Relief for rectal pain after surgery

OurVoice Vol.14 - No.3

I have been having severe rectal pain since my prostate cancer surgery a year ago. A colonoscopy ordered by my GP showed no problems, and medications prescribed by an internist didn’t provide any relief. My surgeon then referred me to a physiotherapist, who showed me some simple exercises. After two appointments, the pain was gone! Is rectal pain common after prostate surgery? How do these exercises work, and wouldn’t it be a good idea for men with this problem to be referred to a physical therapist sooner?

Mild rectal/pelvic pain is quite common following prostate surgery. This pain usually improves after two weeks. On the other hand, severe pain is uncommon. Men who develop severe pain should contact their surgeon to rule out possible causes such as urinary tract infection, bladder neck contracture, hemorrhoids, anal fissure and rectal diseases, to name a few.

Once the surgeon has ruled out nonmuscular causes of pelvic pain after surgery, a referral could be made to a physiotherapist for assessment. The timeframe depends on the tests done by the surgeon and other medical assessments needed. Physiotherapy can then be safely initiated, and can benefit patients who have pelvic pain syndromes that are muscular in origin. It has been proposed that pelvic floor pain arises from spasms, tension or overactivity in one or more of the pelvic muscles (levator ani, coccygeus, piriformis); the referred pain can then be felt around the rectum and anus.

How do these exercises work? Most pelvic floor muscle exercises for pelvic pain syndromes focus on de-training; they are based on the principle that an overactivated muscle should not be further loaded with active exercise until normal, pain-free range and contractile activity have been restored. Relaxation exercises are often combined with a cognitive-behavioural approach involving imagery and desensitization.

A general example used to regain normal movement or contractile activity and reduction of pain would involve contracting the pelvic floor for a period of time (five seconds), then focusing on relaxing the same muscle structures for a period of time (10 seconds) while imagining the muscle melting away. Depending on your specific situation, the exercises would vary. Your physical therapist would perform an assessment and, based on the findings, develop an exercise program for your specific needs. Overall, the purpose of pelvic floor exercises is to increase extensibility and eradicate trigger points, regain normal movement and
contractile activity, and reduce pain.

Biofeedback modalities may be another form of therapy used to re-educate the contractile element of the muscle tone of the pelvic floor. Other options might include: education, counselling on lifestyle modifications, cognitive-behavioural interventions, manual therapy, voiding and defecation training, surface electromyography (EMG; a technique in which electrodes are placed on the skin to detect the electrical activity of a muscle), biofeedback using intra-anal squeeze pressure (manometry), ultrasound imaging, electrical stimulation (TENS), electrical muscle stimulation (EMS), and application of heat and/or cold.

If all else fails, this circumstance could be reflective of postoperative neuropathic pain, and referral to a pain specialist or pain clinic would be appropriate.  

Bill P. Landry, BScPT, BScH, CAFCI, MCPA, is a Principle and Senior Physiotherapist at the Family Physiotherapy Centre in London, Ontario.