A syndrome with pain deep in the rectal area or in the pelvic floor
The pain may be intermittent or continuous.
Up to 85% of chronic, recurrent anorectal pain has been reported as being functional, i.e. with no structural or inflammatory cause 1.
Types of pain
According to the Rome IV Criteria, functional anorectal pain is divided into levator ani syndrome, unspecified functional anorectal pain and episodic pain (proctalgia fugax) 2.
In levator ani syndrome and in unspecified functional pain, pain episodes recur, with a duration of more than 30 minutes at a time, or the pain is constant with exacerbations.
Levator ani syndrome involves tenderness of the levator ani muscle on palpation, which does not occur in unspecified anorectal pain.
Proctalgia fugax pain is brief and occurs irregularly 23.
Myofascial pain is a part of functional anorectal pain. Myofascial pain often involves trigger points and muscle tension.
Aetiology
Levator ani syndrome is believed to be due to a spasm of the levator muscle and excessive tension. The site of the pain reflects the localization of the spastic portion of the muscle.
Muscle tension is thought to compress nerve endings and lead to the sensation of pain.
Typical symptoms include dull pain and a feeling of pressure precipitated by prolonged sitting and alleviated by standing up or lying down.
The syndrome may be associated with a pelvic floor muscle coordination disorder, anismus. Levator ani syndrome may involve coccygodynia.
In unspecified anorectal pain, there is no tenderness of pelvic floor muscles on palpation.
It may be associated with surgery in the pelvic floor area or with inflammation, endometriosis or rectal intussusception in the lesser pelvis.
Psychogenic factors may play a role in the experience of pain.
Myofascial pain is often associated with some other organ disorders, such as dyspareunia, constipation, vulvodynia or bladder pain.
Investigation
Most cases of recurrent anorectal pain (about 85%) are functional.
The primary tasks in primary health care are careful history taking and clinical examination to exclude any signs of severe disease.
Factors to consider
The patient's age and any underlying diseases
Description of the symptoms (duration of symptoms, any symptom that is getting constantly worse, any associated symptoms, bowel movements, appetite, weight changes, etc.)
Clinical examination: general examination, location of the pain, tenderness of the coccyx, gynaecological examination
EMG of the pelvic floor (performed by a physiotherapist; not available in all units)
Further investigation should be done in specialized care as necessary in selected cases.
Colonoscopy if a disease of the colon (tumour, inflammation) is suspected
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.
Treatment
In mild and rapidly passing states of pain experienced as affecting the quality of life only mildly, information of the benign nature of the symptom is usually sufficient.
If needed, proctalgia fugax can be treated with warm sitz baths and, as necessary, topical nitrateAnal Fissure or diltiazem ointment.
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.
Muscle tension can also be treated with botulin injections.
Trigger points identified in the levator muscle can be treated with injections containing local anaesthetic and glucocorticoid.
In especially troublesome cases, sacral nerve stimulation can be tried.
References
Chiarioni G, Nardo A, Vantini I, et al. Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome. Gastroenterology 2010;138(4):1321-9 [PubMed]
Simren M, Palsson OS, Whitehead WE. Update on Rome IV Criteria for Colorectal Disorders: Implications for Clinical Practice. Curr Gastroenterol Rep 2017;19(4):15 [PubMed]
Bharucha AE, Lee TH. Anorectal and Pelvic Pain. Mayo Clin Proc 2016;91(10):1471-1486 [PubMed]
Andromanakos NP, Kouraklis G, Alkiviadis K. Chronic perineal pain: current pathophysiological aspects, diagnostic approaches and treatment. Eur J Gastroenterol Hepatol 2011;23(1):2-7 [PubMed]
Aboseif S, Tamaddon K, Chalfin S, Freedman S, Kaptein J. Sacral neuromodulation as an effective treatment for refractory pelvic floor dysfunction. Urology 2002 Jul;60(1):52-6. [PubMed]