What are the best injections for rectal pain?

[quilter]

Specifically, for pain and severe tightness along the left greater than right ischiococcygeus (posterior portion of the levator ani). This is a separate problem from the PN itself - appears to be caused by scarring in the left sacrum (around S2). Manual release during PT is very helpful and lasts up to a week, though hurts like crazy during Rx. I do exercises and relaxation, but obviously can't do what my PT can. There's a constant sense of left-midline S2 pressure & a foreign body in the rectum which increases with sitting or lying on my back, climbing the pain scale with each BM. It's bad several days each week, when there are multiple BMs in rapid succession. The sacral nerve damage/ischiococcygeus tightness causes incomplete voiding. Even though stools are soft & volume is normal, 3- 10 minutes later I have to go again (on average 7-12 x per day). Seems impossible for a person to produce so much so many days in a row while taking NO stool softener or laxative. On those days the foreign body becomes a burning baseball bat being rammed upward; the tissue is unbearably raw. Most days I use a few OTC hemmorhoidal suppositories with gel to keep things lubricated. On "bathroom days" I wait until I think I'm done for awhile before using Valium/Baclofen suppositories so they aren't wasted, plus lots of pain meds to help the spasms and maybe try to sleep a bit.

For those who don't know my history, this unholy trinity (sacral pain, then rectal pain, then incomplete voiding) started suddenly in July 2012, 6 months after the left sacral neurostimulator was implanted. It was removed Dec 2012 because lots of reprogramming didn't help the new Sx, and pain relief of the PN areas was decreasing. The sacral pain was preceded by 2 weeks of midline-left S2 vibrating/muscle spasm when the SCS was turned off and I was lying flat or slightly bending forward. There was a lead at the spot where the pain started, but the stim was programmed to be felt 4+ inches below it: at the base of the buttock and up into the left vaginal wall and vulva. Until then I'd never had sacral pain or bowel frequency, and only occasional, brief mild left rectal pain (totally different than now), without the current ischiococcygeus issues.

Interestingly, while on a 5-day ketamine infusion after Dr. Hibner's Dec 2013 re-do left PN decompression the sacral pain reduced about 70%. The sacral relief lasted 8-9 weeks even with minimal Oxy and Xanaflex (much less than preop and now). For 10-12 weeks postop the rectal pain and bowel dysfunction were GONE, despite 100-200 mg Colace per day to prevent straining. On that high dosage, had only 1-2 BMs per day. Then the ketamine started to wear off and the 3 problems returned in the same order they started in July 2012. I reduced the Colace to the point where I take only 25 mg maybe once every 10-14 days, when stools start to firm & cause straining. Seems that the ketamine did its job for awhile. There is no diarrhea. Stools are soft, of normal amount each time except that there are way too many several days a week. The sensation to poop comes from the rectum (nerve-related), not colon/abdominal cramping. Totally different from when I had colitis in the 1980's; the GI doc has cleared me for IBD.

Any feedback on what injections/nerve blocks have worked for others will be greatly appreciated. Wonder if Botox can be given there and might settle down that muscle and allow my PT to work even deeper? I may have to find a new pain mgmt anesthesiologist. Mine no longer seems willing to perform nerve blocks (feels they are only helpful diagnostically, because relief is so short-term). Thank you!

[nyt]

Botox is certainly an option. You can double check and make sure they can get the muscle where you need it most.

Have you tried using your suppositories vaginally? That's how I use mine and they help the rectal pain alot. That way you do not have to worry about wasting them.

Since Ketamine helped so much why not look more into that? For most individuals Ketamine does where off and you have to get regular boosters but if it helped as much as it did it seems that might be a good option for you.

Lottanerve had=s done very well with a pain pump. That might be another option.