What's the next step for an 80-year-old female (F) with rectal pain for 7 months after undergoing anterior colporrhaphy, bilateral sacrospinous ligament fixation colpopexy, and cystoscopy, with over-the-counter (OTC) medications being ineffective?

Management of Post-Surgical Rectal Pain in an 80-Year-Old Female

For an 80-year-old female with persistent rectal pain for 7 months following pelvic floor surgery, a comprehensive evaluation with multimodal pain management is necessary, including neuropathic pain medications, pelvic floor physical therapy, and appropriate imaging to rule out structural complications.

Initial Evaluation

Imaging Studies

• Defecography (fluoroscopic cystocolpoproctography) should be performed as the first-line imaging test to evaluate for:

  • Structural abnormalities that may have developed post-surgery
  • Clinically occult sigmoidoceles, enteroceles, or rectoanal intussusceptions
  • Rectocele or other anatomic disturbances 1
  • Functional issues like pelvic floor dyssynergia

• MRI of the pelvis if complex issues are suspected:

  • Superior for evaluating pelvic floor muscles and potential complications
  • Can identify occult abscesses, fistulas, or mesh-related complications 2

Laboratory Assessment

• Complete blood count and inflammatory markers (CRP, ESR) to rule out infectious complications
• Basic metabolic panel to assess renal function, especially if considering certain medications 1

Treatment Approach

Pharmacological Management

1. First-line medications:

   • Multimodal analgesia with acetaminophen and NSAIDs to reduce pain by approximately 30% 1
   • Consider topical anesthetics like lidocaine gel for temporary relief 2

2. For neuropathic pain component:

   • Tricyclic antidepressants (starting with low doses appropriate for elderly patients) are recommended for rectal pain, particularly when frequent or severe 1
   • Consider gabapentin or pregabalin as alternatives if TCAs are contraindicated 3

3. Avoid or use cautiously:

   • Opioids (risk of dependence and constipation in elderly)
   • Certain NSAIDs like ibuprofen, diclofenac, and celecoxib if there are concerns about anastomotic integrity 1

Non-Pharmacological Interventions

1. Pelvic floor physical therapy:

   • Recommended as first-line treatment for post-surgical pelvic floor dysfunction
   • Focuses on relaxation techniques and proper coordination of pelvic floor muscles 1

2. Biofeedback therapy:

   • Particularly effective for patients with levator spasm or anismus
   • Studies show 43% of patients report good to excellent pain relief with this approach 4

3. Electrogalvanic stimulation:

   • Consider for patients who fail to respond to other therapies
   • Approximately 38% of patients report good to excellent pain relief 4

Advanced Interventions (if conservative measures fail)

1. Steroid caudal blocks:

   • Consider for refractory pain, though success rates are lower (18%) 4

2. Surgical consultation:

   • If imaging reveals structural abnormalities requiring correction
   • For patients with complications like mesh erosion or recurrent prolapse 1

Follow-up and Monitoring

• Re-evaluate after 3-6 weeks of initial treatment 1
• If treatment is unsuccessful, consider additional studies based on symptom pattern
• Monitor for medication side effects, particularly in elderly patients

Important Considerations

• Rectal pain following pelvic floor surgery is often neuropathic in origin and requires multimodal analgesic approaches 1
• Persistent pain may indicate occult complications or functional disorders not immediately apparent
• The presence of levator spasm, coccygodynia, or pudendal neuropathy should be evaluated as potential causes 4
• Avoid invasive and irreversible therapeutic procedures without clear evidence of benefit 3

Remember that chronic rectal pain can significantly impact quality of life, and addressing both physical and psychological aspects of pain is essential for comprehensive management.