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PURPOSE: The purpose of this study was to review our results in patients undergoing treatment with 4 percent formalin for radiation-induced injury to the rectum. METHODS: A retrospective review of office charts was performed, identifying all patients undergoing formalin treatment. Patient gender, initial malignancy, prior treatments, response to treatment with formalin, complications, and length of follow-up were reviewed. All patients had flexible endoscopy to assess for proximal sources of bleeding. The indication for treatment was a symptomatic patient with endoscopic evidence of radiation injury. A cotton pledget was used for direct application of 4 percent formalin to the affected area via a rigid proctoscope or anoscope. The treatment was repeated if blanching did not occur or if bleeding continued. Patients were followed up at three-week to four-week intervals and treatment was repeated based on the above indications. Treatments were continued until cessation of bleeding occurred or, when treatment failed, operative treatment was required. RESULTS: Thirty-six patients were identified. Three were lost to follow-up. Symptoms included bleeding in all but one patient, who presented with an ulcer. There were 33 (26 male) patients. Seventeen (51.5 percent) patients had prior treatment. The number of formalin treatments ranged from 1 to 13, with a mean of 3.4. The follow-up ranged from 1 to 60 months, with a mean of 18 months. Twenty-nine (88 percent) patients had improvement or cessation of symptoms. Four (12 percent) patients failed treatment. Two patients were noted to have full-thickness ulcers and both failed formalin treatment. No complications were noted related to formalin treatment. CONCLUSION: We conclude that formalin therapy is a safe and effective form of treatment that can be performed in the office with minimal discomfort and no complications. It can be performed multiple times until results are achieved. Formalin therapy may be useful as a first-line treatment for chronic radiation proctitis, however, a prospective controlled trial comparing modalities is required to prove this to be true.

Inverted duplications associated with terminal deletions are complex anomalies described in an increasing of chromosome ends. We report on the cytogenetic characterization of the first de novo inv dup del(4) with partial 4p duplication and 4q deletion in a girl with clinical signs consistent with “recombinant 4 syndrome”. This abnormality was suspected by banding, but high-resolution molecular cytogenetic investigations allowed us to define the breakpoints of the rearrangement. The terminal duplicated region extending from 4p15.1 to the telomere was estimated to be 29.27 Mb, while the size of the terminal deletion was 3.114 Mb in the 4q35.1 region. Until now, 10 patients with duplicated 4p14-p15 and deleted 4q35 chromosome 4 have been described. In all cases the abnormal chromosome 4 was derived from a pericentric inversion inherited from one of the parents. In conclusion, we have identified the first case of inv dup del(4) with normal parents suggesting that, often, terminal duplications or terminal deletions mask complex rearrangements.

Computed tomography (CT) was used in place of contrast enemas as the initial imaging study to evaluate patients with the clinical diagnosis of acute sigmoid diverticulitis. This report attempts to clarify the role of CT in the management of acute sigmoid diverticulitis by reviewing its usefulness in the diagnosis and treatment of 59 patients. CT established that three patients (5 percent) were hospitalized with an incorrect clinical diagnosis. Thirty-seven patients (62.7 percent) were identified as having uncomplicated acute diverticulitis. These patients were all treated successfully with nonsurgical therapies and were discharged in an average of 6.8 days. In the remaining 19 patients (32.2 percent), CT revealed complicated acute diverticulitis by identifying abscess, fistula, peritonitis, or obstruction. Eleven of these 19 patients required urgent surgery or CT-guided percutaneous drainage of an abscess. The four patients whose abscesses were drained percutaneously responded favorably and underwent an elective single-stage resection. The average hospital stay for patients with complicated diverticulitis was 13.6 days. Computed tomography is a useful aid in the initial management of patients with acute diverticulitis. It is a noninvasive test that recognizes and stratifies patients according to the severity of their disease. It has the further advantage of providing information about extracolonic pathology and anatomic variation useful for surgical planning. Additionally, early CT-guided needle drainage allowed downstaging of complicated diverticulitis, avoided emergent surgery, and permitted single-stage elective surgical resection.

PURPOSE: Technetium-99m-labeled red blood cell scintigraphy, commonly used in the evaluation of acute lower gastrointestinal hemorrhage, often fails to demonstrate a source of bleeding. It would be helpful to characterize a subset of patients more likely to have a positive scan. This study was undertaken to determine whether hemodynamic instability can predict tagged red blood cell scan positivity. METHODS: The records of 50 consecutive patients who underwent tagged red blood cell scanning for the evaluation of acute lower gastrointestinal bleeding were reviewed retrospectively. RESULTS: Patients presenting with a heart rate >100 beats per minute or a systolic blood pressure

Lysyl oxidase (LOX), a copper-dependent amine oxidase, has been implicated in tumor suppression and cell growth regulation. The chromosomal locus of LOX, 5q23, is affected by loss of heterozygosity (LOH) in colon cancer, suggesting that the LOX gene could be affected by LOH and consequently, loss or reduction of LOX function contribute to the tumorigenic process. Identification of microsatellite markers within the LOX locus has allowed us to map the LOX gene within the 5q23.1 region. Analysis of this locus and flanking loci in matched tumor and blood DNA samples from a panel of colorectal cancer patients, demonstrated that 38% (16/42) of informative samples were affected by LOH or allelic imbalance. Furthermore, 75% (6/8) of these tumor samples were shown to have significantly reduced LOX mRNA levels. Similar reduction in LOX levels were detected in a panel of matched normal colon and colon tumor samples. Tumor samples demonstrating LOH by RFLP, were subject to mutational analysis, including RT-PCR, exonic deletion detection by PCR, cDNA and genomic DNA sequencing, and were found to have a spectrum of alterations and mutations affecting the LOX gene. These results confirm that loss or reduction of LOX function during tumor development is a direct consequence of somatic mutations and is associated with colon tumor pathogenesis. © 2001 Wiley-Liss, Inc.

Fourteen patients presenting with presacral cystic lesions were managed over a 20-year period. Retrospective review identified 12 females and 2 males. Fifty-seven per cent were symptomatic at diagnosis. Forty-three per cent presented with pain; half of these patients had infected cysts. All lesions were palpable on digital rectal exam. Computed tomography identified the cyst in all seven patients in which it was performed. The transrectal approach was used for cyst excision in ten patients. One patient had transrectal drainage and wall biopsy only. Three patients underwent posterior parasacral excision. Pathologic review demonstrated four dermoid cysts, four epidermoid cysts, four cyst hamartomas, and two benign teratomas. One cyst hamartoma had a focus of invasive adenocarcinoma. Two complications occurred. There were no deaths. Follow-up averaged 39 months, at which time there were no recurrences. Developmental cysts are the most common presacral tumors. Excision is recommended, and the transrectal approach may be used in select patients with low morbidity and minimal recurrence.

PURPOSE: This study was designed to assess the results of a minimally invasive surgical procedure for the correction of complete rectal prolapse in a poor surgical risk group. METHODS: Over a ten-year period, 40 patients underwent 41 Delorme operations when advanced age and/or poor overall health mitigated against an abdominal approach. Mean age was 82 (range, 30–100) years. Eighty-eight percent were females. Surgery was performed in the prone jackknife position utilizing intravenous sedation and local anesthesia. RESULTS: Follow-up ranges from 1 year to 2 years (mean, 47 months). There have been 9 recurrences in 8 patients (22 percent). Mean time to recurrence was 13 months (range, 1 month to 6 years). One death occurred in an 81-year-old patient within 24 hours of surgery from cardiopulmonary arrest. Minor complications occurred in 25 percent of patients. CONCLUSION: Satisfactory prolapse repair was safely performed in 78 percent of this high-risk group. Pitfalls in performing this procedure relate primarily to associated perineal and colonic conditions. Most prominent among these conditions are weak or absent anal sphincter tone, perineal descent, and previous sphincter injury. Extensive diverticular disease may prohibit effective and complete proximal mucosectomy. An inadequate mucosectomy sets the stage for early recurrence of prolapse.

PURPOSE: Controversy exists over the appropriate preoperative evaluation of colorectal cancer patients. Most surgeons agree that basic laboratory studies are indicated. Computerized tomography of the abdomen and pelvis has been used in our practice to augment the preoperative evaluation of these patients. METHODS: One hundred fifty-eight consecutive patients with primary colorectal carcinoma underwent computerized tomography (CT) of the abdomen as part of their preoperative evaluation. Their medical records were retrospectively reviewed. RESULTS: In 88 patients, 120 findings present on CT were otherwise unknown. Of these, 35 percent were clinically significant in that they allowed the surgeon to alter the proposed operative procedure or added additional technical information for consideration preoperatively. Findings include liver metastasis (26), atrophic kidney (3), and abdominal wall or contiguous organ invasion (11). In addition, two other solid organ carcinomas were detected. In the remaining 70 patients, CT contributed no additional pertinent information about the patient prior to this initial operative procedure. CONCLUSIONS: CT aids in the preoperative evaluation of individuals with colorectal carcinoma. It provides important clinical information that is useful to the surgeon planning the procedure. Additionally, CT permits the patient and his family to be aware of their overall status and to subsequent treatment options. Computerized tomography eliminates the need for preoperative intravenous pyelogram, improves the preoperative staging for metastatic disease, and provides a baseline for comparison during the postoperative follow-up period should recurrence be suspected or adjuvant therapy be planned.

The literature supports the hypothesis that the association of a thromboxane (TX)A2 synthase inhibitor and a PGH2/TXA2 receptor antagonist has a superior antithrombotic effect when compared to both aspirin and single agent alone; a compound endowed with the dual mechanism of action might therefore be of therapeutic value for the management of thrombotic disorders. FCE 27262, an imidazol-1-yl-ethylideneaminooxypentanoic acid, displaces in vitro the binding of [3H]SQ 29,548 to washed human platelets (IC50 = 6.0 +/- 0.6 x 10(-8) M) and antagonizes human platelet aggregation induced by U 46619 in PRP with an IC50 (95% confidence limits) of 4.5(3.3-5.1) x 10(-7) M. It also selectively antagonizes the isolated vessel contraction induced by U 46619. In the rat aorta the Kb (95% confidence limits) was 1.6(0.6-4.3) x 10(-7) M. Additionally it inhibits in vitro TXB2 production in rat and human whole blood, the IC50 being, respectively, 5.9(3.3-9.6) x 10(-8) M and 3.8(2.9-5.0) x 10(-8) M. When administered orally to fed rats it also inhibits ex vivo TXB2 production in whole blood during clotting, the ID50 being 0.62(0.4-0.8) mg/kg. Both in vitro and ex vivo the effect of FCE 27262 on TXA2 synthase was selective, the production of PGE2, the product of a different isomerase from the common precursors, PG-endoperoxides, being concomitantly enhanced. In a canine model of electrically-induced coronary thrombosis, FCE 27262 (1 mg/kg i.v.) inhibits ex vivo TXB2 synthesis (95%), antagonizes U 46619-induced platelet aggregation and prolongs occlusion time (controls: 72 +/- 8 min, FCE 27262: 215 +/- 38 min; p0.01). In the same model both aspirin (5 mg/kg i.v.) and a pure PGH2/TXA2 receptor antagonist (L 670596), at a dose giving a similar degree of TXA2 synthase inhibition and receptor blockade, respectively, are significantly less effective. Thus, FCE 27262 combines thromboxane synthase inhibition and PGH2/TXA2 receptor antagonism in one molecule, resulting in enhanced antithrombotic activity. FCE 27262 thus may be an appropriate pharmacological tool to test the therapeutic potential of the dual mechanism of action.

Psoriatic arthritis (PsA) is an inflammatory joint disease in which environmental factors, particularly trauma and infections, are thought to play an important role. The authors describe the case of a patient with a mild and long-untreated form of PsA which was severely exacerbated by Salmonella typhimurium infection. This case confirms the importance of infectious agents in the occurrence and course of PsA.

Each year we treat several patients with an anterior perineal sinus tract. They do not conform to commonly encountered perineal problems such as pilonidal disease, epidermal cysts, hidradenitis, fistulous abscess, or inflammatory bowel disease. In an effort to improve understanding of the problem and its clinical significance, we reviewed our practice records for the period from 1968 through 1988. Fifty-six patients underwent surgery for an anterior perineal sinus tract. In 31 patients, the clinical and pathologic condition defied classical diagnostic categorization. We have termed these lesions “anterior perineal sinuses.” Their clinical characteristics, treatment, and pathologic assessment form the body of this report. Male predominance (87 percent) and midlife presentation (average age, 44 years) characterized this group. Local symptoms were present from several weeks to several years prior to treatment. Local anesthesia (74 percent) and limited surgery (100 percent) resulted in complete healing in all patients (average, 7 weeks). A 15 percent recurrence rate was noted. The pathologic evaluation demonstrated acute and chronic dermal and subcutaneous inflammation. The etiology of this process remains uncertain. Its predominance along the median raphe suggests a congenital midline inclusion disorder.

Anorectal fistulas associated with Crohn's disease are difficult to manage, particularly when the rectum is diseased. Significant morbidity has been associated with both medical and surgical therapy. Although conventional therapy is acceptable in the management of simple fistulas in Crohn's disease, these approaches often exacerbate rather than ameliorate problems in patients with complex fistulas. The authors report ten cases of complex fistulas in patients with Crohn's disease managed with their technique of long-term, indwelling setons. These setons are placed through the fistula tract and tied loosely to maintain the patency of the fistula without cutting through the sphincters. At the time of insertion, although abscesses are incised and drained, no attempt is made to divide the superficial tissues or sphincter overlying the fistulous tract. The patients ranged in age from 23 to 81 years and had a history of Crohn's disease for 1 to 20 years. All cases resulted in excellent palliation. No patient required a proximal colostomy. These patients have been followed for four months to seven years. Despite severe proctitis in six of these patients at the initial operation, no patient has required a proctectomy. The authors believe this technique achieves adequate palliation and should be employed as the procedure of choice in patients with complex anal fistulas associated with Crohn's disease.

A method for low transection of the rectum within a narrow pelvis is described using the new GIA 90 autosuture instrument.

Electrosurgery is a useful tool. Some basic knowledge of the terms, waveforms and circuits allows more intelligent use. Let us all use the same terms so that we may understand the work of others and share our experiences. Learn about your own particular apparatus and its capability. Practice on a piece of meat if necessary. Be aware of the potential complications reported in the literature, and how they may be prevented.

A retrospective study was done comparing the rates of local recurrence in cancer of the rectum treated by low anterior resection using the stapling device or hand-sewn. It was found that there was no increase in recurrences when the stapler was used, even though lower lesions were treated.

Presented is the authors' experience with 182 patients treated primarily by the one-stage primary resection or two-stage resection. (Hartmann operation). One hundred thirty five patients undergoing primary resection had an associated mortality rate of 2.2 per cent. Of 44 patients operated upon using the Hartmann operation for complicated diverticulitis (obstruction, perforation, abscess formation, or fistula formation) the mortality rate was 4.5 per cent. Primary resection in an elective setting is associated with the lowest mortality and morbidity; however, marked inflammation, obstruction and/or peritonitis preclude primary anastomosis. In the urgent setting the staged operation is associated with acceptable morbidity and mortality.

Injury to the ureters is a serious complication of colonic and rectal surgery. The experience of the authors with routine use of ureteral catheters to minimize this complication is reviewed. It was found that there are minimal complications associated with their use. Injuries to the ureters were not completely avoided. However, unrecognized injuries (except ischemia) did not occur.

The long-acting local anesthetic, bupivacaine, was used in a series of 467 anorectal patients, both inpatients and outpatients. Bupivacaine was found to be safe and effective. Like other local anesthetics, it has none of the operative and postoperative complications frequently associated with general or spinal anesthetics. Its longer duration of action makes it extremely useful in anorectal operations on hospatilized and non-hospitalized patients. The potential hypertensive effects of using epinephrine in the local anesthetic solution appears to be negated by the calming, hypotensive effects of the intravenously administered sedatives in hospitalized patients.

Leukocyte migration inhibition assays were compared in patients with colo-rectal cancer treated by resection and by electrocoagulation. Patients treated by electrocoagulation had identical leukocyte migration inhibition assays before and after treatment. Patients treated by resection were less reactive after treatment, presumably because of peri-operative immunosuppression. This suggests that electrocoagulation may stimulate host immunity in the period immediately following surgery.

The results obtained from 1,012 examinations in an on-going, cooperative study indicate that the overall yield provided by use of the flexible fiberoptic sigmoidoscope is 3.2 times greater than that of examinations with the rigid sigmoidoscope. More than twice (2.4 times) the number of polyps and more than three times the number of cancers were detected with the flexible fiberoptic sigmoidoscope. Experienced endoscopists can perform an examination with the flexible fiberoptic sigmoidoscope expeditiously in the office with minimal patient preparation, a high level of patient and physician acceptance, and relative safety when the usual mandatory colonoscopic precautions and guidelines are obeyed. The extraordinary advantages demonstrated by this study warrant wide clinical application of the flexible fiberoptic sigmoidoscope. We strongly recommend provision be made for appropriate training of physicians in the use of the instrument.

A series of 490 consecutive patients with internal hemorrhoids is presented, in whom the chief treatment has been by the Barron ligating technic.

Ten cases of abdominoendorectal resection for cancer of the proximal and midportions of the rectum have been reported. This procedure differs from other sphinctersaving operations in that the distal 3.5 cm. of the rectum is preserved. The operation is indicated for lesions situated from 6 to 12 cm. internal to the anal canal where, for technical reasons, an anterior resection cannot be done. The morbidity rate is high but in this series it is probably due in some measure to circumstances such as advanced age, obesity, small pelves and factors responsible for poor risks. There appears to be a place for this technic in the management of cancer of the proximal and midportions of the rectum.

Two cases of massive hemorrhage from colonic diverticula are reported in which an eroded artery has been demonstrated as the source of bleeding. Eight previously reported cases have been reviewed.

Seventy-three patients with adenocarcinoma of the sigmoid, rectosigmoid and rectum were reviewed to determine the incidence of suture-line recurrence. Four patients (5.5 per cent) developed suture-line recurrence despite the use of a number of techniques to reduce this problem. All four recurrences were in patients who had Dukes' C lesions of the rectum. It would appear that such recurrences are not related to implantation factors alone.

The levator syndrome consists of the symptoms of pain, pressure or discomfort in the region of the rectum, sacrum, and coccyx. The patients often have gluteal discomfort and high rectal distress. Sitting may aggravate the disorder. Tenderness upon motion of the coccyx is not an important part of this syndrome. Therefore, the term “coccygodynia” should not be used. The syndrome affects women more frequently than men, and occurs most often in the fourth, fifth and sixth decades of life. Although the symptoms are at times vague, the diagnosis is easily made by those who suspect its presence. Tenderness of the levators is always present and most often unilateral and on the left. Its etiology is unclear. In a significant proportion of patients concomitant anorectal disease such as fissure and hemorrhoids is present. Massage with or without diathermy, hot sitz baths, and muscle relaxants such as diazepam have proven to provide effective treatment, and the recurrence rate after therapy is low.

The Hartmann procedure would appear to offer many advantages and few disadvantages in treating those cases of sigmoid diverticulitis complicated by obstruction or pelvic or intraperitoneal abscesses, with or without perforation and diffuse peritonitis.

The initial experience of several colonic and rectal surgeons with the EEA stapling device for low colorectal anastomoses is reviewed. It was found that the EEA gives a better anastomosis than is possible by hand and that a surgeon familiar with doing a low anterior resection can perform it on patients for whom it is not possible by hand. However, the results with the EEA are not perfect or guaranteed. The many complications associated with its use are reviewed, and ways to avoid them are discussed.

The records of 102 patients with levator syndromes were reviewed. All had failed trials of conservative management prior to treatments with electrogalvanic stimulation. The symptoms of 12 patients were subsequently found not to be due to levator syndrome. Of 90 patients with correct diagnoses, 77 percent were relieved or improved after courses of electrogalvanic stimulation, a valuable adjunct to the management of this frustrating condition.

Three hundred and ninety-three patients who had anal fissures were followed continuously for approximately five years. More than 44 per cent of them were cured nonsurgically within a four-to-eight-week period. There was an 8 per cent complication rate, consisting of abscesses and fistulas, necessitating surgical treatment. The recurrence rate following healing was 27 per cent, but a third of these patients had recurrent fistulas that healed in response to further conservative treatment. The authors feel that conservative treatment of anal fissure is justified unless there is advanced anal stenosis.

Based on data from many clinical studies and programs, guidelines are presented for application of the flexible fiberoptic sigmoidoscope in the management of the surgical patient. The flexible fiberoptic sigmoidoscope has proved to be an instrument of extraordinary capability in detecting colorectal neoplasms with yields being two or three times greater than those of the rigid sigmoidoscope in the symptom-resolution, polyp and cancer surveillance patient categories. In addition, the practical advantages of the narrow diameter, flexibility, and length of the fiberoptic sigmoidoscope are readily appreciated when the surgeon finds that he can satisfactorily examine patients with rectal or sigmoid strictures, marked angulations, or contracted lumens in whom a rigid scope would be unsuitable. Data from the authors' comparative study of more than 3000 patients have permitted the development of not only guidelines for the application of the flexible fiberoptic sigmoidoscope but an appreciation of the modified role of the rigid sigmoidoscope and the proper relationship between the flexible fiberoptic sigmoidoscope and the flexible fiberoptic colonoscope. A most important consideration is based on data regarding the site distribution of 400 benign premalignant neoplasms detected in the comparative study. The even distribution of these lesions throughout the terminal 50 cm of colorectum underscores the need to examine as much of the colorectum as possible.

One hundred thirty-eight consecutive patients undergoing elective colonic resections were treated prospectively and randomly with either a long intestinal (Cantor) tube preoperatively, a nasogastric tube placed intraoperatively, or no gastrointestinal tube at all. Patients were evaluated for length of hospital stay, duration of postoperative ileus, adequacy of intraoperative intestinal decompression, gastric dilatation, and operative complications. No significant difference could be seen in the tubed or no-tube group.

The Ripstein procedure was used to effect a cure of rectal procidentia in 30 patients. There was no operative mortality, and morbidity was confined to problems related to two patients with intestinal obstruction, one with fecal impaction, and one with wound infection. We believe the operation to be the treatment of choice in patients to control the anatomic and clinical abnormalities related to rectal procidentia. Associated colonic abnormalities, such as an extremely redundant sigmoid or associated diver-ticulitis, may dictate the choice of a different procedure that does not require introduction of a foreign material.

Many procedures have been advocated to treat pilonidal disease, suggesting that no one method is highly efficacious. In the office, the surgical approach is directed towards three aspects of the condition: pilonidal abscess, recurrent pilonidal disease following surgery and chronic pilonidal disease following spontaneous rupture of an abscess or secondary to incision and drainage. In managing the acute pilonidal abscess, an intradermal injection is given over the indurated, fluctuant area as well as the midline orifice which can almost always be identified. The midline orifice is incised and the incision carried into the abscess cavity. The edges of the cavity are excised. Healing takes place secondarily. A second procedure is rarely needed.

Two hundred thirty-two patients with anal abscesses were followed from six months to 13 years after incision and drain-age was done as an office procedure. Most of these (88 per cent) were evaluated more than two years after the onset of their initial disease. One hundred fifty-four (66 per cent) went on to develop fistula-in-ano, while 78 (34 per cent) had no further problem. Our study encourages us to continue to incise and drain these abscesses in the office, reserving hospitalization for those who later develop fistulas.

A procedure for the outpatient management of acute hemorrhoidal disease is presented. Treatment, using local anesthesia with hyaluronidase, is directed to (1) relieve pain, (2) decrease edema, (3) treat appropriately the internal hemorrhoidal disease, and (4) treat the external thrombosis if present. Adequate treatment of the acute disease will, in a significant proportion of patients, avoid further surgical intervention. Eperience with results of this modality of treatment in patients is presented.

Sixty-eight patients with rectal cancer treated by electrocoagulation are reviewed. All were followed up for a minimum of 5 years. The survival rate in patients with small exophytic cancers is greater than 70 percent. However, the recurrence rate after electrocoagulation is 40 percent. Electrocoagulation offers an alternative for the primary treatment of rectal cancer, particularly in older patients with small lesions.

A prospective study of 443 patients undergoing clean contaminated operations of the colon was undertaken to determine the efficacy of subcutaneous and intraperitoneal antibiotics in reducing infection. All of the patients received a mechanical intestinal preparation as well as preoperative antibiotics taken orally and preoperative and postoperative antibiotics administered intravenously. The over-all wound infection rate was 2 per cent. The routine additional use of subcutaneous or intraperitoneal antibiotics had no proved efficacy in this study.

A case is presented in which a very large circumferential villous tumor was totally removed transanally with complete anatomic and physiologic restoration. Large circumferential tumors of the rectum present formidable technical problems. They may be malignant. When they are benign, abdominoperineal resection can be avoided. A less radical procedure that may be employed with complete resection of the tumor and without stricture formation, is described briefly.

The levator syndrome is an entity characterized by pain high in the rectal area that can be elicited by pressure applied to the levator ani. The etiology, diagnosis, and treatment of this disorder are described. Its importance lies in its misdiagnosis or in the failure to diagnose.