What are the treatment options for rectal spasms?

Treatment Options for Rectal Spasms

For patients suffering from rectal spasms, conservative management with antispasmodics, muscle relaxants, and pain management should be the first-line approach, with more invasive treatments reserved for refractory cases.

Initial Management

• Conservative measures should be attempted first for patients with rectal spasms, including gentle manual reduction under mild sedation or anesthesia if there is incarceration without signs of ischemia 1
• Patients should be placed in Trendelenburg position during manual reduction attempts to facilitate the procedure 1
• Analgesia or mild sedation should be administered before attempting any manual reduction techniques 1

Pharmacological Management

• Muscle relaxants:

  • Cyclobenzaprine (5 mg three times daily) has shown effectiveness in treating levator ani syndrome, which often presents with rectal spasms 2
  • Diazepam may be used to reduce muscle spasm in the rectal area 3

• Pain management:

  • For neuropathic rectal pain, adjuvant analgesics (such as anticonvulsants or antidepressants) can be effective 4
  • NSAIDs can be used for inflammatory causes of rectal pain and spasm 3

Advanced Treatment Options for Refractory Cases

• Physical therapy approaches:

  • Electrogalvanic stimulation (EGS) has shown 38% success rate in chronic rectal pain cases 5
  • Biofeedback therapy has demonstrated 43% success rate and can be particularly helpful for patients with evacuation disorders 5, 1
  • Pelvic floor biofeedback therapy is especially effective for patients with fecal seepage due to evacuation disorders 1

• Injection therapies:

  • Steroid injections may be considered, though they have shown lower success rates (18%) compared to other therapies 5
  • Botulinum toxin injections can be considered for severe, persistent cases 3

• Surgical interventions:

  • Only indicated when conservative management fails and in cases of complications such as rectal prolapse 1
  • For patients with complicated rectal prolapse, the decision between abdominal and perineal procedures should be based on patient characteristics and surgeon expertise 1
  • Immediate surgical treatment is required for patients with signs of shock or gangrene/perforation of prolapsed bowel 1

Diagnostic Workup for Persistent Cases

• Anorectal manometry should be performed to identify anal weakness, reduced or increased rectal sensation, and impaired rectal balloon expulsion 1
• Anal imaging with ultrasound or MRI can identify anal sphincter defects, atrophy, and a patulous anal canal 1
• For patients with suspected rectal prolapse, physical examination including rigid proctoscopy is essential 1

Common Pitfalls and Caveats

• Many patients considered refractory to conservative therapy may not have received an optimal trial, which should include meticulous characterization of bowel habits and circumstances surrounding symptoms 1
• For patients with diarrhea-associated rectal spasms, dietary modifications to eliminate poorly absorbed sugars (sorbitol, fructose) and caffeine should be attempted 1
• Loperamide (2 mg) taken 30 minutes before breakfast and titrated up to 16 mg daily can be effective for diarrhea-associated rectal spasms 1
• The failure rate of non-operative management for incarcerated rectal prolapse is high, and therefore should not delay surgical treatment when indicated 1
• Avoid invasive and irreversible therapeutic procedures without first attempting conservative management 3

Special Considerations

• For patients with fecal seepage and evacuation disorders causing rectal spasms, rectal cleansing with small enemas or tap water can reduce stool leakage 1
• In cases of bile-salt malabsorption causing diarrhea and rectal spasms, cholestyramine or colesevelam may be helpful 1
• Anticholinergic agents and clonidine are alternative options for patients with diarrhea and associated rectal spasms 1