Physicians with some experience in anorectal work almost always encounter patients who have obvious clinical symptoms, but various tests do not demonstrate organic lesions in the anus compatible with them, or even when more obvious diseases such as hemorrhoids, proctitis, sinusitis, or constipation are present, they are not sufficient to explain the existing clinical symptoms. Based on the experience of foreign scholars, such patients are currently diagnosed as having MUS.
This type of disease should draw the full attention of anorectal physicians; otherwise, it increases the economic and mental burden of patients and their families, and wastes a lot of medical resources.
I. Concept of MUS
MUS can be translated as medically unexplained symptoms, i.e., somatization of psychiatric disciplines. It refers to patients who have obvious manifestations of somatic symptoms without definite or sufficient evidence of pathology, and more often than not, are closely related to psychological factors.
Somatization as a symptom can be seen in a variety of diseases and disorders and may be one of the common manifestations of depressive or anxiety disorders; it can be part of the manifestation of a somatic disease; it can also be a core symptom of certain functional disorders; or it can be a long-standing pattern of behavior.
MUS is present in the digestive, cardiovascular, urological, and neurological systems. In terms of the anorectal discipline, some constipation, diarrhea, abdominal pain, abnormal anal sensation, rectal pain, and other long-term presence, and accompanied by significant psychological disorders, the possibility of MUS should be considered.
Second, the clinical characteristics and diagnosis of MUS
(A) MUS is one of the common complaints of anxiety and depression disorders
Patients with depression and anxiety often complain of constipation, bloating, diarrhea, anorectal pain, and foreign body sensation in the anus, especially in the elderly, children, women, or people with chronic mental stress.
By the time the anorectal surgeon can think of the disease, in most cases certain anal or intestinal procedures have already been performed, repeated treatment does not eliminate the symptoms, and after various tests that are thought of, they still do not explain the complaints described by the patient. Therefore, after excluding somatic diseases, MUS due to anxiety and depression should be considered for anal and intestinal symptoms.
(ii) MUS as part of the clinical manifestations of somatic diseases
Patients repeatedly describe their anorectal discomfort, and when the physician requests relevant tests, the patient will produce medical records and various checklists from multiple hospital visits, and read these medical records in detail, but will not find the desired results. In this case, the patient is often diagnosed as having some kind of “functional anorectal disease”, which is not recognized by the patient and treatment is refused. The physician should think about the possibility of MUS of anal symptoms.
The correct approach is for the physician to reexamine the patient carefully and perform the relevant tests, and then to give the patient some reassurance and assurance that some degree of comfort and reassurance will help the patient overcome his or her internal fears and worries about the disease. In this way, the patient is then given the appropriate medication according to the symptoms he or she is exhibiting in order to achieve good results.
(iii) MUS may be a core symptom of some functional somatic syndromes
Some patients diagnosed with IBS who have not received effective treatment for chronic constipation or diarrhea may exaggerate their symptoms and appear to be in great pain. At this point, if the doctor carefully understands the patient’s medical history in depth, and after talking with the patient several times, he or she will find certain social and psychological factors, work and society each patient brings great pressure to be suppressed for a long time, and the patient will naturally or unnaturally convert to a somatic discomfort to complain about.
(iv) MUS is a long-standing behavior
In certain diagnosed rectal pain and rectal discomfort in anal neurosis, some patients already meet the diagnosis of somatoform disorder. According to the Chinese Classification and Diagnostic Criteria of Mental Disorders, 3rd edition (CCMD-3), the diagnostic criteria for somatoform disorders are as follows.
Symptom criteria: meet the criteria of neurological symptoms; predominantly somatic symptoms, and at least 1 of the following manifestations: excessive concern about somatic symptoms (the severity is obviously disproportionate to the actual situation), but not delusional; excessive concern about physical health status, such as excessive concern about the usual physical phenomena and a certain abnormal feeling, but not delusional; repeatedly seeking medical treatment or requesting medical examination, but the negative test results and the doctor’s reasonable repeated visits to the doctor or requests for medical examination, but negative test results and reasonable explanations from the doctor do not dispel their doubts.
Severity Criteria: Impaired social functioning.
Duration of illness: at least 3 months after meeting the symptom criteria.
Exclusion criteria: exclude other neurotic disorders (such as hypochondria, anxiety, panic disorder or obsessive-compulsive disorder), depression, schizophrenia and paranoid psychosis.
III. Etiology and pathogenesis of MUS
The etiology and pathogenesis of MUS are unclear and may be related to the patient’s psychological factors, health outlook, emotional state, underlying personality traits, degree of autonomic arousal, muscle tension, hyperventilation, insomnia, chronic lack of exercise, and impaired perception of external stimuli.
The possible etiology and pathogenesis of MUS within the anorectal discipline is generally considered to be closely related to psychological disorders, with psychological stress having an impact on anorectal function through the central nervous system. Specifically, MUS that manifests as anorectal symptoms is initially associated with gastrointestinal dysfunction (FGID), which in turn is often closely related to psychological disorders. These phenomena, which only have obvious psychological disorders and no objective basis of disease, are called somatization of psychological disorders, and when this somatization is serious enough to the above diagnostic criteria, it is called somatoform disorders.
Among these, the most significant psychological disorders are anxiety and depression, which can co-exist with a single patient. One of the major disorders of anxiety disorders is hypochondriasis, the somatization reaction to suspicion, which forms MUS. the sequence is usually that some stimulating event, which causes anxiety or depression with somatic symptoms, generates the notion of having a disease within the patient. This perception of being ill has 2 transitions, one being complete improvement due to an improvement in the environment or the right intervention; the other being the formation of a hypochondriacal disorder that increases anxiety, followed by an increase in somatic symptoms or selective perceptual changes that eventually make somatization symptoms more pronounced.
A study on the central nervous system (CNS) showed some connection between the brain and anorectal function, indicating that changes in mood have an important effect on gastrointestinal motility; when patients are emotional or in a happy mood, colonic motility is enhanced, and conversely, when patients are depressed, colonic motility is significantly inhibited, inferring that depression and anxiety significantly affect anorectal function.
Fourth, treatment
Treatment needs to take into account 2 types of diseases, one is for common anxiety and depression, and non-pharmacological and pharmacological treatments are given. Non-pharmacological treatment is mainly cognitive-behavioral therapy. Drug treatment is currently used more 5-hydroxytryptamine reuptake inhibitors (SSRI) and 5-hydroxytryptamine and norepinephrine reuptake inhibitors (SNRI). SSRI commonly used drugs are SNRI commonly used drugs are. Second, symptomatic treatment of anal symptoms.
V. Experience
Chinese medicine attaches great importance to the importance of the emotional factors that cause disease, and believes that the basic pathogenesis is the Qi rebellion and disorder. The “nine qi” discussed in the “Nei Jing” in the “hundred diseases born in qi” have six kinds of emotional factors, namely “anger is qi up”, “anger is qi rebellion, and even vomiting blood and supper. Even vomiting blood and food discharge, so the gas is carried forward”; “happy is slow gas”, “happy is slow gas”, “happy is the gas and Zhi Da, Rong Wei Tongli, so the gas is slow” ; “sadness is gas elimination”, “sadness is the heart system is urgent, the lung cloth leaf lift, and the upper jiao is not pass, Rongwei does not disperse, heat in the middle, so the gas elimination carry on”; “fear is gas down”, “fear is the essence, but the lung cloth leaf lift, but the upper jiao is not pass, Rongwei does not disperse, heat in the middle, so the gas carry on”; “fear is gas down”. “fear is the essence but, but the upper jiao closed, closed then gas also, also the lower jiao swelling, so the gas does not work”; “fear is the gas chaos”, “the heart is not based on the fear, the gods have nothing to return, nothing to consider, so the gas chaos is carried out “; “thinking is the gas knot”, “thinking is the heart is stored, the god has returned, the right qi stay and not work, so the qi knot carry on”.
MUS has the typical characteristics of the disease caused by emotions, and it is consistent with the Chinese medicine Qi rebellion pathogenesis, so, according to the different clinical manifestations can be used “Qi rebellion”, “Qi elimination”, “Qi down” Therefore, according to the different clinical manifestations, the symptoms can be summarized by “qi reversal”, “qi dissipation”, “qi down”, “qi disorder” and “qi knot”.