Patients with anorectal and pelvic pain often present to the colorectal surgeon with debilitating symptoms. It is estimated that such symptoms affect as many as 6.6% of the population, but only a third of these patients will seek medical care. Although a diagnosis can usually be made, it is often difficult to completely relieve the patient’s symptoms. Most patients with anorectal pain have organic disease such as hemorrhoids, a fissure, a fistula, or an abscess, or they have postoperative anorectal pain. Treating the underlying cause resolves the pain. This chapter specifically addresses the less common and less treatable causes of anorectal and pelvic pain, such as chronic proctalgia, proctalgia fugax, and coccygodynia.
Although these three syndromes are frequently clustered together, only chronic proctalgia and proctalgia fugax are considered functional, in that an organic cause of anorectal pain is not identifiable. The Rome III criteria are helpful in differentiating chronic proctalgia from proctalgia fugax. These criteria separate chronic proctalgia into levator syndrome and unspecified anorectal pain syndrome depending on findings of a digital rectal examination.
A General Approach
In patients with anal, rectal, or pelvic pain, an anorectal inspection, digital rectal examination, anoscopy, rigid sigmoidoscopy, and/or flexible sigmoidoscopy help rule out treatable conditions such as an anal fissure, an anal fistula, hemorrhoidal disease, inflammatory bowel disease, malignancy, and radiation proctitis. In some circumstances, imaging studies such as plain pelvic radiographs, a computed tomography (CT) scan, pelvic magnetic resonance imaging (MRI), dynamic pelvic MRI defecography, and endoanal ultrasound may be useful. Treatment strategies depend on the diagnosis but are aimed at relieving the patient’s anxiety and pain. First and foremost, patients must be reassured that their symptoms are genuine and part of a well-recognized condition. Then they are reassured that a serious organic problem does not exist. A number of pain-relieving treatments may be suggested, such as warm baths, muscle relaxants, nonsteroidal antiinflammatory drugs (NSAIDs), calcium channel blockers, pelvic massage, electrogalvanic stimulation, local anesthetic/steroid injections, botulinum toxin A (Botox) injections, and biofeedback. Psychological evaluation and treatment also may prove beneficial. Sacral nerve stimulation, which is currently approved by the FDA for the treatment of fecal incontinence, may play a role in some patients. Unfortunately, much of the data regarding treatment strategies are based on case series or small randomized trials. Furthermore, permanent relief or “cure” of these functional problems is frequently not attainable, which can be frustrating for the patient and surgeon alike. Refractory cases are best managed by pain management specialists and/or psychiatrists.
According to the Rome III criteria, three criteria must be met for a diagnosis of chronic proctalgia: the patient must experience chronic or recurrent anorectal pain, the pain must last longer than 20 minutes, and organic causes of the pain (e.g., coccygodynia [described in a subsequent section]) must be excluded. Levator syndrome is differentiated from unspecified anorectal pain syndrome by the presence of levator tenderness upon digital rectal examination.
Levator Ani Syndrome
Levator syndrome is more common in women than in men and is most commonly diagnosed in patients aged between 30 and 60 years. The pain is a dull, aching, pressure sensation that typically is more frequent and gets progressively worse throughout the day. Patients may describe feeling the need to defecate or the feeling that they are sitting on a ball. Pain also may radiate to other areas such as the lower back, vagina, thighs, and perineum. Exacerbating factors include sitting and defecation. Irritable bowel syndrome and pelvic floor dysfunction are present in a majority of the patients. Because of this association, investigation with a defecography or dynamic pelvic MRI may be useful. Nearly a third of the patients have psychological illnesses such as anxiety and depression. Upon digital rectal examination, tenderness is more common upon palpation of the left levator ani muscle.
The cause of levator syndrome is unknown; common theories include spasm of the pelvic floor, inflammation of the levator, or tendinitis of the arcus tendon. Although there is no definitive proof of these theories, treatment strategies are aimed at these possibilities. A majority of cases of levator syndrome are idiopathic, but in a subset of patients, levator spasms are triggered by local trauma such as pelvic surgery, anorectal surgery, and rigid proctoscopy. Of course, anal fissures, anorectal sepsis, pelvic tumors, and prostatitis also may cause secondary levator spasm. These are not considered functional because an organic cause of the symptoms is identifiable.
First, patients should be reassured that there is no malignancy or organic cause for their symptoms but that there is a recognized reason for the pain. Whereas most patients find this information comforting, some may feel “disappointed” that there is no easy surgical or medical remedy. Simple maneuvers that should be utilized by most patients include warm baths, NSAIDs, and muscle relaxants (e.g., diazepam, 5 mg twice a day to three times a day). In patients with underlying psychiatric conditions, antidepressants or anxiolytics may be helpful.
Levator massage and electrogalvanic stimulation (EGS) also may be beneficial. These techniques are used in conjunction with the aforementioned measures. Levator massage is carried out by means of a digital rectal examination, with firm massage of the levator muscles in an attempt to relax the spasm. To be effective, this massage should be performed with the use of some form of anesthetic. Although digital massage is beneficial in the short term, the benefits seem to diminish with time. EGS is also used to treat muscle spasticity. An anal probe is used to deliver low-frequency oscillating current to the pelvic floor muscles. This treatment induces muscle fasciculation and prolonged fatigue, which breaks the cycle of spasm. Again, short-term success is more common than long-term symptom relief.
Botox injection into the levator muscles has been associated with relief of pain in case reports, but a randomized controlled trial in 12 patients revealed no difference between persons who received Botox injections and those who received saline solution injections. Injection of trigger points with a local anesthetic and triamcinolone has also been used with varying success. Sacral nerve stimulation is not currently approved by the FDA for use in pelvic pain syndromes, but a few studies have shown promise.
Major limitations to assessing the literature include variable selection criteria, the lack of a clear definition of outcomes, variable follow-up, and few randomized trials. The randomized trials that have been reported are limited by small sample sizes, inappropriate control groups, and bias as a result of crossover of treatment arms. Chiaroni et al performed a prospective randomized controlled trial to compare the effectiveness of biofeedback, EGS, and levator massage in conjunction with psychological counseling. In patients with levator ani tenderness upon examination, adequate pain relief was achieved in 87% with biofeedback, in 45% with EGS, and in 22% with levator massage. An overall decrease in pain days per month and decreased pain intensities were observed that were maintained for 12 months. In addition, patients with adequate pain relief were able to relax the pelvic floor muscles and evacuate a water-filled balloon regardless of the treatment used, supporting the association of pelvic floor dyssynergia and levator syndrome. Patients without reproducible pain on a rectal examination experienced no benefit from any of the aforementioned treatments.
We have reviewed our experience with patients with levator syndrome. In the 12-year period from 2002 to 2013, 863 patients had 1574 encounters. Patient ages ranged from 25 to 85 years, with an average of 56 years. Sixty percent of the patients were women. Of the 863 patients diagnosed with levator syndrome, 3.3% (n = 29) underwent some form of procedure (Botox or a steroid/analgesic injection). Of the 29 surgical patients, two thirds were men (n = 19) and one third were women (n = 10). Twenty-one patients (14 male and 7 female) underwent Botox injections either via CT guidance or directly in the operating room (one to five times; 60 to 200 units total per injection). Eight of the 21 patients received only one Botox injection, whereas 10 received a second injection, 2 received a third injection, and 1 patient received 5 injections. Two patients also had a trial of steroid injections. Ten patients who received Botox injections (48%) reported initial improvement, whereas 11 (52%) had no improvement at 2-month follow-up. In addition to continuing medical management, all initial responders and three nonresponders received additional Botox injections. All patients experienced recurrence of symptoms within the 12-month follow-up. Ten patients (seven male and three female) underwent triamcinolone (Kenalog)/local anesthetic injections into the affected levator tendon in the operating room (one to six times; 20 to 120 mg Kenalog total). Six of these patients had more than one injection. Fifty percent had initial improvement at 6-week follow-up. Four of those patients (80%) continued with medical management and received no further injections. The five nonresponders, and one initial responder received additional steroid injections. Despite this additional treatment, all but one patient experienced some recurrence within a year. This single patient has been symptom-free for more than 3 years. No complications were reported for either the Botox or steroid injections.