Monkeypox-induced proctitis: a case report of an emerging complication.

PURPOSE: At the outset of the 2022 human monkeypox virus outbreak, the World Health Organization described the self-limited disease as a rash illness associated with nonspecific symptoms such as fever, myalgias, and lymphadenopathy. Historically, the infection caused by this zoonotic virus has presented with rashes primarily on the face, palms, and soles of feet. However, emerging case report literature from the 2022 recent outbreak highlighted more atypical presentations ranging from ocular manifestations to myocarditis. CASE DESCRIPTION: We present a case of a 32-year-old African American male with a past medical history of poorly controlled acquired immunodeficiency syndrome and external hemorrhoids that presented for worsening rectal pain. The patient was afflicted with diffuse skin lesions even present on his hemorrhoids. Initial imaging significant circumferential rectal thickening consistent with proctitis. Subsequent polymerase chain reaction testing confirmed active monkeypox infection, and a 14-day course of twice daily tecovirimat 600 mg was initiated to treat disseminated monkeypox infection. After improved pain control and starting antiviral treatment, the patient was discharged two days later. CONCLUSION: As more cases of monkeypox-associated proctitis emerge, clinicians should keep this disease in their differential due to the growing atypical presentations that have diverged from previous patterns to avoid the risk of misdiagnosing another sexually transmitted infection. Additionally, appropriate medical management is still not definitive and requires further development of evidence-based protocols to treat such patients.

Phantom rectal sensations following abdominoperineal excision of the rectum (APER) and vertical rectus abdominis myocutaneous (VRAM) flap perineal reconstruction.

AIM: Phantom rectum is the sensation of an intact and/or functioning rectum, despite excision at surgery. Abdominoperineal excision of the rectum (APER) may be complemented by reconstructive operations and recently it was reported that patients undergoing APER and vertical rectus abdominis myocutaneous (VRAM) flap reconstruction are more prone to develop phantom sensations at an earlier timeframe and have more persistent symptoms than those who do not have perineal repairs. The aim of this study was to determine the prevalence of phantom rectal sensations in a cohort of these patients. METHOD: Patients who underwent APER and VRAM flap reconstruction for anorectal carcinomas were identified from May 2008 to July 2012. Patients completed a questionnaire evaluating their experience of rectal symptoms post-surgery. RESULTS: Thirty-four of 47 eligible patients were enrolled in the study. PR sensations were experienced by 50 % of patients, the majority of which (65 %) were present for >1 year. The commonest sensation reported was the feeling of faeces in a normal rectum (24 %). Disturbances in quality of life were apparent in 44 %; notably, sleep was affected, patients expressed increased feelings of stress/sadness, heightened levels of anxiety and limitation of daily activities as consequences of PR symptoms. Few patients sought medical advice. CONCLUSION: Fifty percent of patients experience PR sensations post-surgery, comparable with reported data for patients who have undergone APER alone. The addition of VRAM reconstruction does not significantly alter the prevalence of PR symptoms. This paper provides further evidence that phantom rectum occurs frequently and thus all patients undergoing excision of the rectum should be counselled appropriately.

Proactive rectal warming during total-gland prostate cryoablation.

PURPOSE: Proactive rectal warming (PRW), as a modification of prostate cryoablation, was assessed in terms of rectal complications and therapeutic outcomes. MATERIALS AND METHODS: A cohort of 166 patients cumulatively treated between September, 2009 and November, 2012 qualified for study, each undergoing total-gland cryoablation (TGC) for prostate cancer. The initial 100 patients accrued submitted to TGC alone. PRW was administered to the final 66 patients. Preemptive warming is achieved by inserting a cryoprobe midline through perineal skin into anterior rectal wall under ultrasound guidance. The activated probe generates warmth as the ice ball encroaches on rectum. Prospective, post-ablative grading of rectal pain was measured at weeks 1, 2, 4, 8, 12, and 24 by using the Common Terminology Criteria for Adverse Events. Recurrent prostate cancer was gauged by Phoenix criterion (nadir+2 ng/ml). The Mann-Whitney U test and Chi-square test were used to compare clinical characteristics of therapeutic subsets. The Cox proportional hazard model was applied for comparison of cancer recurrence risk by group. RESULTS: Rectal pain (all grades) was experienced by patients treated with (62%) and without (74%) PRW. Although such pain typically resolved with time, it was milder (general lineal model, p=0.023) and less prolonged (median: 0.75 vs 1.5 months; log-rank test, p=0.002) in patients receiving PRW than in controls. Of note, PRW did not heighten cancer recurrence risk (hazard ratio=1.3 [95% CI, 0.3-5.0]). CONCLUSIONS: PRW helps to protect the rectum from freeze injury during prostate cryoablation, significantly reducing post-ablative rectal pain without compromising therapeutic outcomes.

Bowel Preparation Burden, Rectal Pain and Abdominal Discomfort: Perspective of Participants Undergoing CT Colonography and Colonoscopy.

OBJECTIVE: This study aimed to evaluate bowel preparation burden, rectal pain and abdominal discomfort levels and to determine the association between demographic characteristics and those levels among participants undergoing CT colonography and colonoscopy. METHODS: A cross-sectional survey was conducted in eligible Thai citizens who consented to participate all four visits of a free colorectal cancer screening protocol. Three levels (mild, moderate and severe) of burden, pain and discomfort were used to ask the perspective of participants at the final visit, one week after undergoing those two procedures. RESULTS: Data from 1,271 participants completed for analyses - females 815 (64.1%), males 456 (35.9%). The majority of participants experienced mild burden, pain and discomfort. Association between characteristic groups and burden levels differed regarding own income, chronic disease and laxative. Between characteristic groups and pain and discomfort levels differed regarding own income and chronic disease. Participants without their own income rated severe burden lower than those who had (p<0.001), but those without chronic disease rated moderate burden lower than who had (p=0.003). Participants prepared bowel with spilt-dose of PEG rated moderate burden higher than those who prepared with NaP (p<0.001). Participants undergoing CT colonography without their own income and presenting no chronic disease faced severe rectal pain lower than those who had (p<0.001 and p=0.04). Participants without their own income rated moderate and severe abdominal discomfort lower than those who had (p<0.01 and p=0.008). Participants undergoing colonoscopy without their own income and no chronic diseases faced severe rectal pain lower than those who had (p<0.001 and p=0.007). Participants without their own income and no chronic disease rated severe abdominal discomfort lower than those who had (p<0.001 and p=0.005). CONCLUSION: Evaluating the perspectives of customers alongside quality improvement and innovation to reduce unpleasant experiences remains needed in CT colonography and colonoscopy to promote CRC screening.

Rectal Tropism: An Extremely Rare Case of Prostate Cancer Recurrence With Metastasis to the Rectum Postradical Prostatectomy.

Prostate cancer is the most common noncutaneous cancer affecting men in the United States. It is a slow-growing tumor that can be missed during the nascent phase. Prostate cancer commonly metastasizes to the bones and nearby lymph nodes. However, cases of metastatic prostate cancer to the rectum are exceptionally rare. Such metastases may cause obstructive or malabsorption symptoms similar to those observed in primary rectal carcinoma. We present a very rare case of prostate cancer recurrence with rectal metastasis in an elderly male with a history of castration-resistant prostate carcinoma status postradical prostatectomy.

The Impact of Argon Plasma Coagulation in the Treatment of a Solitary Rectal Ulcer Syndrome Revealed by Massive Hemorrhage.

Solitary rectal ulcer syndrome (SRUS) is a rare and chronic rectal condition that can result in a pelvic static disorder. Massive rectal bleeding is a rare manifestation of SRUS. The diagnosis is based on a combination of clinical, endoscopic, and histological findings. The management of bleeding ulcers is usually insufficient with the conventional treatment. Argon plasma coagulation (APC) has been reported to control bleeding. However, its role in healing and improving defecation symptoms is not unanimous in studies. Our case report features a 35-year-old male with terminal constipation and chronic rectal pain, taking laxatives and analgesics, who presented abundant rectal bleeding with hemodynamic instability. The colonoscopy showed two large bleeding rectal ulcers. The histological study of the biopsies was in favor of a solitary rectal ulcer. We have performed multiple sessions of APC. The bleeding was stopped after the first session and there was progressive healing and improvement of the rectal symptoms after other sessions. At 18 months follow-up, the patient is asymptomatic, and no longer uses analgesics and laxatives. Argon plasma coagulation is an effective treatment to control rectal ulcer bleedings. It also improves the healing process and clinical symptoms. However, further controlled studies are needed to support this hypothesis.

Rectal Invasion by Metastatic Prostate Adenocarcinoma.

In men, prostate cancer is the second most diagnosed cancer worldwide. Typical sites for metastasis include bone, lung, and liver. Prostate cancer with gastrointestinal involvement, particularly rectal, has been rarely reported in the literature. As patients with prostate cancer with rectal invasion may present with symptoms similar to those of other gastrointestinal pathologies, such as anal fissures and rectal carcinoma itself, misdiagnosis and delays in care can result. Direct visualization of the rectum via endoscopy, along with biopsy, allows clinicians to make an accurate and timely diagnosis in patients with prostate cancer with rectal involvement, which in turn leads to broader available treatment options.

Incidence and risk factors for rectal pain after laparoscopic rectal cancer surgery.

Objective This study was performed to investigate the incidence of and potential risk factors for rectal pain after laparoscopic rectal cancer surgery. Methods We retrospectively analyzed data from 300 patients who underwent laparoscopic rectal cancer surgery. We assessed the presence of rectal pain and categorized patients into Group N (no rectal pain) or Group P (rectal pain). Results In total, 288 patients were included. Of these patients, 39 (13.5%) reported rectal pain and 14 (4.9%) had rectal pain that persisted for >3 months. Univariate analysis revealed that patients in Group P had more preoperative chemoradiotherapy, more ileostomies, longer operation times, more anastomotic margins of <2 cm from the anal verge, more anastomotic leakage, and longer hospital stays. Multivariate analysis identified an anastomotic margin of <2 cm from the anal verge and a long operation time as risk factors. The presence of diabetes mellitus was a negative predictor of rectal pain. Conclusions In this study, the incidence of rectal pain after laparoscopic rectal cancer surgery was 13.5%. An anastomotic margin of <2 cm from the anal verge and a long operation time were risk factors for rectal pain. The presence of diabetes mellitus was a negative predictor of rectal pain. Thus, the possibility of postoperative rectal pain should be discussed preoperatively with patients with these risk factors.

Visceral sensitivity correlates with decreased regional gray matter volume in healthy volunteers: a voxel-based morphometry study.

Regional changes in brain structure have been reported in patients with altered visceral sensitivity and chronic abdominal pain, such as in irritable bowel syndrome. It remains unknown whether structural brain changes are associated with visceral sensitivity. Therefore, we present the first study in healthy individuals to address whether interindividual variations in gray matter volume (GMV) in pain-relevant regions correlate with visceral sensitivity. In 92 healthy young adults (52 female), we assessed rectal sensory and pain thresholds and performed voxel-based morphometry (VBM) to compute linear regression models with visceral sensory and pain thresholds, respectively, as independent variable and GMV in a priori-defined regions of interest (ROIs) as dependent variable. All results were familywise error (FWE) corrected at a level of PFWE<.05 and covaried for age. The mean (±SEM) rectal thresholds were 14.78±0.46mm Hg for first sensation and 33.97±1.13mm Hg for pain, without evidence of sex differences. Lower rectal sensory threshold (ie, increased sensitivity) correlated significantly with reduced GMV in the thalamus, insula, posterior cingulate cortex, ventrolateral and orbitofrontal prefrontal cortices, amygdala, and basal ganglia (all PFWE<.05). Lower rectal pain threshold was associated with reduced GMV in the right thalamus (PFWE=.051). These are the first data supporting that increased visceral sensitivity correlates with decreased gray matter volume in pain-relevant brain regions. These findings support that alterations in brain morphology not only occur in clinical pain conditions but also occur according to normal interindividual variations in visceral sensitivity.

Trimming of a migrated metal stent for malignant colonic stricture using argon plasma coagulation.

We report the first case of trimming of a migrated metal colonic stent for stent induced severe anorectal pain. We present a case of a 54-year-old female with history of metastatic colorectal carcinoma who had stent placement secondary to obstruction. Subsequent distal migration of the stent caused ulcerations into the rectal mucosa and excruciating anorectal pain. We used argon plasma coagulation (APC) to successfully trim the exposed distal portion of the metal stent and rat tooth forceps to retrieve the stent fragments. The use of APC for trimming metallic stents is an effective procedure that can be used to trim migrated rectal stents that result in significant rectal pain. To date, few studies have been published that use APC to trim metallic stents placed in the gastrointestinal tract. To the best of our knowledge, ours is the only known case in which the indication for stent trimming was severe stent induced rectal pain. The procedure resulted in complete relief of patient symptoms. Therefore, APC is a safe and effective way to trim colo-rectal stents to definitively relieve the symptom of stent induced rectal pain in patients who have experienced distal stent migration and mucosal ulceration.