Pelvic Pain Corner: Gastrointestinal and Anorectal Pelvic Pain

This article focuses on gastrointestinal (GI) and anorectal sources of pelvic pain, which are important adjuncts in our approach to pelvic pain. Addressing these contributors, especially early on, will improve the success of treatment for gynecologic, urologic, neurologic and musculoskeletal pelvic pain.

Assessment
The history should capture associated GI symptoms: rectal bleeding, black stool, nausea, vomiting or weight changes (which may indicate colorectal cancer), bowel function, abdominal/pelvic surgeries, aggravating and relieving factors (e.g. gluten, perineal exposures) as well as more tangential positives (red or swollen joints, skin rashes, past traumatic events, and eating disorders). Thorough examination of the anorectal region with selective diagnostic testing will help in managing cases appropriately.

Musculoskeletal/Neurological Conditions
Musculoskeletal/neurological conditions that can cause anorectal pain include levator ani syndrome, coccygodynia and pudendal neuralgia. The initial approach typically includes pelvic floor muscle relaxation (pelvic floor physiotherapy, PFPT). 

Levator ani syndrome and proctalgia fugax
Levator ani syndrome is characterized by recurrent dull pelvic or rectal pain; it may worsen with defecation. Palpation of the puborectalis and ileococcygeus muscles demonstrates tension and reproduces pain. PFPT (internal vaginal or rectal massage) has been shown in multiple studies to be effective (Weiss 2001; Oyama et al, 2004; Anderson et al 2005; Fitzgerald et al 2013). Injection of onabotulinum toxin is a valid option for refractory cases (Ooijevaar et al 2019; Rao et al 2009;  Bibi et al 2016). Proctalgia fugax (Latin for fleeting rectal pain) presents as sporadic episodes of severe rectal pain that can last from a few seconds to 30 minutes, typically not related to defecation. It is thought to be due to abnormal smooth muscle contraction of the anal sphincter complex. Management is supportive; topical agents to relax the anal sphincter muscle, such as diltiazem, glycerol nitrate, or inhaled salbutamol, can shorten the duration of each attack (Eckardt et al 1996).

Intestinal Conditions
Intestinal conditions that cause pelvic pain include irritable bowel syndrome (IBS), inflammatory bowel disease (IBD, Crohn’s disease, ulcerative colitis), constipation, intestinal stricture, colon cancer, hernia, adhesions, and diverticulitis. Colonoscopy is the most important tool in detecting abnormalities of the colon and rectal wall and is indicated in chronic abdominal pain, rectal bleeding, changing bowel habits (i.e. constipation/diarrhea) and fecal incontinence.

IBD/IBS
Inflammatory Bowel Disease (IBD) is the more severe disorder that includes both ulcerative colitis and Crohn’s Disease, which are typically treated with anti-inflammatory and immunosuppressant medications. Irritable Bowel Syndrome (IBS) is a functional disorder and can include pelvic floor dyssynergia. IBS can result from food sensitivity, sensitization (e.g. a traumatic event) and inflammation. If IBS is associated with fibromyalgia, headaches, chronic fatigue, anxiety, and/or depression, it is important to consider a systemic process such as small fiber polyneuropathy or central sensitization. Due to the complexity of IBS, it is crucial to consider psychological interventions alongside other treatments.

Constipation
Constipation can result from structural or neurological colon disorders, slow bowel motility, pelvic floor dysfunction, or a combination. Treatment typically begins with diet, pelvic floor physical therapy (PFPT) and laxatives; anorectal manometry, a Sitzmark study, and defecography may be indicated.

Anal Pain
Anal pain can occur with prolapsed hemorrhoids, anal fissure, fistula, abscess, rectal (and/or mucosal) prolapse, proctalgia fugax, warts, and anal cancer. Most of these conditions can be diagnosed with a rectal exam and, if needed, anoscopy.

Hemorrhoids
The key element in managing hemorrhoids is to avoid constipation (strategies include hydration and dietary changes to increase fiber intake +/- soluble fiber supplementation) as this interrupts the vicious cycle of chronic straining and hemorrhoidal venous congestion. Toilet positioning can help with the feet on a step stool. PFPT can be an essential adjunct. Sitz baths, topical preparations, and suppositories that contain hydrocortisone are often helpful. Conservative measures are usually sufficient but surgical intervention may be necessary.

Perianal Skin Irritation
If irritated, the skin should be washed daily with a pH balanced cleanser and patted dry using a soft cloth. Friction from vigorous cleansing or scratching may lead to trauma. Skin barrier products containing zinc oxide, petrolatum, or dimethicone provide a physical barrier to irritants and moisture (McNichol et al 2018) and should be reapplied subsequent to cleansing after each bowel movement. Topical antifungals such as clotrimazole and miconazole are recommended under the barrier cream if fungal infection is suspected (McNichol et al 2018; Doughty et al 2012).

Pruritis Ani
Chronic anal itching (pruritis ani) can be triggered by food, fecal soiling, contact dermatitis, psoriasis or infection (Siddiqi et al 2008). Corn starch can be used to prevent moisture build-up and barrier creams to prevent excessive dryness. Perianal dermatological skin growths such as Paget’s disease or cancer need to be considered and can be excluded with skin biopsy.

Anal Fissure
Anal fissure is a tear of the inner lining of the anal canal, usually caused by baseline high anal sphincter tone and exacerbated by chronic constipation and anal trauma. Patients typically report sharp anal pain worsened with bowel movement - like “passing razor blades.” Associated symptoms include minor bleeding, discharge, burning, and itching. Fissure can be confirmed visually by gently spreading the perianal skin. A benign sentinel skin tag may be associated. Further internal examination may require examination under anesthesia to exclude other pathology. Interventions include treating constipation and avoidance of straining and topical relaxing agents such as nifedipine or diltiazem (calcium channel blockers) and glyceryl nitrate (GTN). Injection of onabotulinum toxin and/or fissurectomy may be required.

Conclusion
There are several treatment interventions available for gastrointestinal and anorectal pelvic pain. Since interventions for pelvic pain are synergistic for overall outcome, it is important for pelvic floor specialists to understand the above diagnoses, their initial management, and when to refer for further evaluation.

This article is a summary of a full chapter on gastrointestinal pain found in Facing Pelvic Pain: A Guide for Patients and their Family Members (De E, Stern TA (eds). Due for publication mid 2020; Massachusetts General Hospital Psychiatry Academy, via Amazon). The publication will include a full multidisciplinary monograph on causes and treatments for pelvic pain written for the lay public.

REFERENCES

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Eckardt VF, Dodt O, Kanzler G, Bernhard G. Treatment of proctalgia fugax with salbutamol inhalation. The American Journal of Gastroenterology. 1996;91(4):686-689.

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