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MattiV.Kairaluoma

Functional Pelvic Floor Pain (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.
  • 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 2 3.
  • 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.
  • NSAIDs may be effective in some cases.
  • If needed, proctalgia fugax can be treated with warm sitz baths and, as necessary, topical nitrate Anal 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]