Chronic anal and perianal pain resolved with MRI

MRI of Recurrent Fistula-in-Ano: Is it Different from Treatment-Naïve Fistula-in-Ano and How Does it Correlate with Anal Sphincter Morphology?

Objectives  The main aim of this study was to compare magnetic resonance imaging (MRI) findings of recurrent and treatment-naïve fistula-in-ano and to correlate imaging findings with anal sphincter morphology in recurrent fistula-in-ano. Methods  This is a retrospective study of adult patients who underwent MRI for suspected fistula-in-ano in 2018. After excluding patients with alternative diagnosis, patients were stratified into recurrent ( n  = 103) and treatment-naïve ( n  = 106) fistula-in-ano groups. Two blinded radiologists reread MRI scans in consensus for fistula characteristics and anal sphincter morphology. We compared imaging features of recurrent and treatment-naïve fistula-in-ano, assessed the incidence of anal sphincter scarring among patients with recurrent fistula-in-ano, and studied its association with fistula features. Results  Two-hundred nine patients (187 males) with mean age of 40.6 (standard deviation: 12.2) years were included. Trans-sphincteric, inter-sphincteric, extra-sphincteric, and supra-sphincteric fistula-in-ano were seen in 63.6, 33, 2.9, and 0.5%, respectively. There were secondary tracts, supralevator extension, and secondary cause for fistula in 49.3, 12.9, and 14.8%, respectively. There was no difference between the fistula features of recurrent and treatment-naïve fistula-in-ano, except for significantly fewer external openings among recurrent fistula-in-ano ( p  = 0.005). Among patients with recurrent fistula-in-ano, MRI detected anal sphincter defect/scarring was seen in 53.4% ( n  = 55) and was significantly associated with posterior fistula-in-ano ( p  = 0.031), collections and/or supralevator extension ( p  = 0.010), and secondary tracts ( p  = 0.015). Conclusion  Fistula features of recurrent and treatment-naïve patients were mostly similar. There was high incidence (53.4%) of MRI-identified anal sphincter scarring/defect among recurrent fistula-in-ano, which was significantly associated with posterior fistula, collections, supra or translevator extension, and secondary tracts. Key Points MRI-identified anal sphincter scarring is very common among patients with recurrent fistula-in-ano and seen in more than half of them.There was significantly higher incidence of sphincter scarring among patients who had posterior fistula, collections, supralevator/translevator extension, and secondary tracts.

Percutaneous Tibial Nerve Stimulation in Chronic Post-Surgical Anorectal Pain: A Case Report

<b><i>Introduction:</i></b> Anorectal pain is a symptom with a negative impact on quality of life and it can sometimes develop into a chronic pain syndrome. Structural anorectal pain is treated according to the underlying pathology. In situations of chronic post-surgical pain that is refractory to conventional therapeutic approaches, percutaneous tibial nerve stimulation (PTNS) is an option. PTNS is a neurostimulation technique used in the treatment of lower urinary tract dysfunction. There has been increasing evidence of its benefits for improving other conditions, such as chronic pelvic pain (CPP) and faecal incontinence (FI). <b><i>Case Presentation:</i></b> We report a case of a 45-year-old woman with chronic post-surgical anorectal pain (CPAP) treated with PTNS. The patient reported a consistent and dramatic decrease in both the frequency and intensity of pain, assessed by the Brief Pain Inventory (BPI). A decrease in the pain interference with mood, normal work, and walking/mobility was also noted, as evaluated by BPI and EQ-5D-3L questionnaires. <b><i>Discussion:</i></b> Neuromodulation treatments have been reported as effective for anorectal pain, but reports on the use of PTNS are rare. The tibial nerve is easily accessible and provides an optimal site for neurostimulation without the need of an operating room or anaesthesia. The overall improvement observed in this case of chronic anorectal pain suggests a potential new area of research for PTNS.

Feasibility and characterization of a safe susceptibility-matched endorectal coil for MR spectroscopy

When using endorectal coils, local radiofrequency (RF) heating may occur in the surrounding tissue. Furthermore, most endorectal coils create a susceptibility artifact detrimental to both anatomical magnetic resonance imaging (MRI) and spectroscopy (MRS) acquisitions. We aimed at assessing the safety and MRS performance of a susceptibility-matched endorectal coil for further rectal wall analysis. Experiments were performed on a General Electric MR750 3 T scanner. A variable number of miniaturized passive RF traps were incorporated in the reception cable. The assessment of RF heating and coil sensitivity was conducted on a 1.5% agar-agar phantom doped with NaCl. Several susceptibility-matched materials such as Ultem, perfluorocarbon and barium sulfate were then compared with an external coil. Finally, Ultem was used as a solid support for an endorectal coil and compared with a reference coil. Phantom experiments exhibited a complete suppression of both the RF heating phenomenon and the coil sensitivity artifact. Ultem was the material that produced the smallest image distortion. The full width at half maximum of MR spectra acquired using the susceptibility-matched endorectal coil showed at least 30% narrowing compared with a reference endorectal coil. A susceptibility-matched endorectal coil with RF traps incorporated was validated on phantoms. This coil appears to be a promising device for future in vivo experiments.

The Clinical Characteristics of Patients with Chronic Idiopathic Anal Pain

The aim of this study was to investigate the clinical characteristics, treatment outcomes and psychological distress in patients with chronic idiopathic anal pain. The study was conducted on patients referred to Hangzhou Third Hospital for chronic anal pain from January, 2010 to December, 2014. Patient demographics, clinical history, anorectal physiology, and radiological imaging data were recorded for all patients. The treatment outcome was noted for patients treated and followed up for more than 6 month at the present unit. Ninety-six patients with mean age of 45.1 years (range, 17-82) were studied. Seventy-one patients (74.0%) had functional anorectal pain(FARP). The main complaints were dull, sharp, stabbing, or spasm pain. Among all patients, 34.3% reported that their pain radiated into other locations. Fifty-one patients (53.1%) had bowel dysfunction, while 28.1% patients had urinary dysfunction. The common factors associated with pain relief were day time, lying down and warm water baths; the factors that contributed to aggravated pain were night time, defecation or sitting. 92.7% (89/96) of patients reported symptoms of psychological disturbance. FARP patients exhibited increased depression than non-FARP patients(P<0.05). In addition, female patients were more likely to have depression than male patients (P<0.05). The overall pain treatment success rate was 55.2% (53/96). The pain treatment outcome was better in non-FARP patients than in FARP patients(χ2=3.85, P<0.05). Conclusively, chronic idiopathic anal pain is a complex clinical symptom, involving pelvic floor muscles, the nervous system, endocrine system, and the patients' psychological conditions. Further research is needed to improve diagnosis and treatment for patients with chronic idiopathic anal pain.

Anorectal and Pelvic Pain

Although pelvic pain is a symptom of several structural anorectal and pelvic disorders (eg, anal fissure, endometriosis, and pelvic inflammatory disease), this comprehensive review will focus on the 3 most common nonstructural, or functional, disorders associated with pelvic pain: functional anorectal pain (ie, levator ani syndrome, unspecified anorectal pain, and proctalgia fugax), interstitial cystitis/bladder pain syndrome, and chronic prostatitis/chronic pelvic pain syndrome. The first 2 conditions occur in both sexes, while the latter occurs only in men. They are defined by symptoms, supplemented with levator tenderness (levator ani syndrome) and bladder mucosal inflammation (interstitial cystitis). Although distinct, these conditions share several similarities, including associations with dysfunctional voiding or defecation, comorbid conditions (eg, fibromyalgia, depression), impaired quality of life, and increased health care utilization. Several factors, including pelvic floor muscle tension, peripheral inflammation, peripheral and central sensitization, and psychosocial factors, have been implicated in the pathogenesis. The management is tailored to symptoms, is partly supported by clinical trials, and includes multidisciplinary approaches such as lifestyle modifications and pharmacological, behavioral, and physical therapy. Opioids should be avoided, and surgical treatment has a limited role, primarily in refractory interstitial cystitis.

Chronic pelvic pain

Chronic pelvic pain is pain lasting longer than 6 months and is estimated to occur in 15% of women. Causes of pelvic pain include disorders of gynecologic, urologic, gastroenterologic, and musculoskeletal systems. The multidisciplinary nature of chronic pelvic pain may complicate diagnosis and treatment. Treatments vary by cause but may include medicinal, neuroablative, and surgical treatments.