Proctalgias and allied non-inflammatory perianal dyscrasias: Coccygodynia, proctalgia fugax, neurogenic pruritus ani.

American Journal of Digestive Diseases

13: 330, 1946.

Emil Granet M.D

New York.

The ano-rectal syndromes to be discussed are not infrequently seen in practice and are of interest because each poses problems in etiology, pathological physiology and treatment, the satisfactory solution of which in most cases eludes us. Commonly, pain or discomfort in the perianal region or rectum is due to conditions associated with inflammation or infection. These lesions include:

1. Acute Abscesses - Perianal, Perirectal, Ischiorectal, Supra-levator, Cryptitis. Pilonidal

2. Fistulae

3. Acute and Chronic Fissures

4. Acute Thrombotic Hemorrhoids

5. Specific Chronic Infection - Perianal Tuberculosis, Gonorrhea, Syphilis, Lymphogranuloma Venereum

6. Ulcerative Colitis - Idiopathic, Dysenteric, Amebic, Chronic Hypertrophic Proctitis.

Neoplasms, benign or malignant, involving the anus, rectum, or pelvis, are obvious causes of perianal pain or discomfort,

COCCYGODYNIA

The pain in this syndrome centers about the coccyx, frequently radiating up the rectum, laterally to the gluteal region, and occasionally down the back of the thighs. The characteristic pain is severe, continuous, throbbing, and is commonly brought on by prolonged sitting. Trauma resulting from falls on the sacrococcygeal region or following parturition, or even after ano-rectal surgery is considered the chief etiologic factor of onset in this syndrome. Lesions of the coccyx itself following trauma are infrequent as demonstrated by Duncan (1). He found that in patients with coccygodynia studied at the New York Orthopedic Hospital, fracture of the coccyx was found in only 4% and dislocation in 2% of 262 patients,

The usual symptomatic treatment with sedation, physical therapy, strapping, injection of analgesics about the coccyx, and even coccygectomy have too frequently given little or no relief to the patient, Thiele (2) as a result of careful observation over a period of years believes that the pain in this condition results from tonic spasm of the pelvic muscles which insert into the lateral margins of the coccyx. He reports that as early as 1859. Sir J. Y, Simpson described this mechanism by calling attention to the fact that, "when the coccyx or the coccygeal joints have been injured, or when the surrounding tissues were the seat of inflammation, any contraction of the muscles attached lo the coccyx would excite the characteristic pain of coccygodynia." Thiele demonstrated the definite relationship between the syndrome of coccygodynia and tonic spasm of the levator ani and coccygeal muscles, and in some cases of the piriformis. In 53 patients with coccygodynia personally treated by this author, the physical findings were described as follows: "On digital rectal examination with the patient in the Sims' position, spasm of the levator ami coccygeus is easily detected by latcro-posterinr pressure, the spastic muscles lieing felt stretched from their origin at the arcus tendineus or ischial spine to the side of the coccyx ami the lower part of the sacrum." Piriformis spasm is difficult to detect because the distance of this muscle from the anus makes palpation uncertain.

My personal experience with 12 patients from the Proctological Clinic at the New York Hospital and 8 patients seen in the naval service afloat and ashore, all of whom suffered with coccygeal pain, completely confirms Thiele's findings. However, an added finding, to my knowledge not previously described, was found in about half of the cases seen. This was the presence of well-developed bursae which on finger palpation were found in the lateral pelvis situated between the pubo-coccygeus and the ileo-coccygeus portions of the levator ani. These averaged about 1,5 x 3 cm. in size, were flat, oval, crepitant, and during the acute phase, were exquisitely tender. It is readily conceivable that levator-coccygeus bursitis resulting from injury or infection can cause coccygodynia.

The definitive treatment of coccygodynia is directed toward alleviating muscle spasm. The technic originally described by Thiele places the patient on the table in the Sims' position with the Operator's cotted finger inserted full length into the rectum. He continues "Latero-posterior pressure will place its flexor surface horizontally across the surfaces of the levator ani and coccygeus muscles almost at a right angle to their fibers. These muscles are massaged in the long direction of their fibers in the same manner that a strop is stroked by a razor. Massage is begun lightly. This is necessary because one does not wish to traumatize the extremely tender spastic muscles. As the patient makes subsequent visits, massage is made with increasing pressure. If definite improvement does not result after the first four to six massages over a period of a week or ten days. orthopedic consultation should be sought." My patients were treated every other day for two weeks, then twice weekly for two weeks, and continued at this rate until symptom free. If no improvement was obtained after six treatments, the case was considered a therapeutic failure for this method. Of these, 66% were cured. 30% improved, and 4% or 2 patients were unimproved. My own experience with this method fully confirmed Thiele's good results with massage treatment. Those with tender inflamed bursae did well on massage, the size and tenderness of the bursae subsiding with clinical improvement.

In brief, the syndrome of coccygodynia is associated with tonic spasm of the para-coccygeal muscles and in some instances, with related bursitis. These conditions were commonly cured or alleviated by repeated finger massage of the para-coccygeal muscles, the aim of which is directed toward relieving pain-producing spasm.

Proctalgia Fugax ...... ..

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