A syndrome with pain deep in the rectal area or in the pelvic floor
The pain may be intermittent or continuous.
Types of pain
The pain may be paroxysmal and even arouse the patient at night. The duration of an attack varies from a couple of minutes to a couple of hours. Such episodic pain is also called proctalgia fugax.
Another type of pain is precipitated by prolonged sitting. This more continuous pain is called coccygodynia.
The third group of pain is continuous neuralgia-type pain in the anus (idiopathic proctalgia). It most commonly occurs in elderly women without any pathological findings.
Aetiology
A spasm of the levator muscle is considered the cause of the pain. The site of the pain reflects the localization of the spastic portion of the muscle.
May be associated with surgical operations in the pelvic floor area or with inflammation, endometriosis or rectal intussusception in the lesser pelvis.
Psychogenic factors often play a role.
Investigation and treatment
Possible aetiological factors are assessed.
Investigations in the primary care:
thorough clinical examination (location of the pain, tender spots, tenderness of the coccyx etc.)
gynaecological examination (endometriosis)
EMG of the pelvic floor (may be performed by a physiotherapist; excessive muscle tension or anismus)
colonoscopy (tumour or inflammation in the colon)
Investigations in specialized care (rarely needed, only in troublesome cases):
defecography or magnetic defecography (rectal intussusception; to be suspected if the pain is associated with defecation difficulties or faecal incontinence)
MRI if necessary (cyst in the spinal nerve root canal, schwannoma etc.).
Often no clear cause for the symptom is found and the patient can be reassured of the benign nature of the symptom.
Excessive tension of the pelvic floor muscles or anismus can be treated with electrical stimulation combined with biofeedback. If the patient benefits from the treatment it can be continued with a device intended for home use 1.