rectal pain

[NorthernDoc]

heres the scenario...80 y.o male suffering from severe rectal pain for 3 months ...only when standing , walking or when he has gas. frequent severe nocturnal pains however . No pain when sitting.

No pertinent history...other than AF, and BPH. Has been investigated by Gastro and colorectal surgeons with rectoscopy , colonoscopy, has seen a urologist...all negative.

Has done a lumbar scan that shows severe spinal stenosis at L4-L5 , but nothing lower. L5-S1 completely normal.

on exam...no pain in the legs...neuro normal...sphincter tone normal, bulbocavernous normal , sensation pinprick and light touch in S2-S4 dermatomes normal, straight leg raise normal....the only element is reproduction of pain on digital palpation of the posterior wall of rectum. no mass, no bleeding.

Now my question is, levator ani syndrome? its not proctalgia fugax since it is constant when standing...

Have you ever seen spinal stenosis give rectal symptoms, outside of a cauda equina syndrome of course...which in this case would be ruled out because of normal neuro exam...

what other exam would u do? or would you just treat symptomatically? and levator ani syndrome...any experience with that?

any help would be greatly appreciated

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[clubdeac]

Do rectal EMG. If you think you're treating levator ani syndrome - which is usually brought on by prolonged sitting and defacation - treat with sitz baths, muscle relaxants and digital massage 3-4x/week

 

[axm397]

pelvic PT

 

[Prof Moriarty]

So we've got:

• 80 yo male
• severe rectal pain for 3 months
• ONLY when standing, walking, or w/ gas
• No pain when sitting

Questions:

• The onset was sudden or gradual?
• Where in the rectum exactly?
• How did it start? He just started having constant pain one day?
• What's the quality of the pain? Burning, dull, stabbing, aching?
• The pain is "constant"? At what level on the 10 pt scale? Does it range over the course of the day? Is there a pattern to when it is better/worse? Does anything make it better or worse?

frequent severe nocturnal pains however .

In what position? Lying down in bed? Face down/up? On his side?

No pertinent history...other than AF, and BPH.

• No hx of trauma? A fall? Sitting a lot? Change in behavior prior to onset?
• How many BM's a day? Pain w/ BM?

what other exam would u do?

Seated/standing lateral xray of sacrum/coccyx?

You do acupuncture? If he has a totally negative workup but he's in pain you could treat symptomatically w/ acupuncture.

 

[Sushrutha]

It can be isolated S3 dorsal root radiculopathy?. If all other inflamatory, infective and oncologic causes ruled out can be isolated neuritis from vitamin deficiencies B12 /Riboflavin/Nicain. It looks like a compressive dorsal radiculopathy.

I am not an expert!!!!!!!!! just trying

 

[foxtrot]

Try a diagnostic ganglion impar nerve block. By the way, what technique do most folks out there use for the gang imp block? I did one as a fellow because my staff felt like they never worked and low and behold it didn't work. But an n of 1 does not convince me otherwise.

 

[axm397]

I go through the sacrococcygeal ligament - most of the time I can just use a 25 gauge 1.5 inch - sometimes I will use a 22gauge if the anatomy is not as clear and needle is hard to see. I've done about 4 coccydynia patients in the past 5 months and it has worked well for all but one. We did a couple for rectal pain 2/2 to cancer in fellowship - didn't work very well for that.

 

[clubdeac]

Yeah I'd recommend the sacrococcygeal ligament approach. So much simpler than the anococcygeal ligament approach where you have to put a huge near 90 degree bend in your needle. I did the anococcgeal approach a few times in fellowship and got the nice comma contrast pattern but my attending was freaking out every time cause my needle was within mm of the bowel. It didn't work for the patient's I tried it on but I've heard many get better results for coccydynia like axm said

 

[lobelsteve]

Straight through the ligament under lateral fluoro.
27 1.25 in thin folks, 25 3.5 in Georgians.

0.5cc contrast to get the teardrop shape when just inside the ligament. Go AP to make sure you're midline.

4cc marcaine.

If it works for 3-6 months, repeat. If it works for a few days, consider 4cc 50-100% ETOH. Have had good success and do 1-2 impar per month.

 

[foxtrot]

Thanks for the techniques. Does anyone have any pictures in the lateral view? I looked online but didn't see much.

 

[lovebailey2001]

Thanx Lobesteve, It is really scary to by traditional technique, I do by sacro cocx lig., now happy to know that bigwigs are doing same! does anybody use steroid also? I used for perirectal burning (severe) in Ca prostate patient and it was completely gone till his demise some 4 mths. after.

 

[joshmir]

it sounded like you said the pain was reproducible by palpating at the site...

doesn't that rule out the idea that the pain is referred from irritation of a neurological structure proximally?

 

[powermd]

Straight through the ligament under lateral fluoro.
27 1.25 in thin folks, 25 3.5 in Georgians.

0.5cc contrast to get the teardrop shape when just inside the ligament. Go AP to make sure you're midline.

4cc marcaine.

If it works for 3-6 months, repeat. If it works for a few days, consider 4cc 50-100% ETOH. Have had good success and do 1-2 impar per month.

Do you inject any local before the ETOH?

 

[lobelsteve]

Do you inject any local before the ETOH?

2-3cc 2% lido.

But if for a neuroma- will go straight etoh to prevent dilution, distant spread, and too much volume. 1cc/cm for stumps and scars of 50-100% etoh is how I was taught. Small n, but how often is anyone doing neurolytics?

 

[NorthernDoc]

Thank you all for your sound advice. This patient has become very demanding and time consuming. Over 1 month has past since my first evaluation. I have tried the conservative approach as suggested by most of you with very little improvement.

Lyrica, flexeril, Statex PRN. (small doses as this pt is 87), stool softeners. Pelvic physio which seems to give temporary 2-3 days relief. Sietze baths and digital massage to relax the spastic rectal sphincter.

I am still perplexed at the nature of this pain, exacerbated by gas and the passage of stool. No pain on walking or standing. No coccygeal pain on palpation. no neurogenic claudication in the legs.

My next option if no improvement is a caudal epidural (in the benzon textbook, it is suggested for perineal pain...never used it for that indication in the past, but worth a try...). Here in montreal, i have not found anyone performing impar blocks, and seeing his age, pretty sure the sacrococcygeal ligament would be calcified and difficult to perforate...

 

[lonelobo]

If calcified just crunch through it

 

[axm397]

impar blocks are just as easy as caudals and more likely to help - just advance in the lateral after you identify midline on the AP.

 

[lobelsteve]

impar blocks are just as easy as caudals and more likely to help - just advance in the lateral after you identify midline on the AP.

Impar blocks are easier than caudals. Finding the midline is as easy as looking at the butt crack. Use a lateral and advance through the ligament, shoot 0.5cc Omni and see the teardrop shape ventral to the sc ligament. Fire away.
In an 87 y/o the 27 1.25 will get you there, and prevent you from getting into bowel.

 

[joseppi]

sounds like levator ani syndrome, cause can sometimes be a simple as bering down for BM, muscle goes into spasm and that is what is painful. YOu should be able to palpate is the perineal area, even see increased muscle tone. Why not do the injection first, straight into area palpable of most tenderness, contrast to verify muscle flow pattern.
Waiting around conservatively for one month or more in severe pain doesn't seem like what I'd want for myself if it were me.😱 Diagnostic and therapeutic.

There are some small studies on this, and have seen impressive results in residency. Seems in older patients as well. Older lady and she had complete resolution of pain on followup, prior could not even sit in chair with out pain.

Thank you all for your sound advice. This patient has become very demanding and time consuming. Over 1 month has past since my first evaluation. I have tried the conservative approach as suggested by most of you with very little improvement.

Lyrica, flexeril, Statex PRN. (small doses as this pt is 87), stool softeners. Pelvic physio which seems to give temporary 2-3 days relief. Sietze baths and digital massage to relax the spastic rectal sphincter.

I am still perplexed at the nature of this pain, exacerbated by gas and the passage of stool. No pain on walking or standing. No coccygeal pain on palpation. no neurogenic claudication in the legs.

My next option if no improvement is a caudal epidural (in the benzon textbook, it is suggested for perineal pain...never used it for that indication in the past, but worth a try...). Here in montreal, i have not found anyone performing impar blocks, and seeing his age, pretty sure the sacrococcygeal ligament would be calcified and difficult to perforate...