Ultrasonographic assessment of patients referred with chronic anal pain to a tertiary referral centre

Current applications of transperineal ultrasound in gastroenterology

Transperineal ultrasound is an inexpensive, safe and painless technique that dynamically and non-invasively evaluates the anorectal area. It has multiple indications, mainly in urology, gynaecology, surgery and gastroenterology, with increased use in the last decade. It is performed with conventional probes, positioned directly above the anus, and may capture images of the anal canal, rectum, puborectalis muscle (posterior compartment), vagina, uterus, (central compartment), urethra and urinary bladder (anterior compartment). Evacuatory disorders and pelvic floor dysfunction, like rectoceles, enteroceles, rectoanal intussusception, pelvic floor dyssynergy can be diagnosed using this technique. It makes a dynamic evaluation of the interaction between pelvic viscera and pelvic floor musculature, with images obtained at rest, straining and sustained squeezing. This technique is an accurate examination for detecting, classifying and following of perianal inflammatory disease. It can also be used to sonographically guide drainage of deep pelvic abscesses, mainly in patients who cannot undergo conventional drainage. Transperineal ultrasound correctly evaluates sphincters in patients with fecal incontinence, postpartum and also following surgical repair of obstetric tears. There are also some studies referring to its role in anal stenosis, for the measurement of the anal cushions in haemorrhoids and in chronic anal pain.

Chronic idiopathic anal pain. Results of a diagnostic-therapeutic protocol in a colorectal referral unit

INTRODUCTION

Chronic idiopathic anal pain (CIAP) remains a diagnosis of exclusion. Its study and management still lack a standardized protocol. The aim of this study is to evaluate the results obtained with the diagnostic-therapeutic protocol established in our service.

MATERIAL AND METHODS

We performed a retrospective study of patients diagnosed with CIAP at the Colorectal Unit of the General University Hospital of Elche, between 2005 and 2011.

RESULTS

We evaluated 57 patients with a diagnosis of chronic anal pain for functional anorectal disease (FAD). After the application of our diagnostic protocol, final diagnosis of chronic anal pain (CAP) was achieved in 43 cases (75%), including 22 cases of descending perineum syndrome, 12 of proctalgia fugax, 2 of pudendal neuritis and 7 of coccydynia. In 14 patients exclusion diagnosis of CIAP was established. Among the therapies used on patients with CIAP, biofeedback combined with conservative measures improved symptoms in 43% of the cases. Sacral nerve stimulation was assessed in patients who did not respond to other treatments.

CONCLUSION

Through proper anamnesis, physical examination and complementary tests, a specific diagnosis of the cause of CAP by FAD can be achieved, reducing exclusion diagnosis of CIAP to 25% of cases. Conservative measures combined with biofeedback achieved an improvement in pain in more than 40% of the cases of CIAP in our study. Sacral nerve stimulation can be considered as a treatment option in refractory cases.

Chronic anal and perianal pain resolved with MRI

OBJECTIVE

The purpose of this study was to assess the diagnostic value of anorectal MRI in the care of patients with chronic anal and perianal pain but without findings of abnormalities in the clinical workup.

MATERIALS AND METHODS

Patients referred from a tertiary department of colorectal surgery to the MRI unit with clinically occult chronic anal and perianal pain were included. MRI of the anorectum was performed with an endoanal or pelvic phased-array coil. The images from all examinations were read by two radiologists. MRI findings were correlated with clinical follow-up data.

RESULTS

The study group (103 patients) was stratified into patients with no history of anorectal disease (n = 60) and those who had a history of surgery for anorectal disease (n = 43). MRI findings suggested the final diagnoses in 40 patients (39%). These diagnoses were 28 cases of suppurative lesions (27%), 11 cases of painful scarring of the anus (11%), and one case of metastasis to the sacrum (1%). Suppurative lesions were surgically proved with marked relief of pain after surgery. In the other patients the final diagnoses were 37 cases of levator ani syndrome (36%) and 26 cases of unspecified functional anorectal pain (25%). No MRI abnormalities were found in 33 of the patients with levator ani syndrome and 26 of the patients with unspecified anorectal pain. The two readers had very good agreement (κ = 0.92). The patients with a history of anorectal disease had significantly more MRI findings of abnormalities (60%) than did patients without a history of anorectal disease (23%). The positive predictive value of MRI was 91%, and the negative predictive value was 100%.

CONCLUSION

In 39% of patients, MRI showed abnormalities that were clinically confirmed as the final diagnosis. Surgical treatment will especially benefit patients with suppurative lesions, resulting in relief of pain.

Long-term outcome of the use of botulinum toxin injection for functional anal pain

AIM

Anal pain may occur in the absence of demonstrable anal pathology. Spasm of the sphincter muscles has been suggested as a cause in some patients. We aimed to assess the effectiveness of injection of botulinum toxin in treating this condition.

METHOD

Patients who had injection of botulinum toxin over a 3-year period were identified retrospectively. Patients were excluded if anal fissure or other organic pathology was found to account for their symptoms on examination under anaesthetic. Long-term outcome was assessed at a minimum 3-year post-procedure telephone follow up.

RESULTS

Fourteen (eight male) patients were identified, of median age 50 years. Botulinum toxin (20-200 u) was injected into the internal sphincter. Seven of the 14 patients reported significant improvement in symptoms at 3 months. Seven were available for a structured telephone review at a median of 59 (42-68) months. The four patients who had benefited from the injection had remained asymptomatic.

CONCLUSION

Injection of botulinum toxin into the internal anal sphincter has a role in alleviating symptoms in a small proportion of patients with functional anal pain.