Abstract
A study was undertaken to assess the evaluation and treatment of chronic intractable rectal pain. Sixty consecutive patients, 23 males and 37 females with a mean age of 69 (range, 29–87) years and a mean length of symptoms of 4.5 years, were evaluated by questionnaire, office examination, anal manometry, electromyography, cinedefecography, and pudendal nerve study. In all cases, organic abdominopelvic and anorectal etiologies for the pain were excluded by extensive radiologic and endoscopic evaluation. All patients had failed conservative and medical therapy. Ninety-five percent of patients had one or more associated factors: constipation or dyschezia (57 percent), prior pelvic surgery (43 percent), prior anal surgery (32 percent), prior spinal surgery (8 percent), irritable bowel syndrome (10 percent), or psychiatric disorders (depression or anxiety; 25 percent). Possible etiologies for the pain included levator spasm or anismus in 62 percent, coccygodynia in 8 percent, and pudendal neuropathy in 24 percent of patients. Therapy for pain control included electrogalvanic stimulation (EGS) in 29, biofeedback (BF) in 14, and steroid caudal block (SCB) in 11 patients. Pain control was assessed by an independent observer at a mean of 15 (range, 2–36) months after completion of therapy. Continued successful pain relief was classified by patients as good or excellent after EGS in 38 percent, after BF in 43 percent, and after SCB in 18 percent; overall success was reported by 47 percent of patients. The presence of levator spasm, coccygodynia, or pudendal neuropathy did not influence outcome. The routine use of physiologic investigation of rectal pain may not be justifiable. Moreover, more than half of the patients were refractory to all three therapeutic options used in this study.
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Neill ME, Swash M. Chronic perianal pain: an unsolved problem. J R Soc Med 1982;75:96–101.
Swash M. Chronic perianal pain. In: Henry MM, Swash M, eds. Coloproctology and the pelvic floor. Pathophysiology and management. London: Butterworths, 1985:388–92.
Marti M-C. Essential anorectal pain or idiopathic perianal pain. In: Marti M-C, Givel J-C, eds. Surgery of anorectal diseases with pre- and postoperative management. London: Springer-Verlag, 1990:239–41.
Boisson J, Debbasch L, Bensaude A. Algies anorectalis essentielles. Arch Fr Mal Appar Dig 1966;55; 3–24.
Rubin RJ. Proctalgia fugax. In: Fazio V, ed. Current therapy in colon and rectal surgery. Philadelphia: BC Decker, 1990:68–71.
Grimaud J-C, Bouvier M, Naudy B, Guien C, Salducci J. Manometric and radiologic investigations and biofeedback treatment of chronic idiopathic anal pain. Dis Colon Rectum 1991;34:690–5.
Bleijenberg G, Kuijpers HC. Treatment of the spastic pelvic floor syndrome with biofeedback. Dis Colon Rectum 1987;30:108–11.
Kuijpers HC, Bleijenberg G, deMorrel H. The spastic pelvic floor syndrome, large bowel obstruction caused by pelvic floor dysfunction: a radiologic study. Int J Colorectal Dis 1986;1:44–8.
Grant SR, Salvati EP, Rubin RJ. Levator syndrome: an analysis of 316 cases. Dis Colon Rectum 1975;18:161–3.
Sohn N, Weinstein MA, Robbins RD. The levator syndrome and its treatment with high voltage electrogalvanic stimulation. Am J Surg 1982;144:58–2.
Nicosia JF, Abcarian H. Levator syndrome: a treatment that works. Dis Colon Rectum 1985;28:406–8.
Oliver GC, Rubin RJ, Salvati EP, Eisenstat TE. Electrogalvanic stimulation in the treatment of levator syndrome. Dis Colon Rectum 1985;28:662–3.
Thiele GH. Tonic spasm of the levator ani, coccygeus and piriformis muscles: its relationship to coccygodynia and pain in the region of the hip and down the leg. Trans Am Proc Soc 1936;37:145–55.
Smith WT. Levator spasm syndrome. Minn Med 1959;42:1076–9.
Winnie AP, Hartman JT, Meyers HL,et al. Pain clinic II: intradural and extradural corticosteroids for sciatica. Anesth Analg 1972;51:990–9.
Swerdlow M, Sayle-Creer W. The use of extradural injections in the relief of lumbosciatic pain. Anesthesia 1970;25:128.
Prithvi PR. Epidural steroids. In: PR Prithvi, ed. Practical management of pain. Chicago: Year Book Medical Publishers, 1986:682–6.
Wexner SD, Marchetti F, Salanga VD, Corredor C, Jagelman DG. Neurophysiologic assessment of the anal sphincters. Dis Colon Rectum 1991;34:606–12.
Wexner SD, Daniel N, Jagelman DG. Colectomy for constipation: physiologic investigation is the key to success. Dis Colon Rectum 1991;34:851–6.
Wexner SD, Marchetti F, Jagelman DG. The role of sphincteroplasty for fecal incontinence reevaluated: a prospective physiologic and functional review. Dis Colon Rectum 1991;34:22–30.
Salvati EP. The levator syndrome and its variants. Gastroenterol Clin North Am 1987;16:71–8.
Pilling LF, Swenson WM, Hill JR. The physiologic aspects of proctalgia fugax. Dis Colon Rectum 1965;8:372–6.
Maroy B. Spontaneous and evoked coccygeal pain in depression. Dis Colon Rectum 1988;31:210–5.
Thompson WG, Heaton KW. Proctalgia fugax. J R Coll Physicians Lond 1980:14:247–8.
Billingham RP, Isler JT, Friend WG, Hostetler J. Treatment of levator syndrome using high-voltage electrogalvanic stimulation. Dis Colon Rectum 1987;30:584–7.
Bartram CI, Mahieu PH. Radiology of the pelvic floor. In: Henry MM, Swash M, eds. Coloproctology and the pelvic floor. Pathophysiology and management. London: Butterworths, 1985:160–2.
Shorvon PJ, McHugh S, Somers S, Stevenson GW. Defecography findings in young healthy volunteers. Gut 1987;28:A1361–2.
Whitehead WE, Winget C, Fedoravicius AS, Wooley S, Blackwell B. Learned illness behavior in patients with irritable bowel syndrome and peptic ulcer. Dig Dis Sci 1982;27:202–7.
Whitehead WE, Schuster MM. Gastrointestinal disorders: behavioral and physiological basis for treatment. New York: Academic Press, 1985.
Blanchard EB, Schwarz SP, Neff DF. Two-year follow-up of behavioral treatment of irritable bowel syndrome. Behav Ther 1988;19:67–73.
Wald A. Use of biofeedback in treatment of fecal incontinence in patients with meningomyelocele. Pediatrics 1981;68:45–9.
Cerulli MA, Nikoomanesh P, Schuster MM. Progress in biofeedback conditioning for fecal incontinence. Gastroenterology 1979;76:742–6.
Keren S, Wager Y, Heldenberg D, Golan M. Studies of manometric abnormalities of the rectoanal region during defecation in constipation and soiling children: modification through biofeedback therapy. Am J Gastroenterol 1988;83:827–31.
Weber J, Ducrotte P, Touchais JY, Roussignol C, Denis P. Biofeedback training for constipation in adults and children. Dis Colon Rectum 1987;30:844–6.
Dahl J, Lindquist BL, Tysk C, Leissner P, Philipson L, Jarnerot G. Behavioral medicine treatment in chronic constipation with paradoxical anal sphincter contraction. Dis Colon Rectum 1991;34:769–76.
Wexner SD, Cheape JD, Jorge JM, Heymen S, Jagelman DG. Prospective assessment of biofeedback for the treatment of paradoxical puborectalis contraction. Dis Colon Rectum 1992;35:145–50.
Jorge JM, Wexner SD. A practical guide to basic anorectal physiology. Contemp Surg (in press).
Lievre JA, Bloch-Michel H, Attali P. L'injection transsacree: etude clinique et radiologique. Bull Mem Soc Med Hop Paris 1957;73:1110–8.
Kelman H. Epidural injection therapy for sciatic pain. Am J Surg 1944;64:183–90.
Greenwood JJ, McGuire TA, Kimbell F. A study of the causes of failure in the herniated intervertebral disc operation. J Neurosurg 1952;9:15–20.
Wexner SD, Jagelman DG. Pilonidal sinus, pre-sacral cysts and tumors and pelvic pain. In: Zuidema GD, Condon RE, eds. Surgery of the alimentary tract. 3rd ed. Philadelphia: WB Saunders, 1991:390–405.
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Read at the meeting of The American Society of Colon and Rectal Surgeons, San Francisco, California, June 7 to 12, 1992.
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Ger, G.C., Wexner, S.D., Jorge, J.M.N. et al. Evaluation and treatment of chronic intractable rectal pain—A frustrating endeavor. Dis Colon Rectum 36, 139–145 (1993). https://doi.org/10.1007/BF02051169
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DOI: https://doi.org/10.1007/BF02051169