Evaluation and Management of Chronic Anal Pain

Educational Objectives

The goal of this program is to improve the management of patients with chronic anal pain. After hearing and assimilating this program, the clinician will be better able to:

1. Evaluate patients with chronic anal pain.
2. Formulate an algorithm for the treatment of levator ani syndrome.

Summary

Chronic anal pain: prevalence 7% to 24%; Rome Criteria describe 2 types, proctalgia fugax (short episodes of pain [20 sec-few minutes] with variable frequency) and chronic proctalgia (intermittent or continuous episodes of pain of >20 min); proctalgia fugax — examination necessary to exclude organic causes; condition typically benign; treatment unnecessary unless pain debilitating; can treat frequent episodes with albuterol inhaler; etiology — pain arising from levator ani muscle; outlet dysfunction constipation (ODC); chronic pelvic pain; pudendal neuralgia; coccydynia; pain after anal surgery; exclude organic cause to establish diagnosis of functional pain

Symptoms: pain usually sharp, but sometimes dull and continuous; may be initiated by trigger (eg, bowel movement, sitting for long periods); most patients experience relief at night; analgesic agents commonly relieve pain; constipation (typically associated with ODC)

Physical examination: palpate perianal regions, including coccyx, and internal anal sphincter (document locations of tenderness); if current level of pain low, perform digital rectal examination (DRE), including systematic palpation of levator ani muscle; in men with tenderness anteriorly (levator ani muscle absent), consider prostatitis; assess for paradoxical contraction during DRE by asking patient to squeeze, relax, and push; perform anoscopy to exclude organic pathology (for patients with severe pain, examination under anesthesia necessary)

Special investigations: patients with ODC require anorectal manometry with defecometry (aids in selecting and evaluating progress of treatment); magnetic resonance imaging helpful for detecting retrorectal tumors, outlet dysfunction, and enterocele; consider flexible sigmoidoscopy to look for solitary rectal ulcer

Treatment: coccydynia — obtain radiography of sacrum to exclude organic pathology; injection of corticosteroid with lidocaine effective; for ongoing symptoms, repeat injection in few months; solitary rectal ulcer — conservative treatment recommended initially, including biofeedback or bowel retraining with physical therapist; patients require extensive counseling; ODC — absence of pain common; characterized by high tone and severe tenderness of levator ani muscle; therapy focuses on treatment of constipation and, for those with pain, levator ani syndrome (LAS); hypertonic internal anal sphincter — treatment options include injection with botulinum toxin or limited sphincterotomy; chronic pelvic pain — treat as LAS; refer to urologist or urogynecologist

Treatment of LAS: helpful to present algorithm of treatment to patient; muscle relaxants — administer as first-line therapy (eg, baclofen, methocarbamol, cyclobenzaprine, risperidone); switching of agents may be helpful; diazepam can be used as second-line therapy; albuterol inhaler — for patients with continuous pain, 3 to 4 inhalations per day recommended; for patients with intermittent pain, take at onset of pain; rate of response ≈40% to 50%; other modalities — use soft pillows at home and for travel; apply heat or ice; acupuncture; pain blocks; sacral nerve stimulation (option only after patient develops fecal incontinence); pelvic floor relaxation — refer to specialized pelvic floor physical therapist; guide therapy by documenting diagnosis and prescribing recommended therapy (eg, pelvic floor relaxation for LAS; bowel retraining, pelvic floor relaxation, and trigger point release for ODC); electrogalvanic stimulation — rate of success ≈40%; typically performed in inpatient or outpatient setting, but home device also available; galvanic current fatigue muscle; not appropriate for patients who cannot tolerate anoscopy; injection with botulinum toxin — indicated after failure of less invasive options; inhibits release of acetylcholine by binding at receptor sites on terminals of motor neurons; effect lasts 3 mo, but relief of pain takes 8 to 10 days to manifest; no consensus on standard dose (speaker administers 100 U diluted in 3 mL saline); procedure performed under general anesthesia; injections administered perianally (through perineum) and concentrated in documented area of pain; do not administer into internal anal sphincter (causes incontinence); for patients who achieve initial relief, injections may be repeated in 6 to 8 wk; study (Bibi et al, 2016) shows relief of pain in ≈43% of patients with LAS, rate of recurrence (defined as need for additional injections) of 14%, and that dose of 50 U to 100 U effective

Pudendal neuralgia: characterized as pain limited to innervation territory of pudendal nerve; history of extended bicycle ride or trauma common; diagnosed by relief of pain after pudendal nerve block; refer to pain specialist

Readings

Bharucha AE, Lee TH: Anorectal and pelvic pain. Mayo Clin Proc 2016 Oct;91(10):1471-1486; Bibi S et al: Is Botox for anal pain an effective treatment option? Postgrad Med 2016 Jan;128(1):41-5; Chiarioni G et al: Chronic proctalgia and chronic pelvic pain syndromes: new etiologic insights and treatment options. World J Gastroenterol 2011 Oct 28;17(40):4447-55; Lirette LS et al: Coccydynia: an overview of the anatomy, etiology, and treatment of coccyx pain. Ochsner J 2014 Spring;14(1):84-7.

Disclosures

For this program, members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Zutshi was recorded at the 29th Annual Jagelman/39th Annual Turnbull International Colorectal Disease Symposium, presented by the Cleveland Clinic Foundation, and held April 14-17, 2018, in Fort Lauderdale, FL. For information on the next Jagelman/Turnbull International Colorectal Disease Symposium, please visit clevelandclinicmeded.com. The Audio Digest Foundation thanks the speakers and the sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

GS651601

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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