Systemaattinen lähestymistapa auttaa anorektaalisen kivun hoidossa

Abstract

Tiivistelmä

Peräaukon ja peräsuolen alueen kipu on melko yleistä. Diagnostiikka ja hoito voi olla haastavaa, jos kivun syy ei selviä kliinisessä tutkimuksessa. Taustalla voivat olla paikalliset syyt, toiminnallinen kipu tai neuropaattiset kipuoireyhtymät. Toiminnallisen kivun kolme päädiagnoosia ovat kohtauksellinen kipu (proctalgia fugax), levator ani -oireyhtymä ja epäspesifi toiminnallinen anorektaalinen kipu. Hoidon kulmakiviä ovat fysioterapeuttiset menetelmät ja botuliinitoksiinipistokset. Myös kirurgisesta hoidosta voi olla apua.

English summary

Anorectal pain

Anorectal pain is an obscure disorder affecting up to 11.6 % of general population. Clinical manifestations are discomfort, sharp, dull, burning or tingling pain in the anorectal area or sometimes a foreign body sensation. Three diagnostic categories are identified: local causes, functional anorectal pain and neuropathic pain syndromes. Diagnosis of local causes, such fissure, abscess or severe proctitis, is usually obvious in clinical examination. However, there are also some pitfalls to avoid in the diagnostics, such attributing anal pain due to hemorrhoids or non-existing fissure, or failing to consider less common causes.

Functional anorectal pain syndromes are subdivided into proctalgia fugax, levator ani syndrome and unspecified anorectal pain. The key diagnostic criteria relate to the character and duration of pain and tenderness of the levator ani muscle on examination. In levator ani syndrome and unspecified anorectal pain, the pain is chronic or intermittent with prolonged episodes, in proctalgia fugax brief and infrequent. Neuropathic pain syndromes include coccygodynia and pudendal neuralgia. Both are provoked by sitting, but have their own distinctive character.

The diagnosis and management of chronic anal pain follows a selective approach starting with careful history, digital and proctoscopy examination. Chronic anorectal pain has comorbidities such obstructed defecation, fibromyalgia and symptoms of depression and anxiety are prevalent. Treatment options are individualized to each diagnostic category with some overlapping. These include lifestyle advice, pelvic floor physiotherapy with biofeedback, electrical stimulation, botulinium toxin A and medication. Surgery is warranted for coccygodynia and pudendal nerve compression when other treatments have failed. Multidisciplinary team intervention may be needed and particularly for those with intractable pain in spite of treatment pain specialist referral is recommended.