A systematic review

Physical therapy approach to anorectal pain

Polyana Maria Azevêdo Alves Souza¹; Mayanna Machado Freitas²; Ana Mailén Linari³; Iane Castro Rodrigues⁴; Shiri Nasud Raed Gamez⁵; Romina Andrea Domenech⁶; Valéria Conceição Passos de Carvalho¹; Silvana Maria Macedo Uchôa¹

1: Universidad Católica de Pernambuco (UNICAP). 2: Universidad Católica de Pernambuco (UNICAP)/NUT Kinesiología. 3: Universidad Maimónides (UMAI). 4: Universidad Dom Bosco (UNDB). 5: Pelvine (Centro Especializado en Rehabilitación). 6: Hospital Universitario Austral/Presidente de la Sociedad Kinésica Argentina de Pelviperineología (SOKAP).

Los autores declaran ausencia de conflictos de interés.

Mayanna Machado Freitas: fisiomayannamachado@gmail.com

Received: Decembar 2021. Accepted: octubre de 2022

Polyana Maria Azevêdo Alves Souza: 0000-0002-7410-1731

Mayanna Machado Freitas: 0000-0001-9029-2796

Ana Mailén Linari: 0000-0001-7623-9024

Iane Castro Rodrigues 0000-0002-0703-7581

Shiri Nasud Raed Gamez: 0000-0003-4273-9885

Romina Andrea Domenech: 0000-0002-8311-3777

Valeria Conceição Passos de Carvalho: 0000-0001-8314-9000

Silvana María Macedo Uchôa: 0000-0002-4635-9428

ABSTRACT

Introduction: Anorectal pain is part of the consensus of Functional Gastrointestinal Disorders (FGIDs), now called Disorders of Gut-Brain Interaction (DGBIs). Roma IV criteria subcategorize functional anorectal pain in levator ani syndrome, nonspecific anorectal pain syndrome and proctalgia fugax.

Objective: To conduct a systematic review of physical therapy interventions used in the treatment of functional anorectal pain.

Material and methods: The search for articles was carried out in the Science Direct, Medical Literature Analysis and Retrieval System Online (Medline) databases through the National Center for Biotechnology Information, Virtual Health Library, Scientific Electronic Library Online and SciVerse Scopus. Articles that did not have physical therapy treatment as the main focus were excluded.

Results: Of the 1947 articles found, only 3 met the inclusion criteria. The following therapeutic approaches are reported: electrogalvanic stimulation, electroacupuncture, biofeedback, digital massage, and sitz baths. Patients treated with physical therapy reported improvement and biofeedback was highlighted as the best therapeutic method. The methodological quality of the included studies was considered moderate based on the PEDro scale analysis, with a mean score of 6.

Conclusion: Biofeedback stood out as the best therapeutic resource for anorectal pain. Although pelvic physiotherapy is effective in the treatment of these disorders, it is necessary to carry out more research with a larger sample size and better methodological quality.

Keywords: Pelvic pain, Pelvic floor, Anorectal disorder, Proctalgia.

INTRODUCTION

Anorectal pain is part of the consensus of functional gastrointestinal disorders (FGIDs), currently called gut-brain interaction disorders (GBIDs), defined by the criteria of the Rome Foundation. This is an international entity that through a consensus of experienced professionals on the subject, develops guidelines and provides scientific information to aid in the diagnosis and treatment of these disorders. In 2016, there was an update of the Rome III criteria, which became Rome IV.^1-3 According to Rome IV, functional anorectal pain is subcategorized into: levator ani syndrome, nonspecific anorectal pain syndrome, and proctalgia fugax, which are differentiated according to the duration of pain, the presence of pain on traction of the puborectalis muscle and anorectal sensitivity.^1,4,5 Levator ani syndrome (LAS) is described as constant or recurring pain in the rectum, with episodes of more than 30 min, which can last for hours and is usually aggravated by sitting.^1,4,5 Patients generally report improvement in the recumbent or standing position.⁶ Digital examination reveals spasms of the levator ani muscle and increased tenderness, more frequently on the left side.⁵ In general, the etiology of these spasms with spontaneous onset of pain is unknown and the pathophysiology is related to hypertonic muscles.⁷ LAS affects approximately 6.6% of the world population, more than half of this population is over 30 years of age and it is more frequent in women.^5,6   On the other hand, non-specific functional anorectal pain syndrome is also considered a type of proctalgia like LAS, however, the patient does not present painful discomfort during posterior traction of the puborectalis muscle.⁴ Proctalgia fugax (PF), on the other hand, is defined as sudden severe anorectal pain that subsides quickly, lasts seconds and no more than 30 minutes. It recurs at irregular intervals and is considered acute proctalgia.⁵ Rectal pain is like a kind of cramp, sharp and unbearable and can appear both during the day and at night, and even wake the individual from sleep.^4,5 The Rome IV criterion describes that this anorectal pain presents complete remission between crises and it is not related to defecation.¹ Its pathophysiology is unknown and is fleeting and uncertain. However, some studies suggest that there is compression of the pudendal nerve and/or spasms of the internal anal sphincter.^4,8,9 The prevalence is from 8 to 18%, with no difference between sexes.^2,6,8

The aim of this study was to perform a systematic review to identify the types of physiotherapy interventions that are used for the treatment of anorectal pain.

MATERIAL AND METHODS

The present study is linked to the Faculty of Health and Life Sciences of the Catholic University of Pernambuco (UNICAP) and to the Physiotherapy course of UNICAP. This is a systematic review carried out by Prof. Master Silvana Maria Macedo Uchôa and Maestra Mayanna Machado Freitas. It was guided by the question: What are the physiotherapy treatments performed in patients with anorectal pain? based on the PICOs strategy. (Population, Intervention, Comparison, Outcome, Study Design)¹⁰ (Table 1).

Population: Patients with anorectal pain.

Intervention: Biofeedback.

Comparison: Other physiotherapy interventions in anorectal pain.

Result: Physiotherapy approach used to treat patients with anorectal pain.

Design: Clinical trials.

Table 1. Representation of the PICOs search strategy

Descriptors in Health Sciences (DeCS) and Medical Subject Headings (MeSH) were consulted in Portuguese, Spanish, English and French, combined as follows:

“Anorectal pain AND Physiotherapy”, “Anorectal pain AND Rehabilitación”, “Anorectal pain AND Physiotherapy modalities”, “Proctalgia fugax AND Physiotherapy”, “Proctalgia fugax AND Rehabilitación”, “Proctalgia fugax AND Physiotherapy modalities”, “Nonspecific anorectal pain AND Physiotherapy”, “Nonspecific anorectal pain AND Rehabilitación”, “Nonspecific anorectal pain AND Physiotherapy modalities”, “Levator ani syndrome AND Physiotherapy”, “Levator ani syndrome AND Rehabilitación”, “Levator ani syndrome AND Physiotherapy modalities”.

   The search was carried out through the following databases: Science Direct, Medical Literature Analysis and Retrieval System Online (Medline) through the National Center for Biotechnology Information (PubMed), Virtual Health Library (VHL), Scientific Electronic Library Online (SciELO) and SciVerse Scopus (Scopus). The entire search and selection process of the articles was carried out by independent researchers, with a third reviewer available in case of divergence between the search reports.

    The inclusion criteria to select the articles were: clinical studies that addressed physiotherapeutic treatments in patients with functional anorectal pain published in Portuguese, Spanish, English and French. The exclusion criteria were: articles that did not have physiotherapy treatment in patients with anorectal pain as their main focus; articles with physiotherapy treatments in children, neurological patients and pregnant women; articles with other types of pelvic pain and anorectal pain as a consequence of fissures, hemorrhoids and neoplasias. Repeated articles, editorials, letters, comments, or theses were also excluded.

    The articles were subjected to a selection based on the PRISMA flowchart.¹¹ The analysis was carried out in three steps: The first consisted of searching for studies in the database using the established descriptors; the second covered the selection of titles related to the theme; in the third, the abstracts of the studies selected in the previous step were read. Finally, the reading and complete analysis of the studies was carried out.

    The selected articles were subjected to a methodological quality assessment using the PEDro scale.¹² The analysis was carried out by two authors independently and any disparities were resolved by discussion with the participation of a third party when necessary.

RESULTS

One thousand nine hundred forty-seven articles were identified, of which 3 were included in this systematic review, after selection based on the PRISMA flow chart (Figure 1).

Figure 1. Flowchart according to PRISMA guidelines that summarizes the article selection procedure after the search in the databases.

Among the combined descriptors used for the search, the most found were “Anorectal pain AND Physiotherapy modalities” (20,9%), “Anorectal pain AND Rehabilitation” (14,8%) y “Anorectal pain AND Pelvic Rehabilitation” (8,7%).

  According to the established inclusion criteria, the present study showed 3 publications involving physiotherapeutic treatments for anorectal pain. Table 2 presents the results according to the inclusion criteria defined in these studies.

.

Author	Objective	Methodology	Results
Park et al., 2005^13	To compare electrogalvanic stimulation (Group 1) and local injection therapy of triancinolone, acetonide and lidocaine (Group 2) for the treatment of LAS	N = 53 Group 1 (n = 22), Group 2 (n = 31). Interventions: Conservative pre-treatments, local injection therapy and galvanic stimulation therapy Treatment time: Group 1: 2 weeks Group  2: 15-30 min per day, once or twice a week, for 6 or more times until the patient does not report pain	Local injection therapy showed better short-term results compared to electrogalvanic stimulation.
Chiarioni et al., 2010^14	To compare the efficacy of three different techniques: biofeedback (Group 1), galvanic stimulation (Group 2), and digital massage of the levator ani muscles and sitz baths (Group 3) for the treatment of LAS. Evaluate the physiological mechanisms of treatment.	N = 157 Interventions: biofeedback, galvanic stimulation, digital massage and sitz baths Treatment time: 9 sessions lasting 30-45 minutes	Patients with "highly probable" LAS reported adequate relief in 87% with biofeedback, 45% with galvanic stimulation, and 22% with massage.
Hui et al., 2020^15	To investigate the clinical effect of electroacupuncture combined with biofeedback on functional anorectal pain.	N = 60 Group 1: Electroacupuncture (n = 20) Group 2: Biofeedback (n = 20). Group 3: Electroacupuncture + Biofeedback (n = 20) Treatment time: 10 sessions in the 3 intervention groups	There was significant improvement with the use of electroacupuncture combined with biofeedback for the treatment of functional anorectal pain.

LAS: levator ani syndrome.

Table 2. Interventions and results of the physiotherapy treatments used in the clinical trials included in this review.

The results show that according to the PEDRro scale, the included studies are methodologically of moderate quality, with a mean score of 6 (Table 3). Studies used random assignment methods (100%), obtained measurements of at least one key outcome in more than 85% of subjects initially distributed between groups (100%), and made comparisons between groups (100%) . Data mean and variability were reported in 66.6% of the studies and there was no blinding of subjects, therapists and evaluators in any of the studies.

Evaluation criteria	1	2	3	4	5	6	7	8	9	10	11	Total score
Park et al., 2005^13	1	1	0	1	0	0	0	1	1	1	0	5
Chiarioni et al., 2010^14	1	1	1	0	0	0	0	1	1	1	1	6
Hui et al., 2020^15	1	1	1	1	0	0	0	1	1	1	1	7

Items of evaluation criteria. 1: eligibility and origin, 2: randomization, 3: concealed distribution, 4: baseline comparisons, 5: blinding of subjects, 6: blinding of therapists, 7: blinding of evaluators, 8: evaluations > 85%, 9: intention-to-treat analysis, 10: intergroup comparison, 11: measures of precision and variability.

Score 0 is given when the evaluation criterion is not met and score 1 when the evaluation criterion is met.

Table 3. Evaluation of the methodological quality of the included studies, according to the PEDro scale.

DISCUSSION

The three described types of functional anorectal pain disorders (LAS, nonspecific anorectal pain syndrome, and PF)3 are clinically distinguished based on the duration of the painful episodes and according to the presence or absence of puborectal hypersensitivity.^{1,4 ,5,16} However, the similarity in the symptoms often makes diagnosis difficult.⁵ In the diagnostic criteria for LAS, the 3 studies included in this systematic review use the Rome criteria, which consider it necessary for the individual to present chronic or recurrent anorectal pain for a period equal to or greater than 30 min.1,4-6 In addition , in the physical examination, it is necessary that the patient reports pain on palpation during traction of the puborectalis muscle and that the symptoms have started at least 6 months before the diagnostic confirmation.^4-7 The difference in anorectal pain syndrome nonspecific is the absence of hypersensitivity and/or discomfort during traction of this muscle.^1,4,5,7 En el caso de la PF, los criterios diagnósticos incluyen episodios de dolor localizado en la zona rectal sin relación con la evacuación, con duración de segundos, sin superar los 30 minutos con remisión total entre crisis.^1,2,4-6,8

In all types of functional anorectal pain, other factors that cause pain in the anorectal region must be excluded (for example, ischemia, fissures, inflammatory bowel disease, prostatitis, structural changes in the pelvic floor, muscle abscess, prolapse, among others).^1,2,6

The pathophysiology of functional anorectal pain disorders has not been fully elucidated, making the therapeutic approach difficult.6,9 This could be observed in the study by Chiarioni et al.¹⁴ in which patients were categorized as “highly prone to having LAS” or as “possible diagnosis of LAS”. This was also highlighted by Park et al.,¹³ who reported two possible pathophysiologies of LAS: hypertonus of the levator ani and inflammation of the tendinous arch of the muscle.

Rao et al.⁵ hypothesize that LAS results from spasm of the pelvic floor muscles, associated with high resting anal pressures, corroborating the first hypothesis of Park et al.¹³

Regarding non-specific anorectal pain, its pathophysiology is still unclear and there is no consensus among the studies.¹⁷ However, in PF it was observed that contractions that occur in smooth muscle cause pain.^1,4,18

The three disorders are associated with psychological factors such as stress and anxiety, which hinders the prognosis in these patients, demonstrating the need for multidisciplinary work.^1,4-6,9  High-voltage electrogalvanic stimulation, first described in 1982 by Sohn et al.,¹⁹ to treat LAS, is delivered by an intra-anal probe. It is evident that this modality is simple to use, safe and effective. In one study, a frequency of 80 Hz was used, the voltage and electrical current started at zero and increased progressively as tolerated by the patient, varying the pulse width between 250 and 350 volts. Treatment duration was 1 hour, 3 times a week, over a period of 3-10 days. Similar parameters were used by Nicosia e Abcarin²⁰ in 1985 and more recently by other authors.^13,14 With this therapy, excellent results (complete pain relief and no recurrence) were achieved  in about 69% of the patients, good (complete pain remission) in 21%, and poor (no response to electrogalvanic stimulation) in only 10%.¹⁸ These results corroborate those found in another study, in which patients with a highly probable diagnosis of LAS experienced 45% relief after this therapy.14 On the other hand, others demonstrated complete relief in only 9.1% of patients, partial relief in 36.4% and no efficacy in 54.5%.¹³

Biofeedback therapy for LAS has also been reported in the literature to produce relief of muscle spasms with a success rate of between 34.5 and 91.7%. ^2,14,15,17 Positive results of this therapy were also found in another study, with 87% pain reduction after 9 sessions of 30-45 minute duration.¹⁴   Heah et al.,²¹ in 1997 conducted a study in patients with LAS with the aim of analyzing the effects of biofeedback on pain relief and improvement of anorectal function. They noted that although it had a negligible effect on physiology, it was effective for pain relief, without causing side effects. Biofeedback works by training the mind to relax the levator ani muscles, thereby reducing the spasmodic cycle.  

Hui et al.,¹⁵ in 2020 conducted a clinical trial to investigate the clinical effect of electroacupuncture combined with biofeedback on functional anorectal pain. They studied 60 patients divided into 3 random groups of 20 individuals each. One group was treated with electroacupuncture, the second group with biofeedback and the third with biofeedback and electroacupuncture. They concluded that there was a significant improvement in the group treated with the combination of therapies, compared to the groups treated with only one therapy. 

According to traditional Chinese medicine, functional anorectal pain, also called "large intestine pain" and "5-element correlated pain in the cereal canal", have an etiology and pathophysiology associated with blood stasis in the vessels, which causes the obstruction of the meridians and collaterals. The objective of acupuncture in the treatment of diseases that cause pain is to eliminate the obstruction of meridians and collaterals by regulating the blood circuit in order to provide better conductivity, muscle recovery and nervous excitation.¹⁵

One study used sitz baths associated with digital massage, prior to the start of treatment with local injection or electrogalvanic stimulation, which makes it impossible to draw a conclusion about the exclusive effect of this approach, since two others were later incorporated.¹³ On the contrary, Chiarioni et al.⁴ separately included a group with interventions associated with the sitz bath and digital massage. They found that patients with “highly probable LAS” had significant improvements at months 1, 3, and 6. However, although this result showed a statistically significant difference, the percentage improvement was only 22%.  

The study by Tejirian and Abbas,²² in order to demonstrate the effectiveness of sitz baths, concludes that although there are benefits such as the reduction of perineal edema and relaxation of the levator ani muscles, there is still little evidence to support this treatment. The review by Lang et al.²³ agrees regarding the benefits for pain relief and the scientific evidence.

CONCLUSION

The present study demonstrated that for the treatment of anorectal pain, manifested as levator ani syndrome, nonspecific anorectal pain syndrome, and proctalgia fugax, the kinetic resources used were galvanic electrostimulation, electroacupuncture, biofeedback, sitz baths, and digital massage, either alone or in combination. 

With these therapies, the patients showed improvement in a variable percentage, highlighting biofeedback as the best method.

However, studies in this area are still lacking, so it is essential to continue researching therapeutic resources and their efficacy in these pathologies.

REFERENCES

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6. Davies D, Bailey J. Diagnosis and management of anorectal disorders in the primary care setting. Prim Care. 2017; 44:709-20.

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13. Park DH, Yoon SG, Kim KU, Hwang DY, Kim HS, Lee JK, et al. Comparison study between electrogalvanic stimulation and local injection therapy in levator ani syndrome. Int J Colorectal Dis. 2005; 20: 272-76.

14. Chiarioni G, Nardo A, Vantini I, Romito A, Whitehead WE. Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome. Gastroenterology. 2010; 138: 1321-29.

15. Hui X, Xu Y, Liang H, Zhang Z. Efficacy evaluation of electroacupuncture at Dong's points combined with biofeedback in the treatment of functional anorectal pain. World J Acupuncture-Moxibustion. 2020; 30: 256-61.  

16. Bharucha AE, Wald A, Enck P, Rao S. Functional anorectal disorders. Gastroenterology. 2006; 130: 1510-18.

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18. Vincent C. Anorectal pain and irritation: anal fissure, levator syndrome, proctalgia fugax, and pruritis ani. Prim Care. 1999; 26: 53-68.

19. Sohn N, Weinstein MA, Robbins RD. The levator syndrome and its treatment with high-voltage electrogalvanic stimulation. Am J Surg. 1982; 144: 580-82.

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Heah SM, Ho YH, Tan M, Leong AF. Biofeedback is effective treatment for levator ani syndrome. Dis Colon Rectum. 1997; 40; 187-89.

22. Tejirian T, Abbas MA. Sitz bath: where is the evidence? Scientific basis of a common practice. Dis Colon Rectum. 2005; 48: 2336-40.

23. Lang DS, Tho PC, Ang EN. Effectiveness of the sitz bath in managing adult patients with anorectal disorders. Jpn J Nurs Sci. 2011; 8: 115-28.

COMMENT

Once the most frequent causes of proctalgia have been ruled out, it is mandatory to think about the functional disorders that manifest with anorectal pain. The history of these patients is usually characterized by multiple previous medical consultations in which no professional has been able to resolve their pain, much less give them a diagnosis. It is precisely this difficulty in diagnosis that predisposes to the chronicity of this disease, since there are multiple therapeutic options in which none is clearly superior. In turn, there are few studies with a good level of evidence that help in the matter. The results of this study are a reflection of this. All of this makes it interesting to have this systematic review, whose conclusion mentions biofeedback as the best therapeutic resource, a concept that I share and indicate in these patients.

Sebastián Guckenheimer

Hospital Pirovano, Ciudad de Buenos Aires