What is the treatment for tenesmus?

Treatment of Tenesmus

The treatment of tenesmus depends entirely on the underlying cause: sexually transmitted proctitis requires immediate empiric antibiotics (ceftriaxone plus doxycycline), inflammatory bowel disease requires disease-specific therapy, radiation proctitis responds best to argon plasma coagulation, bacterial dysentery needs fluoroquinolones or azithromycin, and malignancy-related tenesmus may require interventional procedures or neuropathic pain medications when opioid-refractory. 1, 2

Infectious Causes: Sexually Transmitted Proctitis

Immediate Empiric Treatment

• If anorectal pus is present on examination or polymorphonuclear leukocytes are found on Gram stain, initiate ceftriaxone 250 mg IM single dose PLUS doxycycline 100 mg orally twice daily for 7 days immediately without waiting for culture results. 1, 2
• For patients presenting with bloody discharge, perianal ulcers, or mucosal ulcers suggesting lymphogranuloma venereum (LGV), extend doxycycline to 100 mg twice daily for a total of 3 weeks. 1, 2
• Partners who had sexual contact within 60 days before symptom onset must be evaluated, tested, and treated presumptively. 1, 2

Diagnostic Workup

• Obtain detailed sexual history specifically asking about receptive anal intercourse, as this is the primary risk factor. 2
• Perform anoscopy to visualize rectal mucosa and identify inflammation limited to the distal 10-12 cm. 1, 2
• Test all patients for N. gonorrhoeae, C. trachomatis, T. pallidum, and HSV using NAAT or culture. 1, 2
• Perform HIV and syphilis testing in all persons with acute proctitis, as HIV status affects disease severity and treatment approach. 2

Inflammatory Bowel Disease

Symptom Recognition

• Tenesmus is a cardinal symptom of ulcerative colitis, particularly prominent in ulcerative proctitis, occurring alongside bloody diarrhea, urgency, and colicky abdominal pain. 3
• Up to 50% of patients develop pouchitis within 10 years after ileal pouch-anal anastomosis, with tenesmus being a defining symptom. 3

Symptomatic Management

• Loperamide can be used for symptomatic control: initial dose 4 mg followed by 2 mg after each unformed stool, with maximum daily dose of 16 mg. 4
• Probiotics may help restore intestinal microbiota in acute small bowel toxicity. 5
• Dietary counseling is essential, bearing in mind that nutrient malabsorption may occur. 5

Radiation-Induced Proctitis

Primary Treatment

• Argon plasma coagulation is the preferred modality for radiation-induced proctitis causing tenesmus and bleeding, with an 80% response rate. 1
• Multiple treatment sessions are typically required, with a median of 3 sessions needed to achieve control of bleeding and symptoms. 1
• This is a noncontact technique with limited depth of coagulation (2-3 mm), making it safer than other ablative methods. 1

Acute Management

• Acute radiation proctitis symptoms (diarrhea, cramps, tenesmus, urgency, mucus discharge, minor bleeding) typically resolve spontaneously following completion of treatment. 5
• Chronic radiation proctitis may not become apparent until 8-12 months after completing radiotherapy. 5

Bacterial Dysentery (Non-Sexually Transmitted)

When to Treat

• Empiric treatment with fluoroquinolone or azithromycin is indicated for ill immunocompetent patients with fever, abdominal pain, bloody diarrhea, and bacillary dysentery presumptively due to Shigella. 1
• Dysenteric symptoms (fever, tenesmus, blood and/or pus in stool) occur with Shigella, Salmonella, and Campylobacter infections. 1

Critical Pitfall

• Avoid antimicrobial therapy for STEC O157 and other STEC producing Shiga toxin 2, as this may worsen outcomes and increase risk of hemolytic uremic syndrome. 1

Malignancy-Related Tenesmus

Opioid-Refractory Pain

• When tenesmus is refractory to morphine escalation, methadone may be effective as it is lipophilic and exerts lesser activity on gastrointestinal opioid receptors. 6
• Burst ketamine (continuous subcutaneous infusion over 7 days, combined with midazolam and dexamethasone) can decrease pain in difficult-to-manage rectal tenesmus with neuropathic component. 7
• Antiarrhythmic drugs (mexiletine hydrochloride 150 mg in 3 divided doses orally, or continuous IV lidocaine 500 mg/day) may palliate symptoms when tenesmus is attributed to pelvic neurological dysfunction. 8

Non-Opioid Options

• Tricyclic antidepressants (nortriptyline 25 mg daily, amitriptyline 10 mg daily, or desipramine 25 mg daily) showed 61% significant improvement in patients with rectal prolapse-associated tenesmus, with nortriptyline and desipramine having 90-100% response rates. 9

Special Populations

HIV-Positive Patients

• Herpes proctitis can be especially severe in HIV-infected patients, causing particularly intense tenesmus and requiring antiviral therapy. 3, 2
• Cytomegalovirus causes severe proctitis with tenesmus in immunosuppressed HIV-infected patients. 3
• Opportunistic infections (Mycobacterium avium-intracellulare, Cryptosporidium, Microsporidium, Isospora) can cause enteritis with tenesmus. 3

Follow-Up Protocol

Infectious Proctitis

• Retest for gonorrhea or chlamydia 3 months after treatment to detect both treatment failure and reinfection. 2
• Patients with persistent symptoms after treatment require evaluation for reinfection, treatment failure, or alternative diagnoses. 2

Radiation Proctitis

• All patients should be evaluated during follow-up to assess late toxicity for early intervention by a specialist multidisciplinary team (gastroenterologist, nutritionist, surgeon). 5
• Patients recovering from initial complications remain at risk of late and persistent adverse events. 5

Common Pitfalls to Avoid

• Failing to obtain detailed sexual history in patients with infectious proctitis leads to missing sexually transmitted causes. 3
• Not assessing HIV status dramatically affects disease severity and treatment approach. 3
• Assuming all tenesmus in inflammatory bowel disease patients represents active colitis overlooks pouchitis, cuffitis, or irritable pouch syndrome. 3
• Missing malignancy when soft tissue mass or malignant-appearing lymphadenopathy accompanies anorectal inflammation delays diagnosis. 3
• Overlooking medication-induced causes, particularly NSAIDs, which can exacerbate ulcerative colitis. 3