© Springer International Publishing Switzerland 2017
Alexios Carayannopoulos DO, MPH (ed.)Comprehensive Pain Management in the Rehabilitation Patient10.1007/978-3-319-16784-8_1212. Pain in the Pelvic Rehabilitation Patient
(1)
Department of Brain Injury Medicine, Northwestern Medicine: Marianjoy Rehabilitation Hospital, 26W171 Roosevelt Road, Wheaton, IL 60187, USA
Keywords:
Anal painCoccydyniaLevator ani syndromeProctalgia fugaxInterstitial cystitisPainful bladder syndromeDyspareuniaVulvodyniaVaginismusPelvic girdle painSacroiliac joint dysfunctionPubic symphysitisIntroduction
Pelvic Floor physical therapy is a relatively new discipline, starting nearly 40 years ago. It is estimated that nearly 10–20% of women experience chronic pelvic pain, and nearly one-half of all women will experience pelvic floor pain and/or dysfunction within their lifetimes [1]. There are no specific demographics by race, ethnicity, education, or socio-economic status that predispose women to be at greater risk, except that they tend to be of reproductive age. Chronic pelvic pain is defined as a noncyclic pain of 6 months or longer duration, which localizes to the pelvis, anterior abdominal wall below the umbilicus, lumbosacral back or buttocks and leads to functional disability [2]. Common causes of pelvic pain are gynecologic, gastrointestinal, urologic, or musculoskeletal in nature.
History taking can be limited by the patient, in light of their cultural perceptions of what is appropriate for open discussion, even with a healthcare provider. The provider must exercise great sensitivity and must cultivate trust, in order to ensure eliciting the most accurate history. It is important to elicit alleviating and exacerbating factors, levels of pain, prolonged postural or positional issues, impact on functional and/or sexual status, bladder and bowel involvement, past testing, and treatment strategies. Also important is to determine what brought that patient to seek healthcare attention, as well as their goals for treatment.
Assessment of the pelvic floor involves an internal pelvic exam, in addition to the usual physical examination of the lumbosacral and lower extremity musculoskeletal and neurologic systems. A practitioner will assess for impairments involving sensory deficits, weakness, pain, range of motion, and coordination of muscles.
The observation portion of the exam involves assessing for asymmetry and skin abnormalities. The palpation portion of the exam involves assessing for sensory deficits, tender points, and trigger points. The internal exam involves assessing strength, endurance, coordination of pelvic floor muscles for volitional activation, and relaxation.
Anal Pain
Pathophysiology
Anal pain encompasses coccydynia , levator ani syndrome , and proctalgia fugax. The levator ani muscles (pubococcygeus, puborectalis, and iliococcygeus muscles) and coccygeus muscles form the base of the pelvic floor.
The term coccydynia was first introduced in 1859 [3]. Coccydynia indicates pain located around the coccyx itself. The most common cause of coccydynia is external trauma, such as a direct fall unto the coccyx, leading to a bruised, dislocated, or fractured coccyx [4]. Less frequently, coccydynia can be caused from prolonged sitting on narrow, hard, or uncomfortable surfaces. Other causes include repetitive minor trauma, such as bicycle riding or vaginal childbirth. Risk factors include obesity and female gender; women are five times more likely to develop coccydynia as men [5]. Additionally, adults and adolescents are more likely to be diagnosed with this condition than children [6]. It can also be associated with psychological disorders [7].
The pathophysiology of levator ani syndrome includes the levator ani muscles itself, whereby excessive tension is thought to occur, leading to myalgia [8].
The pathophysiology of proctalgia fugax includes smooth muscle dysfunction in the anus [8].
In general, it has been proposed for all these conditions that muscle fiber trauma leads to peripheral and then central sensitization, via a pathway of continued stimulus on local nociceptors. In turn, this causes amplification of the perception of pain from changes in the dorsal spinal cord.
Symptoms
Coccydnia is worsened when changing from a sit to stand position and is localized to the coccyx (tailbone). It may also present with sexual intercourse or with bowel movements.
Levator ani syndrome consists of dull ache or pressure pain located deep within the rectum, with referred pain to the thigh and buttocks, which can last for 20 min or longer, in the absence of any other finding [8]. Patients describe the sensation as that of “sitting on a ball” [8]. Prolonged sitting or defecation, lasting for 20 or more minutes, can bring on the pain [8]. This syndrome is often seen in women under the age of 45 [8].
Functional Limitations
Coccydynia and proctalgia fugax affect the patient’s ability to sustain prolonged sitting and standing; pain generally occurs during defecation and sexual intercourse.
Levator ani syndrome affects sexual intercourse and can also lead to urinary frequency and/or urgency.
Treatment/Common Techniques
Initial
Coccydynia is often thought to be secondary to pelvic floor dysfunction. Coccydynia generally resolves in weeks to months and should be initially treated conservatively. Early treatment may involve the use of a donut or wedge pillow, also known as a coccygeal cushion, which are available over the counter [5]. In levator ani syndrome, intra-vaginal finger exam may reveal a tender muscle band located within the levator muscle. Physical examination is normal in proctalgia fugax . Workup may involve endoscopy and/or imaging studies, which can include CT or MRI, to rule out other serious diagnoses, such as cancer [8]. Most common medications prescribed for pain relief include the non-steroidal anti-inflammatory drugs (NSAIDs). Other medications can treat anal pain, by inhibiting smooth muscle contraction: Inhalers (salbutamol), oral medications (diltiazem and clonidine), and topical medications (nitroglycerin) [8].
Rehabilitation
Modalities with heat or cold can be helpful. Perineal strengthening exercises can be helpful. Patients can be trained to adopt proper sitting posture. Pelvic floor therapists can employ multiple strategies, including trans-anal digital massage, which can reposition a dislocated sacro-coccygeal joint, transcutaneous electrical stimulation (TENS) with either an external or intra-pelvic probe, and electromyographic (EMG)-based biofeedback [8]. Visual biofeedback involves the use of internal and external sensors of muscle activity, which are displayed on a screen for patients to view as they activate and/or relax muscles. Referral to a comprehensive pain management program may be necessary if there is a possibility of psychological overlay in symptoms.
Procedures
A series of coccygeal injections with local anesthetics, with or without steroids, can be used to treat intractable coccydynia [9]. Electrogalvanic stimulation can be effective in treating levator ani syndrome. It uses high voltage, low frequency oscillating electric current via a probe placed in the rectum, which causes fatigue of levator ani muscles [8].
Surgery
Coccygectomy is a surgical procedure of last resort, which involves surgical amputation of the coccyx [10].
Potential Treatment Complications
High complication rates with failure to relieve pain are often seen with surgical coccygectomies [5].
Evidence
Little evidence exists to support the use of interventional procedures in the treatment of chronic coccydynia. Similarly, little evidence is present to support the use of coccygectomy as a way of treating chronic coccydynia.
Conclusion
Anal pain can be a self-limiting condition, which can respond readily to conservative treatment. A smaller subset of patients develop more chronic pain and can be more challenging to treat, and for whom limited evidence is present to effectively treat them.
Interstitial Cystitis: Painful Bladder Syndrome
Pathophysiology
Interstitial cystitis (IC) is characterized as a painful bladder syndrome with associated frequency, urgency, and nocturia, which is seen predominantly in women [11]. Pathophysiology for this condition is not clear, though there are many theories including: occult infection, mucosal/epithelial dysfunction, allergic hypersensitivity, neurogenic inflammation, autoimmune dysfunction, and urine toxicity [12]. No single theory fully explains this condition, but one theory proposes that IC is related to altered integrity of the glycosaminoglycan layer within the bladder, which can lead to an increased permeability to solutes, in particular to potassium [13]. The theory goes on further to suggest that continued exposure of the bladder wall to potassium causes mast cell degranulation, which can lead to an inflammatory response, sensory nerve depolarization, and subsequent pain [13].
Symptoms
IC is characterized by exacerbating and remitting episodes of pain, which can be triggered by emotional and physical stress. Common symptoms include urgency, nocturia, frequency, pelvic pain, pelvic pressure, bladder spasm, dyspareunia, dysuria, and pain after intercourse. Pain is often worse with a full bladder and is felt in the low abdomen, perineum, vulva, vagina, low back, and/or medial thighs [12]. Pain is often relieved with voiding [12]. On average, patients with IC will void 16 times per day, with normal volume of voids [12]. IC is often associated with pelvic floor dysfunction and with pelvic floor muscle spasms. Symptom severity can wax and wane on a daily basis. This condition can coexist with other pain conditions, such as irritable bowel syndrome or fibromyalgia.
Functional Limitations
Patients with this condition will have poor quality of life, as IC generally negatively impacts sexual activity and bladder function.
Treatment/Common Techniques
Initial
Dietary modification towards a milder diet with fewer irritants may be the first step in treatment. A food diary may be kept to monitor symptoms as foods are eliminated and then re-introduced into the diet, which helps to identify the culprit food item [12]. Fluid restriction is not recommended [12]. Oral medications may be prescribed to target allergic response (hydroxyzine), neural inflammation (amitriptyline, gabapentin), pain symptoms (opioids), general inflammation (NSAIDs) to reduce urgency (anticholinergics) and dysuria (pyridine) [12]. Smoking cessation should be encouraged. Behavior modification should be implemented with timed voiding and bladder retraining [12].
Rehabilitation
Psychology can work with the patient to learn and to implement biofeedback, meditation, self-hypnosis, psychotherapy, and relaxation techniques.Related posts:
Pain in the Stroke Rehabilitation Patient
Pain in the Neuromuscular Disease Rehabilitation Patient
Manual Therapy and Pain in the Rehabilitation Patient
Peripheral Nerve Stimulation for the Treatment of Pain in the Rehabilitation Patient
Opioids for the Treatment of Pain in the Rehabilitation Patient
Trigeminal Neuralgia in the Rehabilitation Patient
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