Tenesmus Lucy Walker 28/08/2013

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

Overview Definition Mechanism Causes Assessment ??Investigations Management Options

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

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

Mechanism Disorder of rectal motility due to: – Reduced compliance – High amplitude pressure waves in rectal wall – Increased sensitivity to distension Mixed nocioceptive and neuropathic elements

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

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?

Investigations?? Patient dependant Might consider: – Stool culture – Inflammatory markers – Sigmoidoscopy or colonoscopy

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

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

Adjuvant Analgesia Anticonvulsants Amitriptyline – Use with caution as can cause constipation and exacerbate symptoms NSAIDs

Steroids Dexamethasone 4-16mg may provide some relief – Peritumour oedema – inflammation

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

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

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

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

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

Bulletin Board Loperamide Botox – ?for radiation proctitis Anti-spasmodics at end of life

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

References Berger, Shuster & Von Roenn Eds. (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): 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: Midgley R & Kerr D (1999) Colorectal Cancer. Lancet 353: 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