Evaluation and management of chronic anorectal and pelvic pain syndromes: Italian Society of Colorectal Surgery (SICCR) position statement.

Chronic pelvic pain is a hidden issue which needs to involve many different usually uncoordinated specialists. For this reason there is a risk that treatments, in the absence of well-defined pathways, common goals, and terminology, may be poorly effective. The aim of the present paper is to summarize the evidence on anorectal pelvic pain, offering useful evidence-based practice parameters for colorectal surgeons' daily activity. Analysis of chronic anorectal and pelvic pain syndromes, the diagnostic and clinical optimal needs for evaluation, and the innumerable low evidence treatments and therapeutic options currently available suggests that a multimodal individualized management of pain may be the most promising approach. The limited availability of dedicated centers still negatively affects the applicability of these principles.

Dyssynergic Defecation and Other Evacuation Disorders.

Constipated patients are frequently referred to gastroenterologists for symptoms refractory to lifestyle modifications and laxatives. Dyssynergic defecation, the dyscoordination of rectoanal, abdominal, and pelvic floor muscles to facilitate defecation, is a major cause of refractory primary constipation. Understanding of the diagnosis, evaluation, and management of dyssynergic defecation and other evacuation disorders will allow providers to effectively manage these patients. This review focuses on the definition, pathophysiology, evaluation, and treatment of dyssynergic defecation and other evacuation disorders. Emerging treatments for these disorders include home biofeedback therapy for dyssynergic defecation and translumbosacral neuromodulation therapy for levator ani syndrome.

Proctalgia Syndromes: Update in Diagnosis and Management.

PURPOSE OF REVIEW: Functional anorectal pain syndromes are a neglected yet often disabling clinical entity resulting in significant economic and psychological burden to the patient. The aim of this review is to update the practicing gastroenterologist/coloproctologist on the diagnosis and management of these complicated disorders. RECENT FINDINGS: The updated Rome foundation diagnostic criteria (Rome IV) for functional anorectal pain subgroups chronic proctalgia (levator ani syndrome and unspecified functional anorectal pain) and acute proctalgia (proctalgia fugax) on the basis of symptom duration and digital rectal examination findings. Chronic proctalgia is thought to be secondary to paradoxical pelvic floor contraction in many patients and biofeedback to improve the defecation effort has proven effective for over 90% in the short term. Unfortunately, management of proctalgia fugax remains challenging and treatment outcomes modest at best. A number of therapies to relax the pelvic floor may be employed to improve symptoms in functional anorectal pain syndromes; however, only biofeedback to improve defaecatory dynamics in patients with levator ani syndrome has proven effectiveness in a randomized setting. Further investigation of treatment approaches in proctalgia fugax is required.

Botulinum toxin A versus electrogalvanic stimulation for levator ani syndrome: is one a more effective therapy?

BACKGROUND: Levator ani syndrome (LAS) is a functional disorder that can be a challenge to treat. LAS that is refractory to medical management may be treated with electrogalvanic stimulation (EGS) or Botulinum toxin A (BTX) injection. The aim of the present study was to evaluate the outcomes associated with both EGS and BTX in patients with medically refectory LAS to determine if either demonstrate a long-term benefit or whether one treatment is better than the other. METHODS: A retrospective study was performed on consecutive patients with LAS treated with BTX or EGS at our institute. Patients were identified from a prospectively maintained database. The study time frame was 6 years. RESULTS: One hundred and twenty patients [80 females, mean age 52 years (range 21-84, SD 15.8)] were treated for medically refractory LAS: 102 with BTX and 18 with EGS. With EGS, 28.6% of patients reported a complete response, 14.3% reported a partial response and 57.1% reported no response to treatment. With BTX, 35.5% of patients reported a complete response, 19.7% reported a partial response and 44.7% reported no response to treatment. There was no difference between BTX and EGS with regard to treatment response. Patients who had BTX were more likely to report a short-term benefit in treatment when compared to those patients who had EGS (p = 0.002). This difference between reported outcome to BTX and EGS treatments did not sustain in the long term (p = 0.2). CONCLUSIONS: Both BTX and EGS are to some extent effective at resolving symptoms of LAS. In the short term, BTX appears to be more effective. Neither treatment sustains its benefit in the long term.

A Practical Guide to Biofeedback Therapy for Pelvic Floor Disorders.

PURPOSE OF REVIEW: Biofeedback therapy (BFT) is effective for managing pelvic floor disorders (i.e., defecatory disorders and fecal incontinence). However, even in controlled clinical trials, only approximately 60% of patients with defecatory disorders experienced long-term improvement. The review serves to update practitioners on recent advances and to identify practical obstacles to providing biofeedback therapy. RECENT FINDINGS: The efficacy and safety of biofeedback therapy have been evaluated in defecatory disorders, fecal incontinence, and levator ani syndrome. Recent studies looked at outcomes in specific patient sub-populations and predictors of a response to biofeedback therapy. Biofeedback therapy is effective for managing defecatory disorders, fecal incontinence, and levator ani syndrome. Patients who have a lower bowel satisfaction score and use digital maneuvers fare better. Biofeedback therapy is recommended for patients with fecal incontinence who do not respond to conservative management. A subset of patients with levator ani syndrome who have dyssynergic defecation are more likely to respond to biofeedback therapy.

Botox treatment in patients with chronic functional anorectal pain: experiences of a tertiary referral proctology clinic.

BACKGROUND: Anorectal pain is a symptom which may have both structural and functional causes, and can, sometimes, develop into a chronic pain syndrome. Functional causes in particular are challenging to treat when conservative treatment measures fail. Botulinum toxin A (BTX-A) can be applied to relax the anal sphincter and/or levator ani muscle to break the vicious circle of pain and contraction. In our tertiary referral proctology clinic, we evaluated the outcome of patients treated with BTX-A for chronic functional anorectal pain. METHODS: Our electronic database was searched for patients who had BTX-A treatment for chronic functional anorectal pain from 2011 to 2016. All medical data concerning history, treatments, and clinical outcome were retrieved. The clinical outcome (resolution of pain) was scored as good, temporary, or poor. RESULTS: A total of 113 patients [47 (42%) males; age 51years, SD 13 years, range 18-88 years] with chronic functional anorectal pain were included. The outcome of BTX-A treatment was good in 53 (47%), temporary in 23 (20%), and poor in 37 (33%). To achieve this outcome, 29 (45%) patients needed a single treatment, 11 (44%) a second treatment, and 13 (54%) ≥ 3 treatments. CONCLUSIONS: Chronic functional anorectal pain can be treated successfully with BTX-A in 47% of patients who fail conservative management. Repeated injections may be needed to ensure complete cure in a subgroup of patients.

Perianal abscess mimicking levator ani syndrome: a case report and approach to the differential diagnosis of anorectal pain.

OBJECTIVE: To present the clinical management and comprehensive differential diagnosis of a patient with anorectal pain from a perianal abscess. CLINICAL FEATURES: A 41-year-old woman presented with pain localized to her perianal and gluteal region, accompanied by internal and external rectal pain. Prior to presentation, the patient had received a working diagnosis of levator ani syndrome. INTERVENTION AND OUTCOME: An interdisciplinary management approach was utilized. Diagnostic imaging confirmed the clinical suspicion of a perianal abscess and the patient underwent surgical drainage. SUMMARY: Anorectal pain is complex and multifactorial and a diagnosis such as an abscess should not be overlooked. This case emphasized that practitioners must be diligent in their evaluation and management of patients with anorectal pain, including recognizing situations that require further imaging and interdisciplinary management.

OBJECTIF: Présenter le traitement clinique et le diagnostic différentiel complet d'une patiente atteinte de douleur ano-rectale découlant d'un abcès périanal. CARACTÉRISTIQUES CLINIQUES: Une femme de 41 ans se présente avec une douleur dans la région périanale et fessière, accompagnée de douleur rectale interne et externe. Avant la présentation, la patiente a reçu un diagnostic de travail de syndrome du muscle élévateur de l'anus. INTERVENTION ET RÉSULTATS: On a utilisé une approche de prise en charge interdisciplinaire. L'imagerie diagnostique a permis de confirmer le soupçon clinique d'abcès périanal et la patiente a subi un drainage chirurgical. RÉSUMÉ: La douleur ano-rectale est complexe et multifactorielle; il ne faut pas négliger un diagnostic tel qu'un abcès. Ce cas souligne que les praticiens doivent faire preuve de diligence lors de leur évaluation et prise en charge des patients qui souffrent de douleur anorectale, y compris reconnaître des situations nécessitant une imagerie et une prise en charge interdisciplinaire supplémentaires.

Functional Anorectal Disorders.

This report defines criteria and reviews the epidemiology, pathophysiology, and management of common anorectal disorders: fecal incontinence (FI), functional anorectal pain and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into three subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome (LAS) and unspecified anorectal pain the pain lasts more than 30 minutes, but in LAS there is puborectalis tenderness. Functional defecation disorders are defined by >2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with >2 features of impaired evacuation i.e., abnormal evacuation pattern on manometry, abnormal balloon expulsion test or impaired rectal evacuation by imaging. It includes two subtypes; dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating LAS and defecatory disorders.

Is Botox for anal pain an effective treatment option?

PURPOSE: The aim of this study was to evaluate the efficacy of Botulinum toxin-A (Botox) in relieving anal pain associated with anal fissure (AF) and Levator ani syndrome (LS). METHODS: All patients with medically refractory AF or LS from 2005 to 2012 and treated with Botox injections were included. RESULTS: One hundred and three patients [66 patients (53 female) with AF and 37 patients (26 female) with LS] were evaluated. The minimum/maximum dose of Botox was 20/100 units for AF and 50/200 units for LS. Thirteen (19.7%) patients with AF and 14 (38%) patients with LS received > 1 Botox treatment. The time interval between injections varied from 1 to 12 months. Mean follow-up was 6.4 months for AF and 9 months for LS. Relief of anal pain was noted in 59% of AF and 43% of LS patients. Significant changes in pre- and post-op pain scores were noted in both groups. Nine out of 12 patients with failed sphincterotomy were relieved after Botox treatment. Temporary fecal incontinence was reported in 2/66 (3%) AF patients and 4/37 (10%) of LS patients. Overall, 66% patients' recommended Botox treatment and 72% were happy with the treatment as per telephone interview results. CONCLUSION: Botox relieves pain more effectively in AF than in LS. It is an effective option in medically refractory cases of LS. Higher doses of Botox are safe to use in LS; however, this needs to be evaluated. Botox injections have an overall low complication rate.

Observation on the Efficacy of Point Injection at Xialiao Point (BL 34) for Levator Ani Syndrome / 上海针灸杂志

Objective To observe the clinical efficacy of point injection at Xialiao point (BL 34) for levator ani syndrome. Methods A hundred levator ani syndrome patients were randomly allocated to a treatment group and a control group, 50 cases each. The treatment group received point injection at Xialiao point (BL 34) and the control group was intervened by biofeedback therapy. The Visual Analogue Scale (VAS), component scores of the MOS 36-item Short-From Health Survey (SF-36), anal resting and squeeze pressures were recorded in the two groups before and after the treatment. The therapeutic effects and therapy costs were compared between the two groups.Results The VAS, component scores of SF-36, anal resting and squeeze pressures were significantly changed after intervention in the two groups (P<0.05). After treatment, the VAS, a part of the SF-36 score [physiological function (PF), body pain (BP), vitality (VT) and social function (SF) scores], anal resting and squeeze pressures in the treatment group were significantly different from that in the control group (P<0.05). The total efficacy rate was 88.0% in the treatment group versus 80.0% in the control group, and the difference was statistically significant (P<0.05). The therapy costs in the treatment group were (327.31±13.42) RMB and (408.45±21.56) RMB in the control group, and the difference was statistically significant (P<0.01).Conclusions Point injection at Xialiao point (BL 34) is an effective method for levator ani syndrome.

ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders.

BACKGROUND: Anorectal disorders such as dyssynergic defecation, fecal incontinence, levator ani syndrome, and solitary rectal ulcer syndrome are common, and affect both the adult and pediatric populations. Although they are treated with several treatment approaches, over the last two decades, biofeedback therapy using visual and verbal feedback techniques has emerged as an useful option. Because it is safe, it is commonly recommended. However, the clinical efficacy of biofeedback therapy in adults and children is not clearly known, and there is a lack of critical appraisal of the techniques used and the outcomes of biofeedback therapy for these disorders. PURPOSE: The American Neurogastroenterology and Motility Society and the European Society of Neurogastroenterology and Motility convened a task force to examine the indications, study performance characteristics, methodologies used, and the efficacy of biofeedback therapy, and to provide evidence-based recommendations. Based on the strength of evidence, biofeedback therapy is recommended for the short-term and long-term treatment of constipation with dyssynergic defecation (Level I, Grade A), and for the treatment of fecal incontinence (Level II, Grade B). Biofeedback therapy may be useful in the short-term treatment of Levator Ani Syndrome with dyssynergic defecation (Level II, Grade B), and solitary rectal ulcer syndrome with dyssynergic defecation (Level III, Grade C), but the evidence is fair. Evidence does not support the use of biofeedback for the treatment of childhood constipation (Level 1, Grade D).

Sacral nerve stimulation: an effective treatment for chronic functional anal pain?

AIM: Chronic idiopathic anal pain is a common condition of unknown aetiology. Patients may have co-existing psychiatric disorders and existing treatments are often ineffective. A small number of published case reports suggest that sacral nerve stimulation (SNS) could treat this condition. This pilot study aimed to investigate the efficacy of SNS for the treatment of chronic anal pain. METHOD: Ten patients with chronic idiopathic anal pain were recruited. All had failed to respond to conservative treatments. Clinical and psychological evaluation was performed in all patients prior to SNS. Temporary stimulation of the S3 foramina was performed for 3 weeks and outcome assessed by comparison of a pain score diary and visual analogue score obtained during stimulation and at baseline. Primary outcome was defined as a > 50% reduction in pain score. RESULTS: Of the 10 patients recruited, five were found to have clinical depression. Four patients withdrew from the study prior to testing and six underwent peripheral nerve evaluation (PNE). Three patients had > 50% reduction in pain score and progressed to permanent SNS. Of these, only one had good pain control at latest follow-up of 5 years; the remaining two patients obtained no benefit and had their devices removed or deactivated. These two patients both had depression that was also not improved by SNS. CONCLUSION: This study would suggest that SNS is not an effective treatment for chronic anal pain in the majority of patients. PNE is not an effective means of identifying which of these patients are likely to respond to permanent SNS.

Chronic proctalgia and chronic pelvic pain syndromes: new etiologic insights and treatment options.

This systematic review addresses the pathophysiology, diagnostic evaluation, and treatment of several chronic pain syndromes affecting the pelvic organs: chronic proctalgia, coccygodynia, pudendal neuralgia, and chronic pelvic pain. Chronic or recurrent pain in the anal canal, rectum, or other pelvic organs occurs in 7% to 24% of the population and is associated with impaired quality of life and high health care costs. However, these pain syndromes are poorly understood, with little research evidence available to guide their diagnosis and treatment. This situation appears to be changing: a recently published large randomized, controlled trial by our group comparing biofeedback, electrogalvanic stimulation, and massage for the treatment of chronic proctalgia has shown success rates of 85% for biofeedback when patients are selected based on physical examination evidence of tenderness in response to traction on the levator ani muscle--a physical sign suggestive of striated muscle tension. Excessive tension (spasm) in the striated muscles of the pelvic floor appears to be common to most of the pelvic pain syndromes. This suggests the possibility that similar approaches to diagnostic assessment and treatment may improve outcomes in other pelvic pain disorders.

The effect of intermittent levator massage with caudal block on management of levator ani syndrome: A case report.

Levator ani syndrome (LAS) is a functional disorder of the pelvic floor muscles in which recurrent and persistent distressing pain is felt in the anus without detectable organic pathology. Eighty one percent of coccygodynia was alleviated by the levator massage when the massage motion was repeated 10 to 15 times on each side of the pelvis daily for 5 or 6 days. The authors encountered the LAS patient for whom successive visit to pain clinic was economic burden. Therefore, the authors managed the patient by intermittent levator massage with caudal block, once a week for 3 times, resulting in two years of pain free status. Intermittent levator massage with caudal block may be as effective as successive levator massage and induce longer painless period in the management of LAS.

The effect of intermittent levator massage with caudal block on management of levator ani syndrome: A case report / 대한마취과학회지

Levator ani syndrome (LAS) is a functional disorder of the pelvic floor muscles in which recurrent and persistent distressing pain is felt in the anus without detectable organic pathology. Eighty one percent of coccygodynia was alleviated by the levator massage when the massage motion was repeated 10 to 15 times on each side of the pelvis daily for 5 or 6 days. The authors encountered the LAS patient for whom successive visit to pain clinic was economic burden. Therefore, the authors managed the patient by intermittent levator massage with caudal block, once a week for 3 times, resulting in two years of pain free status. Intermittent levator massage with caudal block may be as effective as successive levator massage and induce longer painless period in the management of LAS.

Anorectal Symtoms and Anorectal Pathophysiologic Findings in Patients with Levator Ani Syndrome and Protalgia Fugax / 대한소화관운동학회지

BACKGROUND/AIMS: Two most common functional anorectal pains, levator ani syndrome and proctalgia fugax, have a significant overlap in diagnosis and a controversy in pathogenic mechanism. Our aim was to evaluate the differences of anorectal symptoms and physiologic findings between the patients with levator ani syndrome and proctalgia fugax. METHODS: Eight patients and 10 patients, who fulfilled Rome II criteria for levator ani syndrome and proctalgia fugax respectively, were evaluated for the various anorectal symptoms using questionnaire and diary, anorectal manometry, balloon defecation, and defecography. RESULTS: Compared with patients with proctalgia fugax, the patients with levator ani syndrome showed higher percentage of symptoms of straining (87.5+/-30.6% vs. 40.5+/-44.9%, p<0.05), and tended to have higher percentage of the sensation of incomplete evacuation (88.1+/-26.4% vs. 53.0+/-41.9%, p=0.056). In anorectal manometric findings, squeezing pressure of the distal anal sphincter tended to be higher in patients with levator ani syndrome (201.7+/-127.7 mmHg vs. 113.0+/-43.9 mmHg, p=0.056). CONCLUSIONS: Levator ani syndrome may be related to the constipation and hyper-contractile external anal sphincter, suggesting that different mechanisms may play a role in the development of anorectal pains in patients with levator ani syndrome and proctalgia fugax.