67 year old woman with a recent H/O Rectal tenesmus, no blood or mucous.Otherwise no other GI findings clinically.Had CAG and stenting 7 years ago. Now upper GI and colonoscopy and biopsy from sigmoid are normal. CECT with contrast showed mild thickening of sigmoid with few diverticula. Uterus and ovaries are atrophic.
Defecating proctogram to rule out recto-rectal intussusception or anterior prolapse as a cause of obstructed defaecation syndrome which may respond to a STARR procedure or lap ventral mesh rectopexy.
Internal providential is what I would work up as the possible underlying cause. Bulking up the stool in the mean time to see whether the symptoms would go away!
Begin with the physical examination (anal inspection, rectal digital examination, anuscopy and rectalsigmoidoscopy) to search for local conditions. Also, stool exams for parasites or occult blood. Treatment will depend on results from this initial workup.
I suggest not do perform only flexible endoscopy but as LZ Abraho mentioned performe Anuscopy and rectoscopy to rule out anal rhagade. If uneventfull you may perform manometry before doing functional MRI.
All right suggestions for a diagnostic classification. Diagnosis before and therapy after.
I should like add rectal manometry to the options previously mentioned.
Sine materia spontaneous or elicited pain of anus, coccyx or rectum is almost always due to depression hypersensitivity. Maroy B. Spontaneous and evoked coccygeal pain in depression. Dis Colon Rectum 1988;31:210-215.
Allodynia of anus , legator ani or coccyx is frequently associated, as depressive signs like fatigue, bad sleep, psychic troubles ...
Adapted anti depressive treatment leads to disappearance of proctologic and other signs as well. La dépression et son traitement : aspects méconnus. L'Harmattan Paris 2011.
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