Guidelines of chronic pelvic pain

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Guidelines of chronic pelvic pain

Postby Alyssa » 21 Oct 2014, 22:20

2/14 Fissure developed
3/14 Diagnosed w/ fissure given Nifedipine
4/14 Referred to Pelvic Floor Physical Therapy=Pelvic Floor Dysfunction
5/14 Fissure declared "healed"/chronic anal pain persists
9/5/14 Botox to pelvic floor
9/22 biofeedback
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Re: Guidelines of chronic pelvic pain

Postby Alyssa » 30 Oct 2014, 11:25

5.1 Introduction
This chapter describes CPP perceived to be associated with the gastrointestinal tract, which is mainly due to
functional disorders and cannot be explained by structural or specific well-defined diseases of the pelvis.
Some points to note:
• There may be a considerable overlap of the gastrointestinal with other pelvic pain syndromes.
• Defined gastrointestinal conditions with specific structural defects and diseases may coexist.
• Behavioural changes such as straining can lead to organic diseases such as rectal prolapse, solitary
rectal ulcer syndrome, or pudendal nerve injury with consecutive faecal incontinence.Some structural
gastrointestinal abnormalities (e.g., postpartum anal sphincter defects, or small rectoceles) are often
observed in asymptomatic individuals and may be coincidental with the gastrointestinal pelvic pain
• Different diseases can aggravate previously asymptomatic functional disorders which may become
symptomatic such as faecal incontinence in patients with diarrhoea of different origins or anal fissure
in patients with dyssynergic defecation.
• Finally, we need to consider that all functional disorders such as anorectal pain are defined on the
basis of retrospectively evaluated longstanding symptoms, which ideally would have been registered
prospectively with symptom diaries (1,2).
5.2 Clinical history
Functional anorectal disorders are diagnosed by symptoms, supplemented by objective findings. The
predominant symptoms that patients are interviewed about are discomfort or pain in relation to their bowel
habits, daily activities, and eating. A precise history of dysfunctional voiding or defecation should be asked,
ideally applying symptom questionnaires for urinary and anorectal symptoms (e.g., Rome III questionnaire
for anorectal pain). Excessive straining at most defecations, anal digitations in dyssynergic defecation, and a
sensation of anal blockage may be found in patients with chronic anal pain. History of anxiety and depression
with impaired QoL is often encountered in anorectal functional disorders and should be evaluated.
5.2.1 Clinical examination and investigations
At clinical examination, perianal dermatitis may be found as a sign of faecal incontinence or diarrhoea.
Fissures may be easily overlooked and should be searched thoroughly in patients with anal pain. Rectal digital
examination findings may show high or low anal sphincter resting pressure, a tender puborectalis muscle in
patients with the Levator Ani Syndrome, and occasionally increased perineal descent. The tenderness during
posterior traction on the puborectalis muscle differentiates between Levator Ani Syndrome and Unspecified
Functional Anorectal Pain and is used in most studies as the main inclusion criterion. Dyssynergic (paradoxical)
contraction of the pelvic muscles when instructed to strain during defecation is a frequent finding in patients
with pelvic pain. Attention should be paid to anal or rectal prolapse at straining, and ideally during bimanual
examination by the gynaecologist to diagnose an enterocele or cystocele.
5.2.2 Diagnostic assessment
The Rome III criteria for diagnosis of functional anorectal diseases include symptoms for each specific
functional disorder as listed below. The gastrointestinal diagnostic assessment should be performed in an
interdisciplinary manner, preferably at a pelvic floor centre by a dedicated team, and appropriate testing. The
most frequently performed investigations are flexible rectosigmoidoscopy or colonoscopy, pelvic ultrasound,
anorectal endosonography and anorectal manometry combined with anal electromyography (EMG) and balloon
expulsion test. Three-dimensional anorectal ultrasound has become an indispensable readily available tool for
the specialised proctologist. Perineal ultrasound offers the advantage of sphincter imaging without insertion of
the transducer into the rectum.
Magnetic resonance imaging in conjunction with MR defecography has become the most valuable
imaging technique to assess anorectal function dynamically. Magnetic resonance imaging studies outline
simultaneously the anatomy of the pelvic floor and allow us to visualise different structural and functional
pathologies, by applying dynamic sequences after filling of the rectum with a viscous contrast medium (e.g.,
ultrasound gel). The following pathologies can be visualised: pelvic floor descent, an abnormal anorectal angle
while squeezing and straining, rectal intussusception, rectocele, enterocele and cystocele. However, limitations
of MR defecography are the left lateral position and the limited space for the patient, which may reduce the
ability to strain and hereby reduce the sensitivity of the method, underestimating the size of entero- and
rectoceles as well as the amount of interception.
Surgical consultations should be available for all patients, plus referral to a urogynaecologist
or urologist when indicated. Biofeedback treatment, botulinum toxin A injection, and percutaneous tibial nerve
stimulation (PTNS) and sacral neurostimulation (SNS) should be available as a complementary therapeutic
option to medical and surgical treatment.
5.3 Pain associated with well-defined conditions
5.3.1 Haemorrhoids
Chronic pelvic pain is rare in haemorrhoidal disease because endoscopic and surgical treatment is mostly
effective in acute disease. The most frequent aetiology of pain without significant bleeding is thrombosed
external haemorrhoids or an anal fissure. Haemorrhoidal pain on defecation associated with bleeding is
usually due to prolapse or ulceration of internal haemorrhoids. Anaemia from haemorrhoidal bleeding is rare
but may arise in patients on anticoagulation therapy, or those with clotting disorders. Different treatments of
haemorrhoids have been evaluated by two systematic Cochrane reviews.
Excisional haemorrhoidectomy (EH) has been compared to the less-invasive technique of rubber band
ligation (RBL), and has been shown to increase pain, with more complications and time off work. However,
despite these disadvantages of EH, complete long-term cure of symptoms is increased by surgery, and
minor complications are accepted by patients (3). Rubber band ligation is the choice of treatment for grade
II haemorrhoids, whereas EH should be reserved for grade III haemorrhoids or recurrence after RBL (3). New
stapler techniques of haemorrhoidopexy are associated with a higher long-term risk of recurrence and prolapse
compared to conventional EH. Further studies are needed (4).
5.3.2 Anal fissure
Anal fissures are tears in the distal anal canal and induce pain during and after defecation. The pain can last for
several minutes to hours. Persistence of symptoms beyond 6 weeks or visible transversal anal sphincter fibres
define chronicity. Fissures located off the midline are often associated with specific diseases such as Crohn’s
disease or anal cancer. Internal anal sphincter spasms and ischaemia are associated with chronic fissures.
Medical therapy with nitrates and calcium channel blockers resulting in anal sphincter relaxation is
more effective in children than in adults (5). Recently, 2% diltiazem ointment has been shown to be superior to
glyceryl trinitrate in terms of time to healing and recurrence rate in children with anal fissure (6).
In adults, 75 RCTs with 17 agents were analysed by a Cochrane review (5). Nitroglycerin ointment
(GTN), isosorbide mono & dinitrate, botulinum toxin A, diltiazem and nifedipine (calcium channel blockers) were
found to be marginally better than placebo, but less efficacious than surgical sphincterotomy. Botulinum toxin
A injection represents an alternative treatment option with a fissure healing rate which is comparable to topical
diltiazem after 3 months (7). Surgery with lateral-internal sphincterotomy is the most studied procedure but
carries the risk of postoperative faecal incontinence, and may be replaced by fissure excision combined with
botulinum toxin A or anal advancement flap (8).
5.3.3 Proctitis
Abdominal and pelvic pain in patients with inflammatory bowel disease and proctitis are often difficult to
interpret. Faecal calprotectin may help to differentiate between inflammation and functional pain, to spare
steroids. Tricyclic antidepressants at low dose can be effective in this situation when acute exacerbation has
been ruled out (9,10).
5.3.4 Irritable bowel syndrome
Although IBS can be associated with pelvic pain, the authors of these guidelines consider a full discussion of
this topic beyond the scope of these guidelines. A number of high quality clinical guidelines address this topic
5.4. Chronic anal pain syndrome
5.4.1 Diagnostic criteria for chronic anal pain syndrome (chronic proctalgia) according to the Rome III
criteria are as follows and must include all of the following:
1. Chronic or recurrent rectal pain or aching.
2. Episodes last at least 20 min.
3. Exclusion of other causes of rectal pain such as ischaemia, inflammatory bowel disease, cryptitis,
intramuscular abscess and fissure, haemorrhoids, prostatitis, and coccygodynia.
These criteria should be fulfilled for the past 3 months with symptom onset at least 6 months before diagnosis
The chronic anal pain syndrome includes the above diagnostic criteria and exhibits exquisite tenderness
during posterior traction on the puborectalis muscle (previously called “ Levator Ani Syndrome”). This common
and debilitating condition is frustrating to treat. Pathophysiology of pain is thought to be due to overactivity
of the pelvic floor muscles. Chiarioni et al. have recently published an RCT demonstrating that biofeedback
treatment was superior to electrogalvanic stimulation and massage for treatment of the chronic anal pain
syndrome. One hundred and fifty-seven patients who had at least weekly rectal pain were investigated, but
only patients with tenderness on traction of the pelvic floor showed a significant treatment benefit. Eightyseven
percent of patients with tenderness of the puborectalis muscle (Rome II: Highly likely Levator Ani
Syndrome) reported adequate relief after one month of biofeedback versus 45% for electrogalvanic stimulation,
and 22% for massage. These results were maintained at 12 months with adequate relief after nine sessions
of biofeedback in 58% of the whole group (Rome II: Highly likely and Possible Levator Ani Syndrome),
after galvanic stimulation in 27% and massage in 21% of patients. As previously described in dyssynergic
defecation, the ability to expel a 50-ml water-filled balloon and to relax pelvic floor muscles after biofeedback
treatment were predictive of a favourable therapeutic outcome (13). The pathophysiology of the chronic anal
pain syndrome is therefore similar to that of dyssynergic defecation, and this favours the role of the pelvic floor
muscles in the pathophysiology of both conditions. Other treatment modalities have been less successful.
5.4.2 Botulinum toxin A in pelvic pain
Chronic pelvic pain associated with spasm of the levator ani muscles and treatment of the puborectalis and
pubococcygeus muscle by botulinum toxin A appears to be promising in some women, as shown in a pilot
study (n = 12). The inclusion criteria were dependent only on vaginal manometry with overactivity of the pelvic
floor muscles, defined as a vaginal resting pressure > 40 cm H2O. Although dyspareunia and dysmenorrhea
improved, non-menstrual pelvic pain scores were not significantly ameliorated (14). In the following doubleblinded,
randomised, placebo-controlled trial, the same group defined pelvic floor myalgia according to the
two criteria of tenderness on contraction and hypertension (> 40 cm H2O) and included 60 women. In this
larger study, non-menstrual pelvic pain was significantly improved compared to that treated with placebo (VAS
score 51 vs. 22; P = 0.009). It was concluded therefore that botulinum toxin A is effective for reducing pelvic
floor-muscle associated pain with acceptable adverse effects such as occasional urinary and faecal stress
incontinence (15). However, recently, a small RCT failed to show any benefit of botulinum toxin A (16).
5.4.3 Sacral neurostimulation and percutaneous tibial nerve stimulation in pelvic pain
In a large cohort of 170 patients with functional anorectal pain from the St. Mark’s Hospital (Harrow, Middlesex,
United Kingdom) sacral nerve stimulation was used in 3 patients (2 improved) while biofeedback was the
most used modality with the greatest treatment effect in patients with defecatory dysfunction (29 patients,
17 improved) (17). Sacral neurostimulation has been reported to be somewhat beneficial in two uncontrolled
studies, showing improvement in about half the patients (18,19). Sacral neurostimulation may be a choice in
patients with CPP who failed to respond to biofeedback and drug therapy. The less invasive percutaneous
tibial nerve stimulation (PTNS) was tested in 12 women with CPP lasting for at least 6 months and showed an
improvement in pain, quality of life and sexual life (20). No “sham” SNS or PTNS control group were used in
neither cited studies, which limits their value as an important placebo effect cannot be ruled out.
5.4.4 Intermittent chronic anal pain syndrome (proctalgia fugax) consists of all the following
diagnostic criteria, which should be fulfilled for 3 months and before 3 months:
1. Recurrent episodes of pain localised to the anus or lower rectum.
2. Episodes last from several seconds to minutes.
3. There is no anorectal pain between episodes.
Stressful life events or anxiety may precede the onset of the intermittent chronic anal pain syndrome. The
attacks may last from a few seconds to as long as 30 min. The pain may be cramping, aching or stabbing and
may become unbearable. However, most patients do not report it to their physicians and pain attacks occur
less than five times a year in 51% of patients. Due to the short duration of the episodes, medical treatment
and prevention is often not feasible. Inhaled beta-2 adrenergic agonist salbutamol was effective in an RCT
in patients with frequent symptoms and shortened pain duration (21). Other treatment options are topic
diltiazem and botulinum toxin A (17). However, there is still some controversy as regards the duration of pain of
intermittent chronic and chronic anal pain syndrome. RCTs do often use different definitions, extending the pain
duration (with a shift to chronic pain) in order to include more patients and to better evaluate the study-drug
5.5 Summary
Chronic pelvic pain is an interdisciplinary entity needing multispeciality and multidisciplinary diagnostic
assessment by a gastroenterologist, urologist, gynaecologist and pain teams as appropriate, with the input
of physicians, psychologists and physiotherapists amongst others. Anorectal pain is investigated best by
endoscopic and functional testing to rule out structural disease that can be treated specifically. Chronic
pelvic pain due to functional disorders remains a therapeutic challenge that may respond to biofeedback
therapy, electrogalvanic stimulation and botulinum toxin A in the case of Levator Ani Syndrome and defecatory
disorders associated with pelvic pain.
5.5.1 Conclusions and recommendations: anorectal pain syndrome
Conclusions on functional anorectal pain LE
Tenderness on traction is the main criterion of the chronic anal pain syndrome. 1a
Biofeedback is the preferred treatment for the chronic anal pain syndrome. 1a
Electrogalvanic stimulation is less effective than biofeedback. 1b
Botulinum toxin is efficient in CPP with spasms. 1b
Percutaneous tibial nerve stimulation is effective in pelvic pain. 1b
Sacral neurostimulation is effective in pelvic pain. 3
Inhaled salbutamol is effective in intermittent chronic anal pain syndrome. 3
Recommendations for functional anorectal pain GR
Functional testing is recommended in patients with anorectal pain. A
Biofeedback treatment is recommended in patients with pelvic pain and dyssynergic defecation. A
Botulinum toxin A and electrogalvanic stimulation can be considered in the chronic anal pain
Percutaneous tibial nerve stimulation can be considered in the chronic anal pain syndrome. B
Sacral neurostimulation should be considered in the chronic anal pain syndrome. C
Inhaled salbutamol should be considered in the intermittent chronic anal pain syndrome. C
Figure 7: Assessment and treatment of anorectal pain syndrome
Pelvic floor
muscle testing
Rectal balloon
expulsion test
Grade A recommended
Grade B recommended
Other comments
Biofeedback treatment
Botulinum toxin A in w omen with pelvic pain
Electrogalvanic stimulation
Percutaneous tibial nerve stimulation
Sacral neuromodulation should be considered
Inhaled salbutamol should be considered in intermittent
anal pain syndrome
Algorithm 5: Diagnosis of chronic anorectal pain
5.6 References
1. Bharucha AE, Wald A, Enck P, et al. Functional anorectal disorders. Gastroenterology. 2006
2. Whitehead WE, Bharucha AE. Diagnosis and treatment of pelvic floor disorders: what’s new and what
to do. Gastroenterology. 2010 Apr;138(4):1231-5. [No abstract available]
3. Shanmugam V, Thaha MA, Rabindranath KS, et al. Rubber band ligation versus excisional
haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev. 2005 Jul;(3):CD005034.
4. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled versus conventional surgery for hemorrhoids.
Cochrane Database Syst Rev. 2006 Oct;(4):CD005393.
5. Nelson R. Non surgical therapy for anal fissure. Cochrane Database Syst Rev. 2003;(4):CD003431.
6. Cevik M, Boleken ME, Koruk I, et al. A prospective, randomized, double-blind study comparing the
efficacy of diltiazem, glyceryl trinitrate, and lidocaine for the treatment of anal fissure in children.
Pediatr Surg Int. 2012 Apr;28(4):411-6.
7. Samim M, Twigt B, Stoker L, et al. Topical diltiazem cream versus botulinum toxin a for the treatment
of chronic anal fissure: a double-blind randomized clinical trial. Ann Surg. 2012 Jan;255(1):18-22.
8. Valizadeh N, Jalaly NY, Hassanzadeh M, et al. Botulinum toxin injection versus lateral internal
sphincterotomy for the treatment of chronic anal fissure: randomized prospective controlled trial.
Langenbecks Arch Surg. 2012 Oct;397(7):1093-8.
Endoscopy normal
Tenderness of puborectalis muscle
* Anorectal manometry
* Balloon expulsion test
* MRI-Defecography
Anorectal pain syndrome
Specific disease guidelines
* Biofeedback
* Electro stimulation
* Physical therapy
Chronic anorectal pain
yes no
Refer to specialist
pain management unit
yes no
Dysfunction present
9. Halpert A, Dalton CB, Diamant NE, et al. Clinical response to tricyclic
2/14 Fissure developed
3/14 Diagnosed w/ fissure given Nifedipine
4/14 Referred to Pelvic Floor Physical Therapy=Pelvic Floor Dysfunction
5/14 Fissure declared "healed"/chronic anal pain persists
9/5/14 Botox to pelvic floor
9/22 biofeedback
Posts: 735
Topics: 26
Joined: 29 Apr 2014, 11:24
Location: San Jose, CA
Has thanked: 136 times
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Gender: Female

Re: Guidelines of chronic pelvic pain

Postby Alyssa » 30 Oct 2014, 11:35

6.1 Neuropathic pain
Much has been written on the subject of peripheral neuropathic pain (1-4) including its diagnosis and
treatment. There are some fundamental principles that are worth considering:
1. Nerve injury is associated with changes both within the peripheral nervous system (PNS) and the
central neural axis including the higher centres. These changes serve to produce an increasing
disparity between stimulus and response (Chapter 2).
2. In the PNS, nerve damage may produce a neuroma that can provide a source of ongoing afferent
central activity. The neuroma may be discreet and palpable to touch or en-passage and not palpable.
Neuromas are sensitive and respond to: compression (e.g., by the surrounding tissue or digital
pressure), temperature change and adrenergic stimulation. Sympathetic nerve fibres can grow into
neuromas as well as the associated dorsal root ganglia, which may result in sensitivity to body
adrenaline changes such as through mood and environment with subsequent changes in pain.
3. Windup is a progressive increase in centrally elicited action potentials per unit peripheral stimulus.
A severe acute insult or a chronic repeated stimulus may result in a transient windup phenomenon
becoming permanent through immediate gene activation and neurochemical and structural neuronal
changes within the CNS. These long-term changes in central sensitisation are associated with
dysfunction of the afferent sensory nervous system and perception, as well as efferent motor,
vasomotor and pseudomotor activity within the pathways of the injured nerve (5).
4. These central changes may result in abnormal afferent processing for nerves other than those
originally damaged, so that increased perception (pain, allodynia and hyperaesthesia) from an area
greater than the expected pattern may occur. In the case of tissues with innervation that overlaps with
an injured nerve, somatic and visceral hypersensitivity (e.g., sensory urge with increased frequency of
voiding/evacuation) may be perceived from those tissues.
Essentially, what may be considered a simple nerve injury may be magnified by the CNS so that a
whole region may be involved and a non-specific regional pain syndrome may arise. There is also
a suggestion that involvement of both the peripheral and CNS in the control of the endocrine and
immunological system may also become abnormal. Certainly, there is a complex interaction between
nerve injury, emotional well being, disability and widespread pain. A proportion of patients go on to
develop CFS, FM and immunological disorders (6-8).
6.2 Anatomy
When considering pelvic pain mechanisms, nerves associated with the pelvis/genitalia are generally divided
into thoraco-lumbar and sacral root afferents. The hypogastric plexus is mixed autonomic (sympathetic and
parasympathetic) and may contain afferents associated with pain.

The inferior anorectal branch may never be a true branch of the pudendal nerve, and may have its origins
directly from the sacral roots. As a consequence, pain associated with pudendal nerve injury may not involve
the anorectal area. Similarly, pain may only be perceived in the anorectal area if the main pudendal nerve is not
involved. In 11% of cases, the inferior anorectal nerve pierces the sacrospinal ligament, possibly increasing the
risk of entrapment. Other variations of the anorectal branch exist with the nerve branching off from the main
pudendal nerve at any point in the gluteal region or within the pelvis. In 56% of cases, the pudendal nerve is a
single trunk as it re-enters the pelvis.
6.3 Aetiology of nerve damage
6.3.1 Anterior groin nerves - aetiology of nerve damage
The primary afferents of the anterior groin nerves enter the spinal cord at the thoracolumbar level (T10 to L3).
Thoracolumbar spinal pathology and any pathology along the course of the nerve may result in neuropathic
pain in the distribution of these nerves. As well as neoplastic disease, infection and trauma, surgical incisions
and postoperative scarring may result in nerve injury (21-23).

6.3.2 Pudendal neuralgia - aetiology of nerve damage
Anatomical variations
Anatomical variations may predispose the patient to developing pudendal neuralgia over time or with repeated
low-grade trauma (such as sitting for prolonged periods of time or cycling) (9,12).

6.3.3 Surgery
In orthopaedic hip surgery, pressure from the positioning of the patient, where the perineum is placed hard
against the brace, can result in pudendal nerve damage (24,25). The surgery itself may also directly damage
the nerve. Pelvic surgery such as sacrospinous colpopexy is clearly associated with pudendal nerve damage
in some cases (26,27). In many types of surgery, including colorectal, urological and gynaecological, pudendal
nerve injury may be implicated.
Sacral nerve roots. The S2-S4 nerve roots may be involved. This is an important differential diagnosis as
tumours must be excluded.

Referred spinal pain
Pain from thoracolumbar pathology may refer to the groin. Spinal pain may become associated with muscle
hyperalgesia and trigger points. The muscle associated pain may spread to involve a range of muscles,
including the pelvic floor muscles with resultant pelvic pain.
Musculoskeletal disorders
Trigger points associated with localised tenderness and pain may be detected in the piriformis, obturator
internus, levator ani, bulbocavernosal and ischeocavernosal muscles, as well as the gluteal, adductor, rectus
abdominus and spinal muscles. All of these may refer the pain to or close to the pelvis.
Pathology of the joints (sacroiliac, pubic symphysis, hip and spinal) may also refer into the pelvis.
Coccyx pain syndrome, a painful coccyx may occur for a number of reasons (Chapter 2).
2/14 Fissure developed
3/14 Diagnosed w/ fissure given Nifedipine
4/14 Referred to Pelvic Floor Physical Therapy=Pelvic Floor Dysfunction
5/14 Fissure declared "healed"/chronic anal pain persists
9/5/14 Botox to pelvic floor
9/22 biofeedback
Posts: 735
Topics: 26
Joined: 29 Apr 2014, 11:24
Location: San Jose, CA
Has thanked: 136 times
Been thanked: 41 times
Gender: Female

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