Case Presentation

Lisa Marie Ruppert, MDAssistant Attending-Rehabilitation ServiceAssistant Program Director-Cancer Rehabilitation FellowshipAssistant Professor of Rehabilitation Medicine-Weill Cornell Medical College

Disclosure

• I have NO RELEVANT financial disclosures.

Case Presentation-Rectal Pain

•DF is a 58 year old female with history of rectal cancer status post low anterior resection in 2001. • She was noted to have osseous and pelvic recurrence in 2008 for which she is status post tumor resection, partial sacrectomy, FOLFOX chemotherapy and radiation therapy. •Her course was complicated by bowel dysfunction and rectal pain

History

• Her symptoms started in 2009 after completion of radiation therapy. • Pain description:– Sharp and localized to the rectum – Constant– Pain increases prior to/with bowel

movements – Associated with a sensation of

spasm/tightness with passage of stool

History

• Bowel pattern– She noted significant constipation

followed by incontinence with soft stool consistency

– Self managed with manual disimpaction 6-7 times per day

History

• She is followed by Palliative Medicine for her pain– Prior treatments have included:

• Hypogastric plexus neurolysis 9/2014• Fentanyl patch 300micrograms every 48 hours• Fentanyl buccal tablet 400micograms as needed• Oxycodone IR 30mg orally every 8 hours as

needed• Gabapentin 300mg orally every 8 hours• Belladonna-opium rectal suppository as needed• Hydrocortisone rectal suppository as needed

• She was referred for recommendations on bowel program and therapeutic modalities for her pain

Question

•What is the mechanism of action of Belladonna and Opium suppositories?

A. Smooth muscle contraction and pain reliefB. Smooth muscle relaxation and pain reliefC. Skeletal muscle contraction and pain reliefD. Stool softener and pain relief

Answer B

• Belladonna and Opium suppository mechanism of action– The pharmacologically active agents

present in the belladonna component are atropine and scopolamine which block the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands, and the CNS causing a relaxation of smooth muscle and drying of secretions. The principle agent in opium is morphine which binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways, altering the perception of and response to pain.

History

• Past Medical History– Hyperlipidemia

• Family History– Parents: MI– Paternal grandfather: rectal cancer–Mother, maternal aunt: breast cancer

History

• Review of Systems– As per history– No urinary frequency, urgency,

hematuria, dysuria, incontinence– No tingling, numbness or weakness

in the lower extremities– No saddle anesthesia

Physical Examination

• CN II-XII grossly intact• ROM full except to hip flexion bilaterally

which was decreased-resulted in pelvic floor pain• Strength 5/5 throughout the bilateral upper

and lower extremities• Sensation intact to light touch and pinprick

except to S2-S5 bilaterally which was decreased when compared to face• Reflexes 2+ and symmetrical throughout

Physical Examination

• Rectal examination– Radiation skin changes and fixed scar

tissue to perineum– Tight rectal sphincter– DAP present– VAC-difficulty coordinating both

contraction and relaxation on command, tone was decreased

Assessment

• Rectal pain and bowel dysfunction were thought to be related to scar tissue involving the pelvic floor musculature and sphincter from surgical intervention and radiation therapy and nerve injury from surgical intervention, radiation therapy and possibly chemotherapy

Recommendations

• Bowel program– Psyllium (e.g.Metamucil)– Adequate hydration– Dietary modifications– Pelvic floor therapy for scar tissue

mobilization, sensory retraining, biofeedback and muscle coordination

• Pain management– Follow up with Palliative Medicine – Pelvic floor therapy– Lidocaine gel 3ml per rectum prior to bowel

movements

Question

•What is the role of psyllium in management of constipation?

A. Acts as a stool softenerB. Increases peristalsis and reduces transit timeC. Decreases peristalsis and increases transit timeD. Results in relaxation of the internal/external anal sphincters

Answer B

• Psyllium is a soluble fiber. It absorbs water in the intestine to form a viscous liquid which promotes peristalsis and reduces transit time.

Question• Which of the following is the correct sequence of

events in normal defecation?A. Colonic contraction to move stool from colon to rectum, rectal distension, relaxation of the internal anal sphincter, conscious urge, relaxation of external anal sphincter and puborectalis muscles allowing defecationB. Colonic contraction to move stool from colon to rectum, rectal distension, relaxation of external anal sphincter and puborectalis muscles, conscious urge, relaxation of the internal anal sphincter allowing defecationC. Colonic contraction to move stool from colon to rectum, relaxation of the internal anal sphincter, relaxation of external anal sphincter and puborectalis muscles, conscious urge, rectal distension allowing defecationD. Conscious urge, colonic contraction to move stool from colon to rectum, rectal distension, relaxation of the internal anal sphincter, relaxation of external anal sphincter and puborectalis muscles allowing defecation

Answer A

• The sequence of events in normal defecation includes colonic contraction to move stool from the colon to the rectum. Stool then distends the rectum, stretching the puborectalis muscle resulting in reflex relaxation of the internal anal sphincter. Conscious urge to defecate then occurs. Under voluntary control, the external sphincter and puborectalis muscles relax, allowing defecation.

Kirshblum, S. Campagnolo, D. Spinal Cord Medicine. Second Edition. Wolters Kluwer/Lippincott Williams and Wilkins. Philadelphia. 2011

Initial Follow up

• Patient reported– Difficulty with manual therapies,

therapy focused on biofeedback and muscle coordination

– Still required manual removal of stool 6-7 times per day

– Had not initiated psyllium– Lidocaine variable efficacy

Initial Follow Up Recommendations

• Initiation of psyllium and stressed hydration and dietary modifications•Collaborated with Women’s Health – Discontinued Belladonna opium ,

hydrocortisone, lidocaine gel– Initiated diazepam suppository

nightly– Continued pelvic floor therapy

Further Follow up

• Patient reported– Initiated psyllium and working

towards all dietary modifications– Continued use of diazepam

suppository– Improved tolerance with manual

therapies– Daily bowel movement followed by

rectal check to ensure emptying

Follow up

• Improved understanding of pain– Pressure-urge to defecate– Inflammatory pain/sensitivity during

passage of stool (intermittent, tolerable, resolves upon evacuation)

– Minimal pain between bowel movements• Activity based-resumed biking for cardiovascular

exercise• Decreased fentanyl transdermal to

100micrograms every 48 hours with hope of further titration

• Off breakthrough Oxycodone and fentanyl buccal