Chiarioni Giuseppe
COC di Valeggio s/M, Divisione di Gastroenterologia dell'Azienda Ospedaliero-Universitaria Integrata di Verona.
Recenti Prog Med. 2011 May;102(5):196-201. doi: 10.1701/659.7668.
Chronic proctalgia is defined by chronic or recurrent episodes of rectal pain or aching lasting at least 20 minutes in the absence of structural or systemic disease explanation for the pain syndrome. Digital rectal examination distinguishes between levator ani syndrome where the patient reports tenderness on palpation of the pubo-rectalis muscle and unspecified functional anorectal pain where no pain can be elicited. There is no consensus on its etiology, but chronic tension of the pelvic floor muscles is the most common view. Diagnosis is focused on excluding organic diseases potentially responsible for the pain. A number of small sized, non-controlled trials have evaluated different treatments for chronic proctalgia with frustrating results for both patients and physicians. A recent well designed, prospective, randomized, controlled trial has evaluated the three most commonly prescribed treatments to relax pelvic floor muscles in chronic proctalgia: biofeedback, electrogalvanic stimulations and digital massage of the levator ani. The study has provided unequivocal evidence that biofeedback is effective treatment for chronic proctalgia, but its efficacy is limited to levator ani syndrome. In these patients a paradoxical contraction of the pelvic floor muscles on attempted defecation has been documented in most cases and its therapeutic reversal do correlate with clinical benefit. Similar data have been also reported in constipation secondary to obstructed defecation. Electrogalvanic stimulation is somewhat effective and may be considered where high biofeedback expertise is not available. No treatment has been proven effective in unspecified functional anorectal pain where analgesic and antidepressant drugs retain a role in the absence of randomized, controlled trials.
慢性直肠疼痛的定义为，在不存在可解释疼痛综合征的结构性或全身性疾病的情况下，出现慢性或反复发作的直肠疼痛或酸痛，持续至少20分钟。直肠指检可区分耻骨直肠肌触诊时有压痛的肛提肌综合征和未明确的功能性肛门直肠疼痛（后者触诊时无疼痛）。其病因尚无共识，但盆底肌肉慢性紧张是最常见的观点。诊断重点在于排除可能导致疼痛的器质性疾病。一些小型、非对照试验评估了慢性直肠疼痛的不同治疗方法，结果令患者和医生都感到沮丧。最近一项设计良好的前瞻性随机对照试验评估了慢性直肠疼痛中最常用的三种放松盆底肌肉的治疗方法：生物反馈疗法、电刺激疗法和肛提肌数字按摩疗法。该研究提供了明确证据，表明生物反馈疗法是治疗慢性直肠疼痛的有效方法，但其疗效仅限于肛提肌综合征。在这些患者中，大多数病例记录到排便时盆底肌肉出现矛盾性收缩，而其治疗性逆转确实与临床获益相关。在排便梗阻继发的便秘中也报告了类似数据。电刺激疗法有一定效果，在没有高生物反馈专业知识的情况下可以考虑使用。在未明确的功能性肛门直肠疼痛中，尚无治疗方法被证明有效，在缺乏随机对照试验的情况下，镇痛药和抗抑郁药仍有作用。
