Tenesmus

1. Tenesmus Lucy Walker 28/08/2013

2. 2010 Palliative Medicine Curriculum • “Know about the causes of tenesmus” • “Assessment and management of tenesmus”

3. Overview • Definition • Mechanism • Causes • Assessment • ??Investigations • Management Options

4. By the end of the session • Refreshed memory on causes of tenesmus • Better understanding of treatment options and their evidence base

5. Tenesmus • A sensation of incomplete evacuation • Often accompanied by a sensation of urgent or abnormally frequent desire to defecate with involuntary straining, but little bowel movement • Can experience painful spasm of the anal sphincter or smooth muscle

6. Mechanism • Disorder of rectal motilitydue to: • Reduced compliance • High amplitude pressure waves in rectal wall • Increased sensitivity to distension • Mixed nocioceptive and neuropathic elements

7. Causes • Carcinoma esp of rectum • Post radiotherapy • Faecal Impaction • Rectal prolapse/ polyps/ fissure/ adenoma/ internal haemorrhoids • Inflammatory Bowel Disease/ Proctitis • Foreign Body • Infection

8. Assessment • When did it start? • Is there a constant urge to empty bowels and how much stool is passed? • Any abdominal pain and where? • Any diarrhoea and vomiting? • Is blood passed? • Any unusual or high risk foods? • Ill contacts?

9. Investigations?? • Patient dependant • Might consider: • Stool culture • Inflammatory markers • Sigmoidoscopy or colonoscopy

10. Management • Depends on underlying cause • Prevent constipation with stool softeners • Treat faecal impaction • Antibiotics if confirmed infection

11. Opiates • Often a poorly opiate responsive pain (Hanks, 1991) but… • Should still be tried • ?Methadone • Mercadante et al (2001) • 1 case report suggesting benefit when escalating Morphine doses unhelpful

12. Adjuvant Analgesia • Anticonvulsants • Amitriptyline • Use with caution as can cause constipation and exacerbate symptoms • NSAIDs

13. Steroids • Dexamethasone 4-16mg may provide some relief • Peritumour oedema • inflammation

14. Nitrates & Calcium Chanel Blockers • GTN paste or 2% ointment • Often not tolerated due to headache • Nifedipine • McLoughlin & McQuillan, 1997 • Reduce smooth muscle spasm so can help with elements of tenesmus pain • Case series evidence (3/4 patients gained benefit) • 10 to 20mg BD M/R preparation

15. Radiotherapy • Can be helpful for symptom control especially if a locally advanced rectal tumour (Midgley & Kerr, 1999) • Less effective in patients who have had surgery • May be most useful in those who have not received chemotherapy

16. Lumbar Sympathectomy • Bristow (1988) • Prospective study • Bilateral chemical lumbar sympathectomy with phenol • 12 patient with cancers and tenesmus unresponsive to pharmocological agents • 80% gained complete pain relief, 1 partial and 1 no relied • All remained symptom free to latest follow up (7 months) • 1 patient had hypotension post op

17. Epidural or Intrathecals? • No papers specifically for tenesmus • Local anaesthetic or opiate • Lots of anecdotal reports

18. Endoscopic Laser Treatment and Metal Expandable Stents • Laser Treatment: • Gevers (2000) • Palliative laser therapy for symptom control • 80% (21) of those with “other symptoms” (including tenesmus) gained symptom relief until death or end of study • 4% perforation rate and 5 (of 219) died due to procedure • Metal Expandable Stents: • Rey (1995) • Stents safe to insert and reduce laser sessions • ?more for relieving obstruction than tenesmus

19. Bulletin Board • Loperamide • Botox • ?for radiation proctitis • Anti-spasmodics at end of life

20. Summary • Mixed nocioceptive and neuropathic pain • Consider underlying cause and don’t forget non-malignant causes • Prevent constipation • Often unresponsive to opiates • No guidelines and no good evidence to recommend one treatment over another

21. References • Berger, Shuster & Von RoennEds. (2012) Principles and Practice of Palliative Care and Supportive Oncology. Lippincott William & Wilkins, US • Bristow A & Foster JMG (1998) Lumbar Sympathectomy in the management of rectal tenesmus pain. Annals of the Royal College of Surgeons of England. 70: 38-9 • Gervers AM et al (2000) Endoscopic laser therapy for palliation of patients with distal colorectal cancer: analysis of factors including longterm outcome. Gastrointestinal Endoscopy. 51(5):580-5 • Hanks (1991) Opioid-responsive and opioid non-responsive pain in cancer. British Medical Bulletin. 47(3):718-731 • McLoughlin R & McQuillan R (1997) Using Nifedipine to treat tenesmus. 11: 419 • Mercadante et al (2001) Methadone in treatment of tenesmus not responding to morphine escalation. Support Care Cancer 9:129-30 • MidgleyR & Kerr D (1999) Colorectal Cancer. Lancet 353:391-99 • Rey J-F et al (1995) Metal stents for palliation of rectal carcinoma: a preliminary report. Endoscopy. 27(7):501-4 • Sedgwick et al (1994) Pathogenesis of acute radiation injury to the rectum. International Journal of Colorectal Disease. 9:23-30 • book.pallcare.info • Palliativedrugs.com • Oxford Handbook of Palliative Medicine • If you can access them: • Rich A, Ellershaw E. Tenesmus / rectal pain - how is it best managed? CME Bulletin Palliat Med 2000;2(2):41-44  • Hunt RW. The palliation of tenesmus. Palliat Med 1991;5:352-53