Rectal pain of neural origin: Resection of sensory rectal branches of pudendal nerve

Background A neural origin should be considered in the differential diagnosis of rectal pain if the onset of the pain is in relationship to previous surgery on the anus or rectum. Study Design A retrospective cohort was identified by computer search of office files from May 2010 to December 2012. Seven patients, two males, and five females, were identified who have been treated surgically for complaints of isolated rectal pain arising from coloproctectomy in three patients (inflammatory bowel disease) and after hemorrhoidectomy in three patients and one patient with mesh placed for urinary incontinence. Patient's mean age was 52.5 years. Mean duration of pain was 29.9 months (range, 9-120 months). Diagnosis was demonstrated by an anesthetic block of the pudendal nerve. Surgical approach was excision of rectal sensory branches of the pudendal nerve in the ischiorectal fossa and implantation of these nerves into the gluteus maximus muscle. Results Outcome data are available, with a mean follow-up of 17.7 months (range, 13-30 months). Of the three coloproctectomy patients, two are considered excellent results and one a poor result. All three of the hemorrhoidectomy patients are excellent results. The one patient who had the mesh placement for urinary incontinence required two attempts to remove all sensory rectal branches and then achieved excellent pain relief. Conclusion Chronic rectal pain should be considered to have a pudendal neural origin after previous anal/rectal surgery. Resection of all rectal sensory branches can give excellent and lasting relief of pain.