F. Functional anorectal disorders

 Bharucha AE, et al.: Functional Anorectal Disorders.

Gastroenterology 2006:130:1510-1518

The following schedule outlines the days and times Takano Hospital receives patients who would like to consult with and be examined by one of our physicians:

 

Time	Monday	Tuesday	Wednesday	Thursday	Friday
8:30– 11:30	X	O	O	O	X

 

To speed up the registration process please download and fill-out the questionnaire in the PDF file below before visiting the hospital.





Neurogenic Intrapelvic Syndrome (NIS)

What is neurogenic intrapelvic syndrome (NIS)?

There are many patients who complain of chronic anal and pelvic pain that unfortunately, is mistakenly thought to originate from the sacrum, coccyx, ligament or muscle. Although the patients visited many clinics and hospitals, the ailment was not properly treated, and these patients suffered from the pain for long periods of time. However, when they were thoroughly examined, it was found that the origin of their pain was the tender indurations along their pudendal nerve. In addition to the pain, they often complain of constipation, incontinence of stool, flatus caused by dysfunctions of the anus, difficult evacuation and/or a feeling of incomplete evacuation caused by dysfunctions of the rectum, abdominal pain and a feeling of fullness due to fecal matter and gas build-up in the colon. We named the combination of these symptoms the “Neurogenic Intrapelvic Syndrome” (NIS) and we treat them as a single syndrome. One of the most common characteristics of NIS is the palpation of tender indurations along the pudendal nerve, which plays an important role in defecation and urination in conjunction with the intrapelvic splanchnic nerves. The pudendal nerve innervates the urethra and anus and the intrapelvic splanchnic nerves innervate the urinary bladder and rectum. In NIS, the above-mentioned complex combination of the 5 symptoms creates a syndrome that is caused by the disorders of the two nerves. The pain observed in NIS often intensifies and continues to the point where it may cause psychological problems.

Age distribution    
    
Quite a few people come to our hospital complaining of symptoms related to NIS. The figure to the right shows a wide age distribution of both male and female patients, with the majority of them being elderly, who suffer from NIS.







The 5 symptomatic groups of NIS

Here, the 5 symptomatic groups of NIS are explained in more detail. In most of the NIS cases, the 5 groups of symptoms appear in various combinations. Moreover, NIS resembles the common cold which is usually accompanied by such symptoms as: sneezing, runny nose, coughing, fever, and headaches.

1. Anal pain
It is a dull pain that usually increases when patients sit for a long period of time. When examined, tender indurations are found along the pudendal nerve at the lateral sides of the sacrum. Digital compression of the nerve elicits the same kind of pain the patient usually experiences.
2. Incontinence
Some patients complain of a leakage of stool and/or flatus. The function of the pudendal nerve is to control anal motility and anal sensation. The disturbance of this nerve will result in a lack of motility and sensation leading to incontinence of stool and flatus. On the other hand, In some cases, evacuation becomes difficult.
3. Defecatory disturbances
Defecation is prompted by the motility and sensation of the anus and rectum. The pelvic nerve and the intrapelvic splanchnic nerves originating from the 2nd, 3rd and 4th sacrum trigger the sensation and motility of the rectum. When either or both of the nerves are damaged, the functions of the anus and/or the rectum are impaired resulting in difficult evacuation.
4. Abdominal symptoms
Colonic functional disturbance usually results in abdominal pain and distention. When stool accumulates in the rectum by rectal and anal dysfunction, the colon becomes spastic in order to evacuate the stagnant stool. The result is that it becomes even more difficult to pass the stool through the spastic colon. The abdominal symptoms are somewhat similar to those of IBS.
5. Lumbar spine symptoms
Lesions of the lumbosacral bones and/or cartilage disks result in lumbago and impairment of the sacral nerves.
 

 

The syndrome appears with high combination rates with other symptoms.

                              
Flow chart from first consultation to treatment

Patient History and examination
The patients are asked detailed questions relating to their present symptoms and then a physical examination is performed. Once that has been completed, each individual patient is given a thorough colon and anorectal examination. The kind of examination depends on the individual symptoms.
↓
Diagnosis
The data obtained from the patients’ present health condition, the physical examination and the colorectal functional examination are carefully analyzed to make a precise diagnosis. The results and appropriate treatment are then explained to the patient.
↓
Treatment
Appropriate treatment is selected depending on the kinds of symptoms.

 Examinations
① Cutaneous sensation
② Anal manometry
③ Rectal sensation
④ Anal sensation
⑤ Anal compliance
⑥ Rectal compliance
⑦ Anorectal reflex
⑧ Evacuation capability
⑨ Electromyography
⑩ Pudendal nerve terminal motor latency assessment
⑪ Anal ultrasonography
⑫ Defecography
⑬ Colonic transit time
⑭ Gastrocolic reflex
⑮ Imaging of residual stool
⑯ Imaging of intrapelvic multiple organs
⑰ Dynamic contrast roentgenography of intrapelvic organs
⑱ Three-dimensional computed tomography of intrapelvic organs
⑲ Spinal roentgenography
⑳ Spinal MRI



Treatments

Pharmacological treatment
Appropriate analgesics and sedatives are selected according to the quality and degree of pain experienced by the patient. This medication in conjunction with the use of laxatives help for proper defecation, softens the stool, and influences the motility of the digestive tract. Moreover, psychosomatic medicine may also be prescribed to patients who suffer from depression and anxiety.
Physical therapy
1. Physical exercises
This includes intrapelvic muscle exercises to create proper posture and improve anorectal motor function. These exercises are done at the hospital around the first 2 weeks and then can be performed at home on their own.
2. Physical therapy using low frequency electric waves is useful for stimulating inactive muscles caused by neurogenic disturbance. Also, near-infrared therapy is useful for healing neural inflammation.
3. Improving anorectal functions  -Biofeedback (BF) therapies-
Recovery of anorectal functions is obtained by letting the patients sense the pressure by observing the EMG of their own anal sphincters. In addition to the above-mentioned sphincteric exercises, BF is also useful for such things as the recovery of anal sensation, rectal sensation and motility.
Psychological treatment
Counseling and autonomic training is used to help patients relax and alleviate mental stress caused by this syndrome.
Acupuncture
Acupuncture is used to improve the blood flow in various parts of the body. This form of treatment enhances neurological functions which helps decrease patient stress, and enhances the body’s natural healing abilities.
Nerve block
Nerve block is performed as a treatment for lumbago and sacral and pudendal pain.

*Operational therapies
Sphincter-plasty is used for severe cases of incontinence. Elevation of the intrapelvic organs and levator muscle is performed for severe descent of the intrapelvic organs.

Symptoms and Recommended Treatments
Suitable treatments are selected for various statuses

 
Results

The results of the above-mentioned treatments over a five year period (2001-2005) are outlined below.  When the 5 main symptoms are individually analyzed, 60-70% of the symptoms disappeared in both men and women within 9 months. When the number of patients who exhibit an improvement in their condition is added, the efficacy rate of the treatment is further increased to around 80%. Recurrence is one of the characteristics that tend to accompany this syndrome. For instance, about 10% of all the patients experience recurrence in the form of tenderness of the pudendal nerve. However, with further treatment, the tenderness in 50% of those cases disappears.
 


For the effective treatment of this syndrome, a well-organized medical team and collaboration among the various hospitals is needed. This syndrome is very complicated because it has many symptoms and a simple approach to this syndrome is ineffective. To avoid this, a well collaborating medical team consisting of many professionals such as medical doctors, pharmacists, nurses, laboratory technicians, radiologists, physiotherapists, nutritionists, medical social workers, and coordinators are needed.
 
NIS Ginnan Kai
The Ginnan Kai is a meeting consisting of the NIS patient’s group. The aims are to exchange information, facilitate learning and education, and to create lasting friendships. These meetings are held three times a year and the contents are uploaded to the home page.

The NIS concept is a new one and rather difficult to understand and be accepted as a single syndrome. Therefore, in order to overcome this situation, I have spent a year traveling all over Japan to lecture at various coloproctology meetings.

Masahiro TAKANO M.D.
Takano Hospital
Center for the treatment of Functional Anorectal Disorders


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