Tenesmus
Lucy Walker28/08/2013
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):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• Midgley R & 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