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Chronic Proctalgia and Chronic Pelvic Pain Syndromes: New Etiologic Insights and Treatment Options

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Chronic Proctalgia and Chronic Pelvic Pain Syndromes: New Etiologic Insights and Treatment Options Online Submissions: http://www.wjgnet.com/1007-9327office World J Gastroenterol 2011 October 28; 17(40): 4447-4455 [email protected] ISSN 1007-9327 (print) ISSN 2219-2840 (online) doi:10.3748/wjg.v17.i40.4447 © 2011 Baishideng. All rights reserved. EDITORIAL Chronic proctalgia and chronic pelvic pain syndromes: New etiologic insights and treatment options Giuseppe Chiarioni, Corrado Asteria, William E Whitehead Giuseppe Chiarioni, Division of Gastroenterology of the Uni- controlled trial by our group comparing biofeedback, versity of Verona, Azienda Ospedaliera Universitaria Integrata electrogalvanic stimulation, and massage for the treat- di Verona, Valeggio sul Mincio Hospital, 37067 Valeggio sul ment of chronic proctalgia has shown success rates of Mincio, Verona, Italy 85% for biofeedback when patients are selected based Corrado Asteria, Department of Surgery and Orthopedics, on physical examination evidence of tenderness in re- General Surgery Unit, Azienda Ospedaliera Carlo Poma di sponse to traction on the levator ani muscle-a physical Mantova, Asola General Hospital, 46041 Asola, Mantova, Italy William E Whitehead, Division of Gastroenterology and Hepa- sign suggestive of striated muscle tension. Excessive tology, Division of Urogynecology, and Center for Functional tension (spasm) in the striated muscles of the pelvic Gastrointestinal and Motility Disorders, University of North floor appears to be common to most of the pelvic pain Carolina at Chapel Hill, Chapel Hill, NC 27599-7080, United syndromes. This suggests the possibility that similar States approaches to diagnostic assessment and treatment Author contributions: Chiarioni G and Whitehead WE contrib- may improve outcomes in other pelvic pain disorders. uted equally to the conceiving of the designing and the drafting of the manuscript; Asteria C provided criticism and suggestion © 2011 Baishideng. All rights reserved. of high intellectual content. Supported by In part by Grant R01 DK031369 from the NI- DDK Key words: Biofeedback; Chronic pelvic pain; Chronic Correspondence to: Giuseppe Chiarioni, MD, Division of proctalgia; Coccygodynia; Levator ani syndrome; Pu- Gastroenterology of the University of Verona, Azienda Os- dendal neuralgia pedaliera Universitaria Integrata di Verona, Valeggio sul Mincio Hospital, 37067 Valeggio sul Mincio, Verona, Peer reviewers: Guang-Yin Xu, MD, PhD, Assistant Pro- Italy. [email protected] fessor, Division of Gastroenterology, Department of Internal Telephone: +39-045-6338548 Fax: +39-045-7950188 Medicine, University of Texas Medical Branch, Galveston, TX Received: March 15, 2011 Revised: June 3, 2011 77555-0655, United States; Bhupendra Kumar Jain, Dr., MS, Accepted: June 10, 2011 Professor of Surgery and Head, Department of Surgery, GTB Published online: October 28, 2011 Hospital and University College of Medical Sciences, Delhi 110 095, India Chiarioni G, Asteria C, Whitehead WE. Chronic proctalgia and chronic pelvic pain syndromes: New etiologic insights Abstract and treatment options. World J Gastroenterol 2011; 17(40): This systematic review addresses the pathophysiol- 4447-4455 Available from: URL: http://www.wjgnet. ogy, diagnostic evaluation, and treatment of several com/1007-9327/full/v17/i40/4447.htm DOI: http://dx.doi. chronic pain syndromes affecting the pelvic organs: org/10.3748/wjg.v17.i40.4447 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 INTRODUCTION impaired quality of life and high health care costs. However, these pain syndromes are poorly understood, Chronic or frequently recurring pain in the anal canal, with little research evidence available to guide their rectum, or pelvis is a prevalent symptom that affects an diagnosis and treatment. This situation appears to estimated 6.6% of the population[1]. Although only 1/3 be changing: A recently published large randomized, of people with such pains consult physicians, they nev- WJG|www.wjgnet.com 4447 October 28, 2011|Volume 17|Issue 40| Chiarioni G et al . Biofeedback and pelvic pain ertheless report significant impairment in quality of life, idiopathic perineal pain, pyriformis syndrome, and pelvic work absenteeism, and psychological distress. However, tension myalgia. Thiele, one of the first researchers to despite its prevalence and impact, relatively little research investigate this pain syndrome, called it coccygodynia, has been published which addresses its epidemiology, although he acknowledged that the pain was not in the pathophysiology, and treatment; and pelvic and rectal coccyx[4]. To provide greater consistency in the diagnosis pain is widely considered frustrating to diagnose and and labeling of anorectal pain syndromes, the Rome Ⅲ treat. This may soon change: Our group recently report- criteria[3] define chronic proctalgia as chronic or recur- ed a randomized controlled trial[2] in which we compared rent rectal pain or aching lasting at least 20 min, in the different approaches to treating chronic proctalgia and absence of structural or systemic disease explanations showed that the results were excellent 85% success rate- for these symptoms[3]. Pain duration of at least 20 min is if the patients were appropriately screened. This study a key feature since shorter episodes of pain are sugges- also provided new insights into the pathophysiology of tive of proctalgia fugax, which is defined as a sudden, se- chronic proctalgia and stimulated renewed interest in vere pain in the anorectal region lasting less than 20 min anorectal pain syndromes. The aims of this review are to and then disappearing completely[3]. Proctalgia fugax critically assess what is known about the diagnosis and may recur, but episodes are rare. Proctalgia fugax is be- treatment of the most common forms of anorectal and lieved to have a different etiology to chronic proctalgia, pelvic pain, namely chronic proctalgia, chronic pelvic although there is no consensus on what causes it. Its pain, coccygodynia, and pudendal neuralgia. This review consideration is beyond the scope of this review, which is meant to help Gastroenterologists and Colorectal Sur- is intended to deal with chronic unremitting diseases. geons when dealing with complex consultation on pelvic Chronic proctalgia is further divided by the Rome Ⅲ pain syndromes. It is mostly focused on chronic proctal- criteria into two subtypes-levator ani syndrome (LAS) gia and issues of differential diagnosis with other pelvic and unspecified functional anorectal pain-based on the pain syndromes. presence or absence of a sensation of tenderness when One of the challenges in caring for patients with the levator muscle is palpated during digital rectal exami- anorectal and pelvic pain is that a number of inflamma- nation. This classification updates the previous Rome tory and structural etiologies must be considered. The Ⅱ classification in which LAS was designated as “highly organic diseases that are most commonly involved in likely” if traction on the pelvic floor produced a report chronic anorectal and pelvic pain are cryptitis, fissure, of tenderness and only “possible LAS” if no tender- abscess, hemorrhoids, solitary rectal ulcer, inflammatory ness was elicited[5]. Subgrouping patients with chronic bowel disease, and rectal ischemia[3]. One should also proctalgia is consistent with clinical experience of dif- consider chronic prostatitis and pelvic endometriosis as ferent response to treatment, but distinct epidemiology potential contributors to chronic pelvic pain[3]. Although and pathophysiology data are lacking[5]. Therefore, data the differential diagnosis is large and unfortunately provided mostly refer to chronic proctalgia patients as a poorly standardized, our experience[2] suggests that no whole. organic disease explanation will be found in approxi- mately 85% of patients presenting to gastroenterologists Pathophysiology with chronic anorectal or pelvic pain. We screened 227 Chronic tension or spasm of the striated muscles of the patients referred for unremitting, chronic rectal pain pelvic floor is commonly assumed to be the pathophysi- with a diagnostic evaluation that included digital rectal ological basis for chronic proctalgia[3,5-7], although there is examination, colonoscopy, pelvic ultrasound and surgical no definitive evidence for this hypothesis. Inflammation consultation in all patients, plus gynecology and urol- of the levator or arcus tendon of the levator ani muscle ogy referrals in selected cases[2]. This extensive work-up has also been suggested as a cause of chronic proctalgia, identified only 33 patients (15%) with a probable organic since tenderness on palpation is most commonly found disease accounting for their symptoms. Thus, for most on the left side where the muscle inserts into the pubic patients with chronic anorectal or pelvic pain, the origin ramus of the pelvis. However, contrary to this tendinitis of the pain is uncertain and the relevant pathophysi- hypothesis, local steroid injection has not been shown ological mechanisms are unclear. These are commonly to be an effective treatment for chronic proctalgia[8]. In defined as “functional” chronic anorectal and pelvic pain retrospective studies, many patients reported prior pel- syndromes since no structural and anatomical disease vic surgery, anal surgery and even spinal surgery as sig- was found. These functional pain syndromes constitute nificant in the development of
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