1. Case Presentation Lisa Marie Ruppert, MD
Assistant Attending-Rehabilitation Service
Assistant Program Director-Cancer Rehabilitation Fellowship
Assistant Professor of Rehabilitation Medicine-Weill Cornell Medical College

2. I have NO RELEVANT financial disclosures.

3. 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

4. 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

5. History
Bowel pattern
She noted significant constipation followed by incontinence with soft stool consistency
Self managed with manual disimpaction 6-7 times per day

6. 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

7. What is the mechanism of action of Belladonna and Opium suppositories?
Question
What is the mechanism of action of Belladonna and Opium suppositories?
A. Smooth muscle contraction and pain relief
B. Smooth muscle relaxation and pain relief
C. Skeletal muscle contraction and pain relief
D. Stool softener and pain relief

9. 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.

10. Past Medical History Family History History Hyperlipidemia Parents: MI
Paternal grandfather: rectal cancer
Mother, maternal aunt: breast cancer

11. Review of Systems History As per history
No urinary frequency, urgency, hematuria, dysuria, incontinence
No tingling, numbness or weakness in the lower extremities
No saddle anesthesia

12. 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

13. Rectal examination Physical 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

14. 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

15. Recommendations Bowel program Pain management 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

16. What is the role of psyllium in management of constipation?
Question
What is the role of psyllium in management of constipation?
A. Acts as a stool softener
B. Increases peristalsis and reduces transit time
C. Decreases peristalsis and increases transit time
D. Results in relaxation of the internal/external anal sphincters

18. 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.

19. 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 defecation
B. 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 defecation
C. 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 defecation
D. 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

21. 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

22. Patient reported Initial Follow up
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

23. 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

24. Patient reported Further Follow up
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

25. 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