Functional and Chronic Anorectal and Pelvic Pain Disorders




Several organic and functional disorders of the urinary bladder, reproductive tract, anorectum, and the pelvic floor musculature cause pelvic pain. This article describes functional disorders in which chronic pelvic and anorectal pain cannot be explained by a structural or other specified pathology. Currently, these functional disorders are classified into urogynecologic conditions or cystitis and painful bladder syndrome, anorectal disorders, and the levator ani syndrome. Although nomenclature suggests that these conditions are distinct, there is considerable overlap of their symptoms and these disorders have much in common.


Several organic and functional disorders of the urinary bladder, reproductive tract, anorectum, and the pelvic floor musculature cause pelvic pain. This article describes functional disorders in which chronic pelvic and anorectal pain cannot be explained by a structural or other specified pathology. Currently, these functional disorders are classified into urogynecologic conditions (ie, chronic prostatitis and chronic pelvic pain syndrome [CP-CPPS] or interstitial cystitis and painful bladder syndrome [IC-PBS]); anorectal disorders (ie, proctalgia fugax); and the levator ani syndrome. Although these disorders are defined by predominant pain, they can be associated with functional disturbances (ie, disordered voiding or defecation). Although this nomenclature suggests that these conditions are distinct, there is considerable overlap of their symptoms, which is perhaps inevitable because the urogenital tract and anorectum are in proximity and intimately related to the levator ani, because visceral discomfort is poorly localized, and because pelvic floor dysfunctions can impair urogenital and anorectal functioning. Indeed, these disorders have much in common. Not only is there overlap among urogynecologic symptoms (eg, CP, benign prostatic hypertrophy, and IC) but also between pain in the urinary bladder (eg, in IC) and sacrum, coccyx, and anus.


Cardinal features of chronic functional anorectal and urogynecologic disorders include the following:




  • Disorders are diagnosed by symptoms, supplemented by objective findings in IC



  • Predominant symptom is discomfort or pain; patients may also have dysfunctional voiding or defecation



  • Frequently associated with impaired quality of life, anxiety, and depression



  • Pathophysiology is barely studied and poorly understood; visceral hypersensitivity and pelvic floor dysfunction may play a role



  • Therapy is guided by clinical features; therapeutic approaches have not been rigorously tested in clinical trials



Before symptom questionnaires were available, reports of these disorders were based on physician-coded diagnoses, and diagnostic criteria probably varied among studies. Although validated symptom questionnaires for urinary and anorectal symptoms are available ( Table 1 ), diagnostic criteria, particularly for urogynecologic conditions, are not established. These differences may partly explain why prevalence estimates vary across and even within studies.



Table 1

Symptom questionnaires for chronic pelvic disorders



















Condition Questionnaire
Lower urinary tract symptoms in men with benign prostatic hypertrophy AUA Symptom Index
Men with chronic prostatitis and chronic pelvic pain syndrome National Institutes of Health Chronic Prostatitis Symptom Index
Interstitial cystitis and painful bladder syndrome Interstitial Cystitis Symptom Index
Functional anorectal pain Rome III Questionnaire


Functional anorectal pain


Based on clinical features, the Rome III criteria recognize two forms of functional anorectal pain: levator ani syndrome and proctalgia fugax. In the levator ani syndrome, pain is generally prolonged (ie, lasts for hours); is constant or frequent; and is characteristically dull. In proctalgia fugax, the pain is brief (ie, lasting seconds to minutes); occurs infrequently (ie, once a month or less often); and is relatively sharp. This classification system does not include coccygodynia, which refers to patients with pain and point tenderness of the coccyx, as a separate entity. Most patients with rectal, anal, and sacral discomfort have levator rather than coccygeal tenderness.


Levator Ani Syndrome


Definition


The levator ani syndrome is also called levator spasm, puborectalis syndrome, chronic proctalgia, pyriformis syndrome, and pelvic tension myalgia. The levator ani syndrome is characterized by relatively constant or frequent dull anorectal pain, often associated with tenderness to palpation of the levator ani but not urinary symptoms or an organic disease that can explain pain.


Epidemiology


The prevalence of symptoms compatible with levator ani syndrome in the general population is 6.6%. More than 50% of affected people are aged 30 to 60 years, and it is more common in women (7.4% of all women) than in men (5.7% of all men). Although disability associated with levator ani syndrome can be significant, only 29% of people with levator pain had consulted a physician. In a postal survey of 5430 adults, people with levator ani syndrome reported missing an average of 17.9 days from work or school in the past year, and 11.5% reported that they were currently too sick to work or go to school. There are no published data on the frequency with which the levator ani syndrome is encountered in medical practice.


Pathophysiology


Tenderness to palpation of pelvic floor muscles in chronic pelvic pain and levator ani syndrome may reflect visceral hyperalgesia or increased pelvic floor muscle tension, the pathophysiology of which is unknown. Uncontrolled observations suggest that patients may have increased anal pressures or electromyogram activity. Higher anal pressures may reflect increased external or internal anal sphincter tone. Inability to relax pelvic floor muscles suggests pelvic floor dysfunction. It is unclear if the association between chronic pelvic pain and psychosocial distress on multiple domains (eg, depression and anxiety, somatization, and obsessive-compulsive behavior) reflects an underlying cause or an effect of pain.


Clinical features


The diagnosis is based on characteristic symptoms in the absence of anorectal and pelvic pathophysiology. The diagnostic criteria are 12 weeks, which may not be consecutive, of the following:



  • 1.

    Chronic or recurrent rectal pain or aching, and


  • 2.

    Episodes last 20 minutes or longer, and


  • 3.

    Other causes of rectal pain, such as ischemia, inflammatory bowel disease, cryptitis, intramuscular abscess, fissure, hemorrhoids, prostatitis, and solitary rectal ulcer, have been excluded



The pain is often described as a vague, dull ache, or pressure sensation high in the rectum. It is often worse with sitting than with standing or lying down. Physical examination may reveal overly contracted levator ani muscles and pelvic floor tenderness to palpation. For unknown reasons, tenderness is often asymmetric and more frequently affects the left than the right side. The diagnosis is considered to be highly likely if patients have symptoms and abnormal physical signs and possible if patients have symptoms but not tenderness to levator palpation.


Patients with levator ani syndrome have significant elevations on the hypochondriasis, depression, and hysteria scales of the Minnesota Multiphasic Personality Inventory. This pattern occurs in chronic pain patients and is often referred to as the “neurotic triad”. Although clinical observations suggest that levator ani syndrome is frequently associated with an impaired quality of life, there is limited evidence in this regard.


Treatment


Appropriate testing (eg, sigmoidoscopy, defecography, ultrasound, or pelvic MRI) to exclude other causes of pain (eg, Crohn’s disease, anal fissures) and to identify associated conditions (eg, defecatory disorders) should be performed as necessary. There are no controlled studies of treatments for chronic intractable anorectal pain. Although uncontrolled studies suggest that electrogalvanic stimulation, biofeedback training, digital massage of the levator ani muscles, and sitz baths may be effective, management of chronic intractable anorectal pain can be a “frustrating endeavor”. Electrogalvanic stimulation improved pain in 10 of 27 patients in one study. In a study of 316 patients with the levator syndrome, 68% of patients reported “good results” after a combination of massage; sitz baths; muscle relaxants; and diathermy (method unspecified). The technique for levator massage is described later. Biofeedback therapy improved pain but had variable effects on anal pressures. Hot sitz baths may alleviate pain not only by counterirritation but also because immersion in hot water may reduce anal pressures in patients with anorectal pain. Ultrasound-guided injection of local anesthetics or alcohol for pelvic nerves (eg, pudendal nerve) is of unproved efficacy.


If the patient’s distress or other circumstances require that treatment be undertaken, the only advice that can be offered at present is to do no harm; select a treatment, such as biofeedback, that has no significant adverse consequences. Surgery should be avoided.


Proctalgia Fugax


Definition


Proctalgia fugax is defined by sudden, severe intermittent pain in the anal area lasting several seconds or minutes in the absence of an organic disorder to explain pain.


Epidemiology


The prevalence of proctalgia fugax has been difficult to determine because sufferers tend not to report episodes to their physician except in the most severe cases. The estimated prevalence ranges from 8% to 18% and is comparable in men and women. Symptoms rarely begin before puberty.


In the US Householder Study, subjects with proctalgia fugax missed an average of 12.8 days from work or school in the past year, and 8.4% of them reported that they were currently too ill to work or attend school. It is unknown, however, if the reported disability was the result of proctalgia fugax, which seems unlikely, or other disorders in these patients.


Pathophysiology


The pathophysiology of proctalgia fugax is unclear and is entirely based on small case reports, which observed increased myoelectric activity and anal resting pressure during episodes of proctalgia. An uncontrolled study suggested that most patients were perfectionistic, anxious, or hypochondriacal. A hereditary form of proctalgia fugax associated with hypertrophy of the internal anal sphincter has also been reported.


Clinical features


The diagnosis is based on characteristic symptoms in the absence of anorectal and pelvic pathophysiology. The criteria are 12 weeks, which may not be consecutive, of the following:



  • 1.

    Recurrent episodes of pain localized to the anus or lower rectum, and


  • 2.

    Episodes last from seconds to minutes, and


  • 3.

    There is no anorectal pain between episodes.



Attacks are generally not related to a specific triggering factor, are often precipitated by stressful life events or anxiety, and may last from a few seconds to as long as 30 minutes. In a study of 148 patients of whom one third had proctalgia fugax, the pain was localized to the anus in 90% of patients, occurred less than five times a year in 51%, and lasted less than 1 minute in 57%. In most, activity was not interrupted by this pain and only 20% had ever reported it to a physician. The pain has been described as cramping, gnawing, aching, or stabbing; may range from uncomfortable to unbearable; and radiates infrequently.


Management


For most patients, the episodes of pain are so brief that remedial treatment is impractical. Because symptoms occur infrequently, prevention is not feasible. The emphasis is on reassurance and explanation. For patients with frequent symptoms, treatment may be considered. In a randomized controlled trial, the inhaled β 2 -adrenergic agonist salbutamol was more effective than placebo for shortening the duration of episodes of proctalgia. The α 2 -adrenergic agonist clonidine reduced symptoms in a single patient. Coexistent psychologic issues should be addressed with behavioral or pharmacologic therapies.

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Feb 26, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Functional and Chronic Anorectal and Pelvic Pain Disorders

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