Poster 109: Phantom rectum pain: an intractable pain syndrome: a case report.1

Abstract Setting: Outpatient physical medicine clinic. Patient: A 74-year-old woman with ulcerative colitis. Case Description: The patient underwent a total colectomy with an ileostomy 6 years before presentation. 4 years later, after initiating a stationary bicycle exercise program, she developed intractable pain in the sacrococcygeal, perianal surgical area. Imaging studies of the rectal area failed to identify an anatomic derangement or source of pain. Failed trials of multiple analgesic medications included nonsteroidals, antidepressants (3), muscle relaxants (3), opioids (5), and antiepileptic drugs (4). Anesthetic interventions, including perianal lidocaine with steroid injections, lumbar epidural steroid injections, and phenol to the sacral nerves, provided no relief. Intrathecal morphine pump and implanted spinal stimulation trials failed to provide any benefit and were discontinued. Assessment/Results: Intractable sacrococcygeal perianal pain in the absence of a rectum with no response to intense medical and peripheral treatment supported a central or phantom pain syndrome mandating a different conceptual pain rehabilitation approach. Discussion: On referral to our rehabilitation clinic, coordinated physical and psychologic therapy combined with use of high-dose opioids (300μg of transdermal fentanyl; 80mg of methadone), adjunctive medications, and botulinum toxin type A injections to pubococcygeus and pelvic floor muscle pain generators offered a modicum of pain relief. Conclusions: Phantom pain presenting in unusual nonlimb areas has been reported in descriptions of anatomic loss. Phantom rectum pain syndrome was defined by the location, character of pain, and nonresponse to peripheral treatment. Conceptual categorization of intractable nonlimb pain as phantom pain allows for an enhanced biopsychosocial approach to pain resource utilization.