When biofeedback fails to relieve chronic rectal pain — what comes next
In patients with chronic primary anal pain syndrome — recurrent rectal pain or aching lasting at least 30 minutes per episode, persisting for 3 or more months, with exquisite tenderness on posterior traction of the puborectalis muscle, and other causes excluded — inadequate pain relief after biofeedback treatment raises the question of what the appropriate next step is.
Clinical scenario
Chronic or recurrent rectal pain or aching; episodes of at least 30 minutes; exquisite tenderness on posterior traction of the puborectalis muscle; symptom duration of at least 3 months; other causes of rectal pain excluded — including ischaemia, inflammatory bowel disease, haemorrhoids, prostatitis, and coccyx pain syndrome.
Previous treatment — insufficient response
Biofeedback treatment with pelvic floor muscle relaxation training did not achieve adequate relief of chronic rectal pain by one month. This protocol defines the next therapeutic step after that failure.
Next-line approach
When biofeedback has not delivered adequate relief, the recommended approach involves a neuromodulation technique targeting nerve pathways implicated in the pain. A primary option and an alternative are defined in the full protocol — neither the sequence nor the specifics are outlined here.
References
- Diagnostic criteria for primary chronic anal pain syndrome (chronic proctalgia) according to the Rome IV criteria are as follows and must include all of the following: chronic or recurrent rectal pain or aching; episodes last at least 30 minutes; and exclusion of other causes of rectal pain, such as ischaemia, inflammatory bowel disease, cryptitis, intramuscular abscess and fissure, haemorrhoids, prostatitis and coccyx pain syndrome.
- Primary chronic anal pain syndrome includes the above diagnostic criteria and exhibits exquisite tenderness during posterior traction on the puborectalis muscle.
- Offer percutaneous tibial nerve stimulation in chronic primary anal pain syndrome.
- Offer sacral neuromodulation in chronic primary anal pain syndrome.
- Percutaneous tibial nerve stimulation is effective in anal pain.
- Sacral neuromodulation is effective in anal pain.