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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Tenesmus is a spurious feeling of the need to evacuate the bowels, with little or no stool passed. Tenesmus may be constant or intermittent, and is usually accompanied by pain, cramping and involuntary straining efforts. It can be a temporary and transient problem related to constipation. The term rectal tenesmus is sometimes used to differentiate from vesical tenesmus, which is an overwhelming desire to empty the bladder.
There are a number of possible causes of tenesmus. The most common is inflammatory bowel disease. Causes include:
- Crohn's disease.
- Ulcerative colitis.
- Anorectal abscess.
- Infective colitis.
- Colorectal tumours, especially polyps.
- Radiation proctitis: this may follow irradiation for tumours of other sites, such as bladder tumours, cervical carcinoma and prostatic tumours.
- Irritable bowel syndrome.
- Thrombosed haemorrhoids.
- Endometriosis: can affect the rectum and cause pain and tenesmus.
- Rectal chlamydia trachomatis infection: this is becoming more common in heterosexual females.
NB: tenesmus can be a common symptom in those patients with advanced colorectal, genitourinary or prostate cancer.
It is essential to make a thorough assessment to identify the cause of tenesmus. It is particularly important to consider serious underlying causes (eg, malignancy, inflammatory bowel disease) when there may be associated symptoms such as weight loss and rectal bleeding.
- If the cause of the problem is not apparent, FBC, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) may indicate an underlying inflammatory condition.
- Sigmoidoscopy and even colonoscopy may be required.
- Plain abdominal X-ray may be of value.
- Sexually active females presenting with rectal pain and tenesmus should be screened for chlamydial infection of the rectum.
Management will depend on the cause:
- Where the problem is constipation, simple measures such as increasing dietary fibre may help.
- Malignancy requires appropriate intervention. In advanced rectal carcinoma, radiotherapy can relieve tenesmus.
- Multidisciplinary laparoscopic treatment is usually undertaken for women with bowel endometriosis. Depending on size of the lesion and site of involvement, full-thickness disc excision or bowel resection is performed by an experienced colorectal surgeon.
- A thrombosed pile requires incision and evacuation.
- In distal ulcerative colitis, although topical treatments can help significantly with distal disease, they often pose difficulty or discomfort for patients with tenesmus.
- Modern radiotherapy techniques reduce the risk of radiation proctitis. Although it often responds to conservative management, intervention is required if symptoms persist.
- Endoscopic therapy using argon plasma coagulation has been shown to be more effective and to be safer than other endoscopic techniques for chronic radiation proctitis.
- Oral diltiazem has been shown to be beneficial when given as an adjunct therapy for management of chronic malignancy-associated perineal pain, specifically with characteristics of pressure-type pain and tenesmus.
Further reading and references
Tagami K, Yoshizumi M, Inoue A, et al; Effectiveness of Gabapentinoids for Cancer-related Rectal and Vesical Tenesmus: Report of Four Cases. Indian J Palliat Care. 2020 Jul-Sep26(3):381-384. doi: 10.4103/IJPC.IJPC_203_19. Epub 2020 Aug 29.
Hong J, Lee SY, Cha JG, et al; Unusual Presentation of Anal Pain and Tenesmus from Rectal Arteriovenous Malformation Successfully Treated with Ethanol Sclerotherapy. Case Rep Gastroenterol. 2021 Mar 315(1):262-268. doi: 10.1159/000513147. eCollection 2021 Jan-Apr.
Ni Laoire A, Fettes L, Murtagh FE; A systematic review of the effectiveness of palliative interventions to treat rectal tenesmus in cancer. Palliat Med. 2017 Dec31(10):975-981. doi: 10.1177/0269216317697897. Epub 2017 Mar 1.
Stowers KH, Hartman AD, Gustin J; Diltiazem for the management of malignancy-associated perineal pain and tenesmus. J Palliat Med. 2014 Sep17(9):1075-7. doi: 10.1089/jpm.2014.0149. Epub 2014 Aug 14.
Solomon ML, Middleman AB; Abdominal pain, constipation, and tenesmus in an adolescent female: consider Chlamydia proctitis. J Pediatr Adolesc Gynecol. 2013 Jun26(3):e77-9. doi: 10.1016/j.jpag.2013.01.003. Epub 2013 Mar 19.
Kye BH, Cho HM; Overview of radiation therapy for treating rectal cancer. Ann Coloproctol. 2014 Aug30(4):165-74. doi: 10.3393/ac.2014.30.4.165. Epub 2014 Aug 26.
Wolthuis AM, Tomassetti C; Multidisciplinary laparoscopic treatment for bowel endometriosis. Best Pract Res Clin Gastroenterol. 2014 Feb28(1):53-67. doi: 10.1016/j.bpg.2013.11.008. Epub 2013 Dec 2.
Renée Marchioni Beery, Sunanda Kane; Current approaches to the management of new-onset ulcerative colitis. Clin Exp Gastroenterol. 2014 7: 111–132. Published online 2014 May 9. doi: 10.2147/CEG.S35942.
Rustagi T, Mashimo H; Endoscopic management of chronic radiation proctitis. World J Gastroenterol. 2011 Nov 717(41):4554-62. doi: 10.3748/wjg.v17.i41.4554.