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MattiV.Kairaluoma

Syndroma Pelvis Spastica

Essentials

  • 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.
  • NSAIDs and spasmolytes may be effective in some cases.
  • If needed, proctalgia fugax can be treated with topical nitrate ointment Anal Fissure or with an oral calcium channel blocker.
  • 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.
  • Trigger points identified in the levator muscle can be treated with injections containing local anaesthetic and corticosteroid.
  • In especially troublesome cases, sacral nerve stimulation can be tried 2.

    References

    • Salvati EP. The levator syndrome and its variant. Gastroenterol Clin North Am 1987 Mar;16(1):71-8. [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]