Treating Chronic Pelvic Pain Syndrome with Recurrent Rectal Pain and Puborectalis Muscle Tenderness

Clinical Scenario

This protocol addresses patients with chronic pelvic pain syndrome who present with chronic or recurrent episodes of rectal pain or aching. The presentation meets Rome IV diagnostic criteria for primary chronic anal pain syndrome, requiring all of the following:

• Chronic or recurrent rectal pain or aching, with episodes lasting at least 30 minutes
• Symptom duration of at least 3 months
• Exclusion of other causes of rectal pain — including ischaemia, inflammatory bowel disease, haemorrhoids, prostatitis, and coccyx pain syndrome
• Exquisite tenderness on posterior traction of the puborectalis muscle

Treatment Approach

The preferred first-line intervention for this presentation is biofeedback therapy targeting the pelvic floor. Evidence from randomised controlled trials supports this approach over alternative interventions for patients with confirmed puborectalis tenderness. The full structured regimen — including the specific training components and clinical pathway — is available in the complete protocol.

Treatment Goal

Adequate relief of chronic rectal pain at 1 month. In patients with confirmed puborectalis muscle tenderness, substantially higher rates of adequate relief have been demonstrated with the preferred approach compared to alternative interventions.