Functional Anorectal Pain: Difference between revisions

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==== Proctalgia Fugax ====
==== Proctalgia Fugax ====
For this disorder pain is momentary, present for seconds to minutes and happens sporadically such as once a monthly or less<ref name=":5" />.  
For this disorder pain is momentary, present for seconds to minutes and happens sporadically such as once a monthly or less<ref name=":5" />. Please use the link for more information on this disorder; [[Proctalgia Fugax]].  


== Epidemiology ==
== Epidemiology ==
Chronic perianal pain is a prevalent symptom that affects approximately 6.6% population.<ref name=":1">Drossman DA, Li Z, Andruzzi E, Temple RD, Talley NJ, Thompson WG, Whitehead WE, Janssens J, Funch-Jensen P, Corazziari E. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci. 1993;38:1569–1580. [PubMed] [Google Scholar]</ref>


== Pathophysiological Process ==
== Pathophysiological Process ==
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== Diagnostic Assessment  ==
== Diagnostic Assessment  ==
Diagnosis of chronic proctalgia relies on clinical symptoms of recurring pain in d rectum lasting 20 minutes or more.<ref name=":1" /> 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
Diagnosis of chronic proctalgia relies on clinical symptoms of recurring pain in d rectum lasting 20 minutes or more.<ref name=":1">Drossman DA, Li Z, Andruzzi E, Temple RD, Talley NJ, Thompson WG, Whitehead WE, Janssens J, Funch-Jensen P, Corazziari E. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci. 1993;38:1569–1580. [PubMed] [Google Scholar]</ref> 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  ==
== Differential Diagnosis  ==

Revision as of 15:01, 22 September 2020

This article is currently under review and may not be up to date. Please come back soon to see the finished work! (21/09/2020)

Introduction[edit | edit source]

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 criterias, 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[edit | edit source]

Levator Ani Syndrome[edit | edit source]

This syndrome has other names including 'levator spasm, puborectalis syndrome, and pelvic tension myalgia' (p.531)[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[edit | edit source]

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[edit | edit source]

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

Epidemiology[edit | edit source]

Pathophysiological Process[edit | edit source]

  • The pathophysiological basis for chronic proctalgia has previously been assumed to be tension, spasm or inflammation of the striated pelvic floor muscles[6][7][8]
  • 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 [9][10]
  • Childbirth can also be a precipitating factor[11]
  • Anxiety disorders, depression and stress[12][13]

Clinical Presentation[edit | edit source]

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 [14][15]

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 [9][12]

Diagnostic Assessment[edit | edit source]

Diagnosis of chronic proctalgia relies on clinical symptoms of recurring pain in d rectum lasting 20 minutes or more.[16] 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[edit | edit source]

  • 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[edit | edit source]

The first line of treatment most commonly provided is reassurance that pain is benign and is not suggestive of malignanacy[17]

Diazepam; a study revealed that hot sitz baths and or diazepam were effective for relieving pain in 68% of 316 chronic proctalgia patients[18]

Physiotherapy Management[edit | edit source]

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[edit | edit source]

References[edit | edit source]

  1. Simren M, Palsson OS, Whitehead WE. Update on Rome IV criteria for colorectal disorders: implications for clinical practice. Current gastroenterology reports. 2017 Apr 1;19(4):15.
  2. Drossman DA, Thompson WG, Talley NJ, Funch-Jensen P, Janssens J, Whitehead WE. Identification of sub-groups of functional gastrointestinal disorders. Gastroenterology International. 1990;3(4):159-72.
  3. 3.0 3.1 3.2 3.3 Drossman L, Chey WE, Kellow J, Tack J, Whitehead WE. Functional gastrointestinal disorders; disorders of gut-brain interaction. The Rome Foundation. 2016.
  4. 4.0 4.1 4.2 4.3 Rao SS, Bharucha AE, Chiarioni G, Felt-Bersma R, Knowles C, Malcolm A, Wald A. Anorectal disorders. Gastroenterology. 2016 May 1;150(6):1430-42.
  5. Bharucha AE, Lee TH. Anorectal and pelvic pain. InMayo Clinic Proceedings 2016 Oct 1 (Vol. 91, No. 10, pp. 1471-1486). Elsevier.
  6. Whitehead WE, Wald A, Diamant NE, Enck P, Pemberton JH (2000) Functional disorders of the anus and rectum. 2nd ed. Drossman DA, Corazziari E, Talley NJ, Thompson WG, Whitehead WE, editors. Rome II: The Functional Gastrointestinal Disorders. McLean: Degnon Associates 483-542
  7. 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.
  8. 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.
  9. 9.0 9.1 Gilliland R, Heymen JS, Altomare DF, Vickers D, Wexner SD. Biofeedback for intractable rectal pain: outcome and predictors of success. Dis Colon Rectum. 1997;40:190–196. [PubMed] [Google Scholar]
  10. 10.0 10.1 Salvati EP. The levator syndrome and its variant. Gastroenterol Clin North Am. 1987;16:71–78.[PubMed] [Google Scholar]
  11. Salvati EP. The levator syndrome and its variant. Gastroenterol Clin North Am. 1987;16:71–78.[PubMed] [Google Scholar]
  12. 12.0 12.1 Wald A. Functional anorectal and pelvic pain. Gastroenterol Clin North Am. 2001;30:243–51, viii-ix.[PubMed] [Google Scholar]
  13. . Renzi C, Pescatori M. Psychologic aspects in proctalgia. Dis Colon Rectum. 2000;43:535–539.[PubMed] [Google Scholar]
  14. Wald A, Bharucha AE, Enck P, Rao SSC. Functional anorectal disorders. 3rd ed. Drossman DA, Corazzairi E, Delvaux M, Spiller RC, Talley NJ, Thompson WG, and Whitehead WE, editors. Rome III: The Functional Gastrointestinal Disorders. McLean: Degnon Associates; 2006. pp. 639–685. [Google Scholar]
  15. Whitehead WE, Wald A, Diamant NE, Enck P, Pemberton JH, and Eao SSC. Functional disorders of the anus and rectum. 2nd ed. Drossman DA, Corazziari E, Talley NJ, Thompson WG, and Whitehead WE, editors. Rome II: The Functional Gastrointestinal Disorders. McLean: Degnon Associates; 2000. pp. 483–542. [Google Scholar]
  16. Drossman DA, Li Z, Andruzzi E, Temple RD, Talley NJ, Thompson WG, Whitehead WE, Janssens J, Funch-Jensen P, Corazziari E. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci. 1993;38:1569–1580. [PubMed] [Google Scholar]
  17. Wald A. Functional anorectal and pelvic pain. Gastroenterol Clin North Am. 2001;30:243–51, viii-ix.[PubMed] [Google Scholar]
  18. Grant SR, Salvati EP, Rubin RJ. Levator syndrome: an analysis of 316 cases. Dis Colon Rectum. 1975;18:161–163. [PubMed] [Google Scholar]