Anorectal Disorders: Chronic or Recurrent Anorectal Pain
Using this page:
Click on the numbers next to each box or decision point to see more information. e.g. 1
Click on any reference indicator to see details. e.g.
1
patient with chronic or recurrent anorectal pain
proctalgia fugax
do history and physical exam/tests suggest structural disease?
is pain associated with bowel movements or eating?
is pain episodic and brief with pain-free intervals?
do appropriate diagnostic workup for inflammatory bowel disease, perianal/perirectal abscesses, anal fissure painful gynecologic disorders
assess for painful functional gastrointestinal disorders (i.e. IBS)
is the levator muscle tender to palpation?
unspecified functional anorectal pain
levator ani syndrome
1
2
3
4
5
6
7
8
9
10
Case History - Chronic or Recurrent Anorectal Pain | Close |
A 52 year old woman is referred to a gastroenterologist because of rectal discomfort of 8 months duration (Box 1, Fig 3). She describes the pain as a deep, dull aching discomfort, lasting for some hours, and often precipitated or worsened by sitting (Box 2). The pain is not associated with bowel movements or eating (Box 4). The pain occurs inconsistently but is present, at a moderate level of severity, for as many as 4-5 days each week, and there are no pain-free intervals (Box 6). She averages 5 bowel movements weekly, passed with minimal straining and, on some occasions with a sense of incomplete evacuation; there has been no change in bowel habits and no rectal bleeding. There is no history of dyspareunia, dysuria, back pain or trauma. She has had no pelvic surgery. A pelvic exam by her gynecologist was normal and a pelvic ultrasound was negative (Box 2). A screening colonoscopy 2 years ago was normal. She has no other significant medical illnesses.
General physical examination, including abdominal and neurological examination, is normal. Digital rectal examination discloses no perianal disease or tenderness (Box 2). Anal canal tone and squeeze are normal. Perianal pinprick sensation and anal wink reflex are normal. Palpation of the coccyx is not painful and no masses are felt. However, there is tenderness with posterior traction of the puborectalis muscle, greater on the left than right (Box 8).
The gastroenterologist arranges a complete blood count and ESR and recommends flexible sigmoidoscopy and perianal imaging (Box 2), to exclude inflammation and neoplasia. These tests are normal. A diagnosis of levator ani syndrome is made (Box 9).