Is Botox for anal pain an effective treatment option?

Optimal management of functional anorectal pain: a systematic review and network meta-analysis

Functional anorectal is idiopathic and characterised by severe and potentially intractable anorectal pain. The current review aims to appraise available evidence for the management of functional anorectal pain and synthesise reported outcomes using network meta-analysis. PubMed, CENTRAL and Web of Science databases were searched for studies investigating treatments for functional anorectal pain. The primary outcome was clinical improvement of symptoms and the secondary outcome was pain scores reported during follow-up. A Bayesian network meta-analysis of interventions was performed. A total of 1538 patients were included from 27 studies. Intramuscular injection of triamcinolone, sacral neuromodulation (SNM) and biofeedback were most likely to be associated with improvement in symptoms [SUCRA (triamcinolone) = 0.79; SUCRA (SNM) = 0.74; SUCRA (Biofeedback) = 0.61]. Electrogalvanic stimulation (EGS), injection of botulinum toxin A and topical glyceryl trinitrate (GTN) were less likely to produce clinical improvement [SUCRA (EGS) = 0.53; SUCRA (Botox) = 0.30; SUCRA (GTN) = 0.27]. SNM and biofeedback were associated with the largest reductions in pain scores [mean difference, range (SNM) = 4.6-8.2; (Biofeedback) = 4.6-6]. As biofeedback is noninvasive and may address underlying pathophysiology, it is a reasonable first-line choice in patients with high resting pressures or defecation symptoms. In patients with normal resting pressures, SNM or EGS are additional options. Although SNM is more likely to produce a meaningful response compared to EGS, EGS is noninvasive and has less morbidity. Whilst triamcinolone injection is associated with symptomatic clinical improvement, the magnitude of pain reduction is less.

Defining the Economic Burden of Perioperative Venous Thromboembolism in Inflammatory Bowel Disease in the United States

BACKGROUND

Patients with IBD are at increased risk of venous thromboembolism.

OBJECTIVE

This study aims to define the economic burden associated with inpatient venous thromboembolism after surgery for IBD that presently remains undefined.

DESIGN

This study is a retrospective, cross-sectional analysis using the National Inpatient Sample from 2004 to 2014.

SETTING

Participating hospitals across the United States were sampled.

PATIENTS

The International Classification of Diseases, 9th Revision codes were used to identify patients with a primary diagnosis of IBD.

INTERVENTIONS

Major abdominopelvic bowel surgery was performed.

MAIN OUTCOME MEASURES

The primary outcome measured was the occurrence of inpatient venous thromboembolism. Univariate and multivariable patient- and hospital-level logistic regression models were used to compare patient characteristics, hospital characteristics, and outcomes between venous thromboembolism and non-venous thromboembolism cohorts. Total average direct costs were then compared between cohorts, and the resulting difference was extrapolated to the national population.

RESULTS

Of 26,080 patients included, inpatient venous thromboembolism was identified in 581 (2.2%). On multivariable analysis, diagnosis of ulcerative colitis, transfer status, length of preoperative hospitalization, and insurance status were independently associated with inpatient venous thromboembolism. Patients with venous thromboembolism were observed to be associated with an increased median length of stay (17.6 vs 6.7 days; p < 0.001) and higher inpatient mortality (5.0% vs 1.1%; OR 4.7, SE 3.2-7.0; p < 0.001). After adjusting for clinically relevant covariates, the additional cost associated with each inpatient venous thromboembolism was $31,551 (95% CI, $29,136-$33,965).

LIMITATIONS

Our study is limited by the administrative nature of the National Inpatient Sample database, which limits our ability to evaluate the impact of clinical covariates (eg, use of venous thromboembolism chemoprophylaxis, steroid use, and nutrition status).

CONCLUSION

Inpatient venous thromboembolism in abdominopelvic surgery for IBD is an infrequent, yet costly, morbid complication. Given the magnitude of patient morbidity and economic burden, venous thromboembolism prevention should be a national quality improvement and research priority. See Video Abstract at http://links.lww.com/DCR/B544.

DEFINICIN IMPACTO ECONMICO DE LA TROMBOEMBOLIA VENOSA PERIOPERATORIA EN LA ENFERMEDAD INFLAMATORIA INTESTINAL EN LOS ESTADOS UNIDOS

ANTECEDENTES:Pacientes con enfermedad inflamatoria intestinal (EII) tienen un mayor riesgo de tromboembolismo venoso (TEV).OBJETIVO:Definir el impacto económico de TEV hospitalaria después de la cirugía por EII, que en la actualidad permanece indefinida.DISEÑO:Un análisis transversal retrospectivo utilizando la Muestra Nacional de Pacientes Internos (NIS) de 2004 a 2014.ENTORNO CLINICO:Hospitales participantes muestreados en los Estados Unidos.PACIENTES:Se utilizaron los códigos de la 9ª edición de la Clasificación Internacional de Enfermedades (ICD-9) para identificar a los pacientes con diagnóstico primario de EII.INTERVENCIONES:Cirugía mayor abdominopélvica intestinal.PRINCIPALES MEDIDAS DE VALORACION:Incidencia de TEV en pacientes hospitalizados, utilizando modelos de regresión logística univariado y multivariable a nivel de pacientes y hospitales para comparar las características de los pacientes, las características del hospital y los resultados entre las cohortes de TEV y no TEV. Se compararon los costos directos promedio totales entre cohortes y la diferencia resultante extrapolando a la población nacional.RESULTADOS:De 26080 pacientes incluidos, se identificó TEV hospitalario en 581 (2,2%). En análisis multivariable, el diagnóstico de colitis ulcerosa, el estado de transferencia (entre centros hospitalarios), la duración de la hospitalización preoperatoria y el nivel de seguro medico se asociaron de forma independiente con la TEV hospitalaria. Se observó que los pacientes con TEV se asociaron con un aumento de la duración media de la estancia (17,6 versus a 6,7 días; p <0,001) y una mayor mortalidad hospitalaria (5,0% versus a 1,1%; OR 4,7, SE 3,2 -7,0; p <0,001). Después de ajustar las covariables clínicamente relevantes, el costo adicional asociado con cada TEV para pacientes hospitalizados fue de $ 31,551 USD (95% C.I. $ 29,136 - $ 33,965).LIMITACIONES:Estudio limitado por la naturaleza administrativa de la base de datos del NIS, que limita nuestra capacidad para evaluar el impacto de las covariables clínicas (por ejemplo, el uso de quimioprofilaxis de TEV, el uso de esteroides y el estado nutricional).CONCLUSIÓN:TEV hospitalaria en la cirugía abdominopélvica para la EII es una complicación mórbida infrecuente, pero costosa. Debido a la magnitud de la morbilidad el impacto económico, la prevención del TEV debería ser una prioridad de investigación y para mejoría de calidad a nivel nacional. Consulte Video Resumen en http://links.lww.com/DCR/B544.

Proctalgia Syndromes: Update in Diagnosis and Management

PURPOSE OF REVIEW

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.

RECENT FINDINGS

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.

Botulinum toxin A versus electrogalvanic stimulation for levator ani syndrome: is one a more effective therapy?

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Botox treatment in patients with chronic functional anorectal pain: experiences of a tertiary referral proctology clinic

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.

Botulinum toxin improves pain in chronic anal fissure

Highlights

Chronic anal fissure is a common condition associated with intense pain.Local botulinum toxin injection is a valid option in its management.Pain intensity scores significantly improved after BoNT injection.Side effects were rare and mild.Our results support the inclusion of BoNT in the management algorithm of chronic anal fissure.

Introduction

Chronic anal fissure is a common condition associated with intense pain. Local botulinum toxin injection is a valid option in its management. The purpose of this study was to evaluate the efficacy of botulinum toxin on pain relief in chronic anal fissure patients.

Methods

We conducted a retrospective cohort study, involving 81 consecutive patients referred to a chronic pain management unit due to a chronic anal fissure for treatment with botulinum toxin, during a 4 year period. Data were collected from hospital records regarding pre-treatment and post-treatment pain (numeric rating scale), side effects, need for botulinum toxin reinjection and need for surgical treatment. We used standard statistical methods for inter (t-test and qui²) and intra-group (paired sample t-test) comparisons, according to variables distribution.

Results

Pain intensity rest score significantly improved after BoNT injection [variation: -4.2 ± 2.9 (p < 0.001)], as did pain post-defecation score [variation: -5.1 ± 3.0 (p < 0.001)]. 8.6% needed botulinum toxin reinjection and 23.5% were submitted to surgery. Side effects were reported in 8.6%.

Discussion

The efficacy of botulinum toxin use on pain reduction along with its non-permanent and minor side effects support its role in the resolution of chronic anal fissure. However, treatment failure in the long term is still significant.

Conclusion

Botulinum toxin is effective on pain relief in patients with chronic anal fissure, which supports its inclusion in the management algorithm of this condition.