Management of chronic perineal pain-case report

[mary jane]

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* Pain Management Centre, Royal Infirmary Hospital, Leicester (UK)

Correspondence: Waqas Ashraf Chaudhary, University of Leicester, LE1 6TP, Leicester (UK); E-mail: wacc1@le.ac.uk

ABSTRACT

The management of a case of perineal pain with a combination of treatment modalities is presented. A 42-year-old female with severe chronic perineal pain was unable to sit and work. Interventional pain management technique was applied to get rid of pain. At the end of treatment, the patient recovered completely, was able to sit and returned to work as a postal employee.

Key Words: Perineal pain; NSAID; Caudal block; Amitryptaline; Perineum; Visual analogue scale (VAS)

Citation: Chaudhary WA. Management of chronic perineal pain. Anaesth Pain & Intensive Care 2011;15(3):170-172.

INTRODUCTION

Chronic perineal pain is a debilitating condition with a significant impact on the quality of life affecting both genders. Urogenital and gastrointestinal disorders might be the presenting symptoms and offer a diagnostic dilemma to the primary care doctors and general practitioners (GP). Often, the pain localised to the perineum can be a warning sign of acute or chronic tissue injury to the abdominal and pelvic organs or structures, with no identifiable pathology.

Chronic perineal pain is an uncommon problem; its pathogenesis is unclear, and difficult to treat. The etiology of chronic perineal pain may include chronic abacterial prostatitis, autoimmune disease, psychosomatic disorder or other diseases. We present a case report of a patient in which perineal pain started insidiously, was internal, and finally, she was unable to sit and work and became depressed and scared.

CASE REPORT

A 42 years old female with a history of constant burning and dull aching pain in the anus was referred to pain clinic by her GP for pain management. The pain started insidiously about 6 years back, was intermittent and lasted for a short duration. The initial pain episodes were infrequent. Oral paracetamol and/or NSAID’s provided good pain relief in the beginning, but the frequency of pain episodes increased over a period of time. At the time of her reporting to our pain clinic, her pain was constant and localised to the anal area, affecting the work efficiency during day time and sleep at night. The VAS pain score was 6 throughout the wakeful hours. The pain tended to aggravate during defecation and lasted for several hours (VAS 8/10). The act of voiding the bowel was dreaded. The pain, however, did not interfere with sexual activity.

The initial relief experienced with the oral medication was no longer effective. An anal dilatation under general anaesthesia did not provide relief. Investigations such as sigmoidoscopy, proctoscopy, colonoscopy, CT scan and MRI did not reveal any pathology.

Her per-rectal examination revealed a tender, band like spot on the levator ani muscle at 3’o clock position below the Hilton’s line. A caudal epidural block with 0.25% bupivacaine in combination with 0.5mg morphine sulphate was administered and tab. amitriptyline 5mg PO advised 2 hours prior to bed time. There was complete pain relief (VAS 0/10) for a week. She had no difficulty in defecation and there was no post defecation burning pain. During this period she had good undisturbed sleep at night. The pain recurred with the same intensity after a week. A repeat caudal epidural block and oral tab. amitriptyline 5mg PO extended the duration of pain relief to three weeks. The recurrence of pain at the end of three weeks was less intense and was tolerable (VAS 5/10). Per rectal examination revealed the tender band spot on the levator ani muscle at the same 3’o clock position but with less pain intensity. She was advised gentle local massage of the tender band spot with 2% lignocaine gel three times a day for a fortnight. On follow up, the tender band spot was minimal on per rectal examination and the pain reduced considerably (VAS 2/10) on palpation. There was no difficulty to move bowel but the post defecation burning pain persisted for about half hour with less intensity (VAS 4/10). The continuous pain during wakeful hours was absent. A third caudal epidural block with 0.25% bupivacaine in combination with 0.5mg morphine sulphate provided complete pain relief. Oral amitriptyline 5mg was advised to be continued for another six months; after which, she was completely symptom free but remained worried about the recurrence. A reassurance and psychotherapy boosted her confidence. Follow up was advised for 4years.


source: http://www.apicareonline.com/case-repor ... se-report/