Chronic pelvic pain is a hidden issue which needs to involve many different usually uncoordinated specialists. For this reason there is a risk that treatments, in the absence of well-defined pathways, common goals, and terminology, may be poorly effective. The aim of the present paper is to summarize the evidence on anorectal pelvic pain, offering useful evidence-based practice parameters for colorectal surgeons\' daily activity. Analysis of chronic anorectal and pelvic pain syndromes, the diagnostic and clinical optimal needs for evaluation, and the innumerable low evidence treatments and therapeutic options currently available suggests that a multimodal individualized management of pain may be the most promising approach. The limited availability of dedicated centers still negatively affects the applicability of these principles.

Constipated patients are frequently referred to gastroenterologists for symptoms refractory to lifestyle modifications and laxatives. Dyssynergic defecation, the dyscoordination of rectoanal, abdominal, and pelvic floor muscles to facilitate defecation, is a major cause of refractory primary constipation. Understanding of the diagnosis, evaluation, and management of dyssynergic defecation and other evacuation disorders will allow providers to effectively manage these patients. This review focuses on the definition, pathophysiology, evaluation, and treatment of dyssynergic defecation and other evacuation disorders. Emerging treatments for these disorders include home biofeedback therapy for dyssynergic defecation and translumbosacral neuromodulation therapy for levator ani syndrome.

OBJECTIVE: Functional anorectal pain syndromes are a neglected yet often disabling clinical entity resulting in significant economic and psychological burden to the patient. The aim of this review is to update the practicing gastroenterologist/coloproctologist on the diagnosis and management of these complicated disorders.
RESULTS: The updated Rome foundation diagnostic criteria (Rome IV) for functional anorectal pain subgroups chronic proctalgia (levator ani syndrome and unspecified functional anorectal pain) and acute proctalgia (proctalgia fugax) on the basis of symptom duration and digital rectal examination findings. Chronic proctalgia is thought to be secondary to paradoxical pelvic floor contraction in many patients and biofeedback to improve the defecation effort has proven effective for over 90% in the short term. Unfortunately, management of proctalgia fugax remains challenging and treatment outcomes modest at best. A number of therapies to relax the pelvic floor may be employed to improve symptoms in functional anorectal pain syndromes; however, only biofeedback to improve defaecatory dynamics in patients with levator ani syndrome has proven effectiveness in a randomized setting. Further investigation of treatment approaches in proctalgia fugax is required.

Levator ani syndrome (LAS) is a functional disorder that can be a challenge to treat. LAS that is refractory to medical management may be treated with electrogalvanic stimulation (EGS) or Botulinum toxin A (BTX) injection. The aim of the present study was to evaluate the outcomes associated with both EGS and BTX in patients with medically refectory LAS to determine if either demonstrate a long-term benefit or whether one treatment is better than the other.
A retrospective study was performed on consecutive patients with LAS treated with BTX or EGS at our institute. Patients were identified from a prospectively maintained database. The study time frame was 6 years.
One hundred and twenty patients [80 females, mean age 52 years (range 21-84, SD 15.8)] were treated for medically refractory LAS: 102 with BTX and 18 with EGS. With EGS, 28.6% of patients reported a complete response, 14.3% reported a partial response and 57.1% reported no response to treatment. With BTX, 35.5% of patients reported a complete response, 19.7% reported a partial response and 44.7% reported no response to treatment. There was no difference between BTX and EGS with regard to treatment response. Patients who had BTX were more likely to report a short-term benefit in treatment when compared to those patients who had EGS (p = 0.002). This difference between reported outcome to BTX and EGS treatments did not sustain in the long term (p = 0.2).
Both BTX and EGS are to some extent effective at resolving symptoms of LAS. In the short term, BTX appears to be more effective. Neither treatment sustains its benefit in the long term.

OBJECTIVE: Biofeedback therapy (BFT) is effective for managing pelvic floor disorders (i.e., defecatory disorders and fecal incontinence). However, even in controlled clinical trials, only approximately 60% of patients with defecatory disorders experienced long-term improvement. The review serves to update practitioners on recent advances and to identify practical obstacles to providing biofeedback therapy.
RESULTS: The efficacy and safety of biofeedback therapy have been evaluated in defecatory disorders, fecal incontinence, and levator ani syndrome. Recent studies looked at outcomes in specific patient sub-populations and predictors of a response to biofeedback therapy. Biofeedback therapy is effective for managing defecatory disorders, fecal incontinence, and levator ani syndrome. Patients who have a lower bowel satisfaction score and use digital maneuvers fare better. Biofeedback therapy is recommended for patients with fecal incontinence who do not respond to conservative management. A subset of patients with levator ani syndrome who have dyssynergic defecation are more likely to respond to biofeedback therapy.

BACKGROUND: Anorectal pain is a symptom which may have both structural and functional causes, and can, sometimes, develop into a chronic pain syndrome. Functional causes in particular are challenging to treat when conservative treatment measures fail. Botulinum toxin A (BTX-A) can be applied to relax the anal sphincter and/or levator ani muscle to break the vicious circle of pain and contraction. In our tertiary referral proctology clinic, we evaluated the outcome of patients treated with BTX-A for chronic functional anorectal pain.
METHODS: Our electronic database was searched for patients who had BTX-A treatment for chronic functional anorectal pain from 2011 to 2016. All medical data concerning history, treatments, and clinical outcome were retrieved. The clinical outcome (resolution of pain) was scored as good, temporary, or poor.
RESULTS: A total of 113 patients [47 (42%) males; age 51years, SD 13 years, range 18-88 years] with chronic functional anorectal pain were included. The outcome of BTX-A treatment was good in 53 (47%), temporary in 23 (20%), and poor in 37 (33%). To achieve this outcome, 29 (45%) patients needed a single treatment, 11 (44%) a second treatment, and 13 (54%) ≥ 3 treatments.
CONCLUSIONS: Chronic functional anorectal pain can be treated successfully with BTX-A in 47% of patients who fail conservative management. Repeated injections may be needed to ensure complete cure in a subgroup of patients.

Levator ani syndrome (LAS) is a functional disorder of the pelvic floor muscles in which recurrent and persistent distressing pain is felt in the anus without detectable organic pathology. Eighty one percent of coccygodynia was alleviated by the levator massage when the massage motion was repeated 10 to 15 times on each side of the pelvis daily for 5 or 6 days. The authors encountered the LAS patient for whom successive visit to pain clinic was economic burden. Therefore, the authors managed the patient by intermittent levator massage with caudal block, once a week for 3 times, resulting in two years of pain free status. Intermittent levator massage with caudal block may be as effective as successive levator massage and induce longer painless period in the management of LAS.

OBJECTIVE: To present the clinical management and comprehensive differential diagnosis of a patient with anorectal pain from a perianal abscess.
METHODS: A 41-year-old woman presented with pain localized to her perianal and gluteal region, accompanied by internal and external rectal pain. Prior to presentation, the patient had received a working diagnosis of levator ani syndrome.
RESULTS: An interdisciplinary management approach was utilized. Diagnostic imaging confirmed the clinical suspicion of a perianal abscess and the patient underwent surgical drainage.
CONCLUSIONS: Anorectal pain is complex and multifactorial and a diagnosis such as an abscess should not be overlooked. This case emphasized that practitioners must be diligent in their evaluation and management of patients with anorectal pain, including recognizing situations that require further imaging and interdisciplinary management.
OBJECTIVE: Présenter le traitement clinique et le diagnostic différentiel complet d’une patiente atteinte de douleur ano-rectale découlant d’un abcès périanal.
UNASSIGNED: Une femme de 41 ans se présente avec une douleur dans la région périanale et fessière, accompagnée de douleur rectale interne et externe. Avant la présentation, la patiente a reçu un diagnostic de travail de syndrome du muscle élévateur de l’anus.
UNASSIGNED: On a utilisé une approche de prise en charge interdisciplinaire. L’imagerie diagnostique a permis de confirmer le soupçon clinique d’abcès périanal et la patiente a subi un drainage chirurgical.
UNASSIGNED: La douleur ano-rectale est complexe et multifactorielle; il ne faut pas négliger un diagnostic tel qu’un abcès. Ce cas souligne que les praticiens doivent faire preuve de diligence lors de leur évaluation et prise en charge des patients qui souffrent de douleur anorectale, y compris reconnaître des situations nécessitant une imagerie et une prise en charge interdisciplinaire supplémentaires.

This report defines criteria and reviews the epidemiology, pathophysiology, and management of common anorectal disorders: fecal incontinence (FI), functional anorectal pain and functional defecation disorders. FI is defined as the recurrent uncontrolled passage of fecal material for at least 3 months. The clinical features of FI are useful for guiding diagnostic testing and therapy. Anorectal manometry and imaging are useful for evaluating anal and pelvic floor structure and function. Education, antidiarrheals and biofeedback therapy are the mainstay of management; surgery may be useful in refractory cases. Functional anorectal pain syndromes are defined by clinical features and categorized into three subtypes. In proctalgia fugax, the pain is typically fleeting and lasts for seconds to minutes. In levator ani syndrome (LAS) and unspecified anorectal pain the pain lasts more than 30 minutes, but in LAS there is puborectalis tenderness. Functional defecation disorders are defined by >2 symptoms of chronic constipation or irritable bowel syndrome with constipation, and with >2 features of impaired evacuation i.e., abnormal evacuation pattern on manometry, abnormal balloon expulsion test or impaired rectal evacuation by imaging. It includes two subtypes; dyssynergic defecation and inadequate defecatory propulsion. Pelvic floor biofeedback therapy is effective for treating LAS and defecatory disorders.

OBJECTIVE: The aim of this study was to evaluate the efficacy of Botulinum toxin-A (Botox) in relieving anal pain associated with anal fissure (AF) and Levator ani syndrome (LS).
METHODS: All patients with medically refractory AF or LS from 2005 to 2012 and treated with Botox injections were included.
RESULTS: One hundred and three patients [66 patients (53 female) with AF and 37 patients (26 female) with LS] were evaluated. The minimum/maximum dose of Botox was 20/100 units for AF and 50/200 units for LS. Thirteen (19.7%) patients with AF and 14 (38%) patients with LS received > 1 Botox treatment. The time interval between injections varied from 1 to 12 months. Mean follow-up was 6.4 months for AF and 9 months for LS. Relief of anal pain was noted in 59% of AF and 43% of LS patients. Significant changes in pre- and post-op pain scores were noted in both groups. Nine out of 12 patients with failed sphincterotomy were relieved after Botox treatment. Temporary fecal incontinence was reported in 2/66 (3%) AF patients and 4/37 (10%) of LS patients. Overall, 66% patients\' recommended Botox treatment and 72% were happy with the treatment as per telephone interview results.
CONCLUSIONS: Botox relieves pain more effectively in AF than in LS. It is an effective option in medically refractory cases of LS. Higher doses of Botox are safe to use in LS; however, this needs to be evaluated. Botox injections have an overall low complication rate.