Came across case in reddit/chronic pain that wanted to know what to do for undetermined chronic anal pain. Well there is lots but if constipation is also an issue, then anal biofeedback is treatment of choice.
In
Byrnes, Kevin Gerard, et al. “Optimal management of functional anorectal pain: a systematic review and network meta-analysis.” European Journal of Gastroenterology & Hepatology 34.3 (2022): 249-259.
https://journals.lww.com/eurojgh/abstract/2022/03000/optimal_management_of_functional_anorectal_pain__a.1.aspx
“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.”
Local injection with triamcinolone steroid or botulinum, and various injections to nerve center ganglion impar would be expedient in the right hands. More info below:
Sorry would take a whole chapter to elucidate each item so will expand as can:
Biofeedback – muscle feedback training to teach you how to loosen rectal muscles by “hearing” how tight they are being held
Gilliland, Robert, et al. “Biofeedback for intractable rectal pain: outcome and predictors of success.” Diseases of the colon & rectum 40 (1997): 190-196.
Electrogalvanic Stimulation
“One device employs electrogalvanic stimulation through a rectal probe for approximately 15 minutes. Reports of 80% to 90% improvement in unselected cases”
Wald, Arnold. “Functional anorectal and pelvic pain.” Gastroenterology Clinics of North America 30.1 (2001): 243-252.
https://www.sciencedirect.com/science/article/pii/S088985530570176X
Local cortisone injection
Byrnes, Kevin Gerard, et al. “Optimal management of functional anorectal pain: a systematic review and network meta-analysis.” European Journal of Gastroenterology & Hepatology 34.3 (2022): 249-259
“improvement in symptoms [SUCRA (triamcinolone) = 0.79”
Feng J, Cheng J, Xiang F. Management of intractable pain in patients treated with hemorrhoidectomy for mixed hemorrhoids. Ann Palliat Med. 2021 Jan;10(1):479-483.
https://apm.amegroups.org/article/view/61292/pdf
Botulinum into rectal/anal muscles
Ooijevaar, R. E., et al. “Botox treatment in patients with chronic functional anorectal pain: experiences of a tertiary referral proctology clinic.” Techniques in coloproctology 23 (2019): 239-244.
https://link.springer.com/content/pdf/10.1007/s10151-019-01945-8.pdf
Case report of simple caudal block working in rectal pain:
I wrote about it here:
Chronic Rectal Perineal Pain Helped by Simple Caudal Block
http://painmuse.org/?p=5327
Ganglion Impar blocks – injection nerve central behind coccyx
I discussed it re tailbone issues:
http://painmuse.org/?p=4411
But it is used for anorectal pains too:
Ng, Thomas, Anjana Sekaran, and Alopi Patel. “GanGlion impar injection for relief of refractory anorectal pain in multiple ScleroSiS patientS.” Pain 5.7 (2021): 343-346.
Use of modified pulsed radiofrequency ablation was also used in one case in above article
Injecting with botulinum(botox) might give more lasting results as well:
Korean J Pain Vol. 23, No. 1, 2010. Ganglion Impar Block With Botulinum Toxin Type A for Chronic Perineal Pain Su Jin Lim, MD, Hue Jung Park, MD, Sang Hoon Lee, MD, and Dong Eon Moon, MD
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2884216/
I wrote about it here:
New Treatment of Perineal / Pelvic Pain – Botox to Ganglion Impar
Tailbone Sacral spinal stimulator is always an option:
Govaert, Bas, et al. “Sacral neuromodulation for the treatment of chronic functional anorectal pain: a single center experience.” Pain Practice 10.1 (2010): 49-53.
https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1533-2500.2009.00318.x
Falletto, Ezio, et al. “Is sacral nerve stimulation an effective treatment for chronic idiopathic anal pain?.” Diseases of the colon & rectum 52.3 (2009): 456-462.
Comment – I cannot believe the wide variety of options available.