Low Anterior Resection- chronic peri-rectal pain

[DesertDoc16]

---

Members do not see this ad.

I have a patient patient (also a fellow doc) with chronic peri-rectal pain after LAR for rectal CA. S/P chemo/radiation. 3 years out, Cancer free and back to work but terrible peri-rectal pain that radiates to coccyx area, worse at end of day, worse after BM, deep throbbing/aching pain. I don’t deal with a lot of pelvic pain in my practice (I’m part of an Ortho group), but did a fair amount in fellowship.

Was going to start with ganglion impar block
Gabapentin, maybe try TCA
Any role for trial of pudendal block or hypogastric plexus block?
Know of any rectal suppository analgesics that can help?
Any luck with S2 DRG for these cases?

Thanks in advance, this is a good dude, young guy and one of our own who’s life was turned upside down with stage 3 rectal cancer out of the blue. F*ck cancer.

 

[Agast]

Ganglion impar block for sure. BTW you will have to bill/code it as a coccyx joint (small joint) injection to get it approved. I don’t think you’re going to get the coverage you want with the superior hypogastric plexus block. Pudendal maybe. There’s OTC lidocaine cream for rectal use. Preparation H has a version. I would also start Nortriptyline now. I have one rectal patient who loves it. I’m assuming your patient is already doing stool softeners.

 

[painfree23]

Ganglion impar block for sure. BTW you will have to bill/code it as a coccyx joint (small joint) injection to get it approved. I don’t think you’re going to get the coverage you want with the superior hypogastric plexus block. Pudendal maybe. There’s OTC lidocaine cream for rectal use. Preparation H has a version. I would also start Nortriptyline now. I have one rectal patient who loves it. I’m assuming your patient is already doing stool softeners.

Ever RF ganglion impar? Results?

 

[Agast]

Ever RF ganglion impar? Results?

We used phenol in fellowship for neurolysis and it worked great. I’m not keen on putting an RF probe in there but it’s supposed to work as well.

 

[DesertDoc16]

Ganglion impar block for sure. BTW you will have to bill/code it as a coccyx joint (small joint) injection to get it approved. I don’t think you’re going to get the coverage you want with the superior hypogastric plexus block. Pudendal maybe. There’s OTC lidocaine cream for rectal use. Preparation H has a version. I would also start Nortriptyline now. I have one rectal patient who loves it. I’m assuming your patient is already doing stool softeners.

This group is awesome

Thank you, ya… stool softeners are used.

Good call on the coccyx joint billing

I love nortriptyline too, wasn’t sure how much it would help in this situation, I’ll make sure we start it

I’ll look into the OTC lidocaine!

 

[DesertDoc16]

We used phenol in fellowship for neurolysis and it worked great. I’m not keen on putting an RF probe in there but it’s supposed to work as well.

What about pulsed RF?

 

[DOctorJay]

Oreos posted some images previously for coccyx RFA. Search for those or reach out to him directly if you want to include in your treatment.

 

[lobelsteve]

What about pulsed RF?

Go for it, no downside. If effective and not long lasting, cook it with thermal.

 

[Baron S]

I did a traditional RFA a few months ago for chronic coccydynia. Guy had complete relief for about 2 months but then came back. No adverse effects, just not as long of relief as I had hoped.

 

[painfree23]

Go for it, no downside. If effective and not long lasting, cook it with thermal.

I did a traditional RFA a few months ago for chronic coccydynia. Guy had complete relief for about 2 months but then came back. No adverse effects, just not as long of relief as I had hoped.

22g?

 

[Agast]

I did a traditional RFA a few months ago for chronic coccydynia. Guy had complete relief for about 2 months but then came back. No adverse effects, just not as long of relief as I had hoped.

I have a patient who needs alternating coccyx RFA and L5/S1 interlaminar for tailbone pain.

 

[Baron S]

22g?

Yeah that would work. I use a 54mm curved tip. I tried just doing an impar block with a 25g a bit ago and it did not go well, need more oomf to get it there.

 

[lobelsteve]

20g standard rf needle

 

[DesertDoc16]

Go for it, no downside. If effective and not long lasting, cook it with thermal.

Thanks.
Ya, I went through his CT to see how far rectum is from anterior border of the coccyx. I’m assuming you just advance enough so that the the non-insulated portion of the RF needle tip is beyond the anterior border of the sacrum in lateral projection (using trans-sacrococcygeal ligament approach)?