20151026 pain meeting

1. Perianal Pain
Cheng Wei Chun

2. vessel
secretroy duct
soft tissue &
appendages
nerve
bone
muscle

5. Association symptoms
pruritis
bleeding(rectal/GI tract)
occult blood
lump/palpable mass
fecal passage habit(difficult/impaction/incontinece)

6. Conditions Associated with
Pruritus Ani

9. Treatment
GI symptom relief: per OS, trans-anal, topical.
Infectious etiology control: anti-bacterial, candida,
parasite, virus
Local pathologic etiology control(surgical)
warm water bath, PT for injured sphincter or nerve.

10. Levator ani syndrome
Myofacial pain syndrome
Trigger point (pelvic floor)+/- referred pain (post.
buttock, thigh)
Jump sign
coexist w/ somatic, psychologic disorder
TPI, anti-depression/anxiety, PT
botulim toxin A(NOT approval by FDA)

11. Coccyadynia
Strain of sacrococcygeal lig, fx, arthritis.
tail bone, localized pain; radiation to ; lower sacrum,
perineum
F> M, difficult vaginal birth
may coexistent sacroiliitis
NSAID or COX-2; foam donut
Sacrococcygeal lig. injection, PT

12. Pudendal neuralgia
Symptoms: Pain or numbness involving the area between the
legs, including the genitals and occasionally some of the
inside of the thigh. Often only one side is affected. The pain
may be aggravated by sitting
• Diagnosis: MR Neurography imaging can identify
entrapments. Injections can confirm the diagnosis and can
help.
1. passes under the piriformis muscle
2. crosses the sacrospinous lig. and dives under the sacrotuberous lig.
3. travels across the obturator foramen within the Alcox canal
4. upon exit from Alcox canal and branching in the perineal area (between the legs)
• entrapment or irritation of the Impar ganglion on the internal surface of the coccyx.
https://www.youtube.com/watch?v=5suF07z42UE

13. Proctalgia Fugax

14. Non-pharmacology intervention
Four-quadrant field block
https://www.youtube.com/watch?v=TpHjQ-zmZd0
Caudal block(Epidural), saddle block(spinal)
Pudendal nerve block(saddle nerve block)
https://www.youtube.com/watch?v=yYFwffGup_M
https://www.youtube.com/watch?v=XCMs2vyxbvo
Inferior anal nerve block
Sacrococcygeal lig. injection

15. Malignancy
Current American Academy of Family Physicians
(AAFP) and American Cancer Society (ACS)
guidelines call for screening of all patients for
colorectal cancer beginning at 50 years of age in
the general population and 40 years of age in those
with risk factors or a family history of the disease.3

16. References
Common Anorectal Conditions: Part I. Symptoms
and Complaints
Am Fam Physician. 2001 Jun 15;63(12):2391-2398.
Atlas of Common Pain Syndromes(book)
Steven D. Waldman
Essentials of Pain Medicine 3rd edition
Benzon