floor or vagina[3].

Unspecified Functional Anorectal Pain

In this syndrome pain will also be present for 30 minutes to being continuous in the rectum. However, it does not present with levator ani soreness on palpation[3].

Proctalgia Fugax

For this disorder pain is momentary, present for seconds to minutes and happens sporadically such as once a month or less[4]. Please use the link for more information on this disorder; Proctalgia Fugax.

Epidemiology

A symptom specific questionnaire, Rome IV questionnaire, was used in 1990 to conduct a large population based survey to establish the extensiveness of the three types of functional anorectal pain disorders[6]. Pain resulting from the combination of these disorders was 11.6% and levator ani syndrome accounted for 6.6%[6], No physical examination was conducted and therefore, the findings did not separate levator ani syndrome and unspecified functional anorectal pain[3]. In addition, there was little difference in the incidence of anorectal pain or it's types between men and women in this survey[3]. The occurrences of anorectal pain was found to be greater in those under 45 years of age, 14% > 45 years vs 9% </= 45 years). Finally, it was estimated that 8.3% with functional anorectal pain and 11.5% with levator ani syndrome indicated they were currently too disabled to work or attend school[6]

In recent times there is currently 'no published data' (p.532)[3] on the commonness to which chronic anorectal pain is came upon in clinical practice[3].

Pathophysiological Process

There is poor insight into the pathophysiology of functional anorectal pain and can happen without of any pathology[7]. Levator ani syndrome is thought to be caused by hypertonic pelvic floor muscles[3], as may be identified by an increase in muscle tone of the puborectalis sling[8] . It was found a presence of pelvic floor muscle spasm, raised anal resting pressure[9] and dyssynergic defecation[10] to be contributors of levator ani syndrome. The latter refers to an inefficiency through defecation process in the anorectum[5] but does not include constipation[3].

3D medical illustration presenting Levator ani Author; https://www.scientificanimations.com/

The Rome IV criteria has highlighted in it's earlier editions that the three types of functional anorectal pain were classified under the title chronic proctalgia[3]. However, it is now recognised the symptom of levator ani soreness, relates to a muscular component as opposed to a rectal source for pain. This is now accepted by the definition of levator ani syndrome and the title of chronic proctalgia has been discontinued[3].

Clinical Presentation

Patients presenting with levator ani syndrome or unspecified functional anorectal pain often describe the feeling of pain as a dull ache or a sense of pressure upmost in the rectum. This is usually aggravated by a long duration of sitting, such as long distance car journey, and lessened by standing or lying [5][11][12]. The pain rarely occurs at night but it's severity can rise throughout the day. It may be made more severe with sexual intercourse, stress or defecation[13] [14]. Associations have been made between patients presenting with levator ani syndrome, who are also experiencing psychosocial distress[5] and impacted quality of life[15], this includes anxiety disorders, depression and stress[13][16]. Other causative factors to functional anorectal pain can include childbirth[17] and surgery, inclusive of herniated lumbar disk, hysterectomy, or low anterior resection[5].

A digital rectal examination may be performed to ascertain the presence of tenderness when traction is applied to the levator ani muscle[18]. Often a lack of symmetry may be noted on the physical exam and pain is mainly left sided. Presently, there is no logic as to why this side is generally more affected[18][19].

Summary of clinical features for one of the subtypes of functional anorectal pain. Table adapted from Bharucha & Lee 2016 (p.1473)[5]
Variable Levator ani syndrome
Average age 30-60 years
Sex Men less than women
Pain Quality

Pain Duration

Typical Pain Location

Pain at other sites

Precipitating factors

Vague dull ache or pressure sensation

30 minutes or longer

Rectum

No

Sitting long period, Stress, sexual intercourse, Defecation, Childbirth, Surgical procedure.

Urinary symptoms

Sexual dysfunction

Psychosocial symptoms

No

No

Possible

Internal pelvic tender points

External pelvic tender points

Yes (Puborectalis) with asymmetry (left side greater than right side).

No

Further clinical investigations conducted to exclude other diseases may include sigmoidoscopy and suitable imaging studies such as defecography, ultrasound, or pelvic CT[18].

Diagnostic Criteria

Diagnosis of Levator Ani Syndrome, as per Rome IV criteria [3], must present with all symptoms listed below:

  • Chronic or recurrent rectal pain or aching.
  • Episodes last 30 minutes or longer.
  • Soreness during traction on the puborectalis.
  • Elimination of other sources of rectal pain, see differential diagnosis below.
  • Criteria is to be met for the last 3 months with symptom onset at a minimum of 6 months before diagnosis.

The diagnosis of unspecified functional anorectal pain has the same criteria as that for chronic levator ani syndrome, but there is no soreness during posterior traction on the puborectalis muscle. Again criteria is met for the last 3 months with symptom onset at a minimum of 6 months before diagnosis[3][4].

Differential Diagnosis

  • Anal fissures
  • Fistulas
  • Inflammatory bowel disease
  • Prostatitis
  • Coccygodynia
  • Major structural changes of the pelvic floor.
  • Pudendal neuralgia
  • Anorectal or intramuscular abscesses
  • Viral/bacterial infections in the rectum area
  • Hemorrhoids or thrombosed hemorrhoids
  • Rectal foreign body
  • Disorders associated with thrombosis, or necrosis that can result in pain[3][4][20]

Outcome Measures

The Rome IV Diagnostic Questionnaires were comprised to scan for functional gastrointestinal disorders, create an inclusion criteria in clinical trials, and provide for epidemiologic surveys. Individual questionnaires have been devised for adults, children and adolescents, and infants and toddlers[21].

Management/Interventions

The first line of treatment most commonly provided is reassurance that pain is benign. Conservative lines of treatment are used first in the management of functional anorectal pain, this may include life style adaptations, diet changes, fibers, laxatives, and pelvic floor physiotherapy. However, if conservative management is unsuccessful, these functional disorders can be difficult to treat[20]. In the instance of levator ani syndrome a range of treatments aimed at relaxing the levator ani muscles may be implemented[18];

  • Digital massage of the levator ani muscles[22]
  • Sitz baths[19]
  • Muscle relaxants such as methocarbamol, diazepam[19], and cyclobenzeprine
  • Electrogalvanic stimulation (EGS)
  • Sacral nerve stimulation[23]
  • Biofeedback training

A randomized controlled study unveiled that biofeedback is markedly more effective than EGS or digital massage[10]. Patients were grouped as 'highly likely' to have levator ani syndrome if traction on the levator muscles produced soreness or as possible levator ani syndrome if they did not [10]. All 157 patients were treated for 9 sessions that included psychologic counselling along side biofeedback, EGS, or massage. Results were monitored at 1, 3, 6, and 12 months. The results demonstrated sufficient relief as 87% for biofeedback, 45% for EGS, and 22% for massage. Pain days per month declined from 14.7 at initial to 3.3 post biofeedback, 8.9 post EGS, and 13.3 post massage. Pain levels reduced from 6.8 (0–10 scale) at beginning to 1.8 post biofeedback, 4.7 post EGS, and 6.0 post massage. Improvements were preserved for 12 months[10]. The pathophysiology of levator ani syndrome is alike to that of dyssynergic defecation[10]. In a more recent review it was reported biofeedback improves the defecation manner and attested effective for above 90% of patients in the short term[24].

[25]

Where conservative management has been unsuccessful botox may be considered as an alternative. In a study conservative management was given for 3 months then treatment with Botulinum toxin type A (BTX-A), as well as ongoing physiotherapy by a pelvic floor physiotherapist. BTX-A was found to give a prolonged remedy in 47% of patients with chronic functional anorectal pain. A further 20% had an initial response to treatment, but reverted within 3 months[20]. Patient sample size in this study was small, 113 total. It was noted in patients with solitary hypertonia of the levator ani appeared to present worse than those with only hypertonia of the anal sphincter or a mixture of both, but this difference was not statistically significant (p=0.06)[20]. In comparison, another earlier study found injection of botulinum toxin into anal sphincter did not relieve anorectal pain present in levator ani syndrome[26]. This earlier study did not include the combined management of pelvic floor physiotherapy and botox for these patients[20], thus highlighting the value of physiotherapy pelvic health intervention for this patient group.

Physiotherapy Intervention[27]

In order to grasp a full insight of the magnitude and attributes of each patient's symptoms and to devise an individualised treatment plan, the physiotherapy appraisal must take into account the patient's diagnosis, the results of any further investigations, conduct a detailed interview, and comprehensive physical examination. The pelvic floor examination in patients with anorectal disorders is the same as that for patients presenting for urinary incontinence, with particular attention on details admissible to the anorectum.

Anal palpation will give assessment of the measure of the anal sphincter and it's resting tone and contractility. The anorectal angle can also be surmised; it is normally between 60h and 130h. Furthermore, feces in the rectum and its texture can be evaluated here, the tone and contractility of the posterior aspects of the pelvic floor muscules (puborectalis, pubococcygeus, iliococcygeus, and ischiococcygeus). The coccyx is an important bone of attachment for the pelvic floor muscles and it's akin fascia, the location and mobility of the coccyx are also assessed, and painful areas can be palpated.

A-puborectalis, B-rectum, C-level of anorectal ring and anorectal angle, D-anal canal, E-anal verge, F-representation of internal and external anal sphincters, G-coccyx & sacrum, H-pubic symphysis, I-Ischium, J-pubic bone.

A functional assessment is conducted in supine and sitting position to allow reproduction of the patient's evacuation endeavors, without actual evacuation. This will give information on whether the patient is producing sufficient push, with enough pelvic floor and anal sphincter easing. Spasms in this area may be provoked during this examination. The sitting posture used by the patient during evacuation is recognised. During this examination the way in which intra-abdominal pressure is raised and it's impact on abdominal wall noted.

Examination of the abdominal wall is conducted through palpation and functional testing. Palpation of the colon and identification of locations of soreness. Functional activities include coughing or lifting of the upper or lower limbs. Breathing pattern and how the diaphragm moves is assessed. Overall a comprehensive examination of the thoracolumbar spine and pelvis can be performed to give insight of the functional abdominopelvic workings[28].

A variety of physiotherapy treatment choices are accessible, including:

  • Patient education
  • Exercise
  • Manual techniques
  • Biofeedback
  • Electrical stimulation
  • Balloon techniques
  • Functional applications during evacuation procedure

The treatment of anorectal disorders is many-sided and the selection of a treatment has to account for;

  • Contractility and patient mastery of the pelvic floor and the anus
  • Receptiveness and conformity at the rectum
  • Intestinal motion
  • Evacuation procedure
  • Diet
  • Yellow flags

To give some further detail into the physiotherapy treatments one can begin to give suitable information at the subjective interview, such as bowel and bladder routines, diet to establish best stool consistency, and general health. Thereafter, using a pelvic model, drawings, information pamphlet, and an evacuation diary to give insight into bowel routines , the patient will prevail of a basic understanding of the gastrointestinal system and it's operations, with particular importance on the control that can be executed via the pelvic floor muscles.

Straining during defecation is dismayed, to reduce pressure on the bladder, pelvic floor, and pudendal nerve and affiliated branches. Patients who have hardship in evacuating without straining are educated to use an evacuation procedure that promotes relaxation at the anal sphincter, in conjunction utilising the diaphragm to aid raising intra-abdominal pressure. If more pressure is required a patient can then be trained to use transversus abdominis to raise pressure and guide the push posteriorly.

Additionally, many patients with anorectal dysfunction may have a flare in their symptoms during stressful episodes and helping a patient to identify this aspect may aid them to control or reduce a relapse of symptoms. Onward referral to a psychologist or psychiatrist may be necessary.

In relation to patient exercise, they are to learn to locate and control the muscles of the pelvic floor and abdominal wall. Patients conferring for pain that is related to hypertonicity need to acknowledge a rise of muscle tone and should be taught to relax the muscles to forestall or limit the pain. Part of the exercise program is the regular practice of the correct evacuation procedure.

Manual therapy at pelvic floor level can be used to enhance proprioception, modify muscle tone and change the pain experience. Other techniques in this category include coccygeal mobilisation and anal sphincter dilation that are conducted via the anus. A pressure can be applied by the patient on the top of their perineum to allow the patient to recollect that the correct evacuation procedure has been executed. Moreover, intestinal or abdominal massage is another manual technique that can be performed by the physiotherapist during clinic sessions, but can be shown to a patient to perform at home. Finally, active hip and knee flexion to press and relieve the abdominal material can be used as a tool by a patient to promote peristalsis and the clearance of stool and flatulence.

Reference List

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