Proctalgia Fugax

Definition/Description[edit | edit source]

Digital rectal exam nci-vol-7136-300.jpg

Proctalgia fugax or functional recurrent anorectal pain is part of a spectrum of functional gastrointestinal disorders presenting as episodes of sharp fleeting pain that recur over weeks, are localized to the anus or lower rectum, and last from seconds to several minutes with no pain between episodes, in the absence of an organic disorder to explain pain, .[1] The severity can be severe enough to wake the patient from sleep. The patient describes the symptoms as a blunt knife inserted into the rectum[2]. The pain is localized to the lower rectum and anus[1] and unrelated to defecation. [3]

Clinically Relevant Anatomy[edit | edit source]

levator ani muscles

The levator ani muscles as a component of the pelvic floor diaphragm in addition to its role as a supportive structure and keeping visceral and internal organs in place. Contraction of levator ani muscle assistes in process of evacuation by lowering the urethral and anal pressure. Abnormality in muscle contraction cause defecation disorders[4].

External, and Iinternal sphincter in red.

The anal sphincter consists of the internal and external anal sphincter; the internal anal sphincter a ring of muscles that contract at rest and relax during defecation, and the external anal sphincter is a skeletal muscle fibers adherent to the skin that control the defecation as during contraction it prevent decation.

Epidemiology /Etiology[edit | edit source]

It is a transitory disorder that usually does not need further investigations and can be treated by a primary health care physician. It is difficult to detect its prevalence as the patient does not seek a doctor's help unless the symptoms become severe it represents about 8- 18%[5]and is more common among women than men between 30 and 60 years most affected age[3].

Abnormal smooth muscle contraction and the increase in anal pressure were suggested to be the cause of pain sensation, because the intermittent, infrequent, and the short duration of the pain associated with proctalgia fugax make identifying its mechanism difficult. The definite causes of proctalgia are still unclear but first, exclusion of any pelvic or anorectal pathophysiology is important. Proctalgia fugax is common after vaginal hysterectomy, sclerotherapy for hemorrhoids, and intramuscular abscess[6]. Anxiety, stressful conditions, and irritable bowel syndrome in addition to an abscess, anal fissure, or hypertrophy of the internal anal sphincter[7].

Characteristics/Clinical Presentation[edit | edit source]

The patient will complain of episodes of localized pain at the lower rectum and anus, the episode lasts for a second to minutes (20 minutes maximum) with no pain between episodes. Symptoms may occur once per month, with no factors that trigger symptoms, however, anxiety and stress may induce symptoms[6]. Symptoms like; nausea, vomiting, sweating, and dizziness are rare. Episodes occur at irregular intervals and are unpredicted[2]. In a study the intervals range from 1-18o times/ year[8], another study demonstrated the recurrence of proctalgia fugax less than 5 times/ year in 51% of patients.

Differential Diagnosis[edit | edit source]

  • Levator ani syndrome.
  • Chronic proctalgia[3].
  • Chronic benign prostatitis.
  • Urogenital abnormalities[6].

Diagnostic Procedures[edit | edit source]

Rome III diagnostic criteria for proctalgia fugax include the following:

  • Reporting symproms for at least 3 months
  • Recurrent anal or lower rectum pain episodes.
  • Episodes last from seconds to minutes not more than 20 minutes and sometimes last up to 30 min according to Rome IV criteria[9].
  • No anorectal pain between episodes.

In research, it is important for symptoms to be checked for 3 months while in clinical practice proctalgia can be diagnosed before three months[9][10].

Proctalgia is the diagnosis of exclusion, it is important to first exclude organic pelvic or recto-anal pathology, anal histology or imaging may be required[8].


Medical Management[edit | edit source]

sitz bath

The symptoms of proctalgia fugax are rare and last for a short time, thus making its diagnosis and finding treatment options challenging[12]. The key is reassuring and explaining to the patient about the disorder that “cramp in your bottom” is harmless and not indicative of any serious bowel disease. As the episodes of pain are brief and infrequent, they usually don’t need treatment. A hot sitz bath is recommended[3]. For patients suffering from long, frequent symptoms:

  • Oral diazepam( short-term course) as a muscle relaxant.
  • Topical treatment with glyceryl trinitrate, or diltiazem.
  • Inhalation of β2 adrenergic agonist salbutamol.
  • Local anesthetic blocks, clonidine, or botox injections can be considered after clarification of risk and benefit[13].

Physical Therapy Management[edit | edit source]

Overactive or spasm of the pelvic floor muscles is common in the most pelvic floor disorder syndromes from this, we can find different disorders may respond to the same treatment approach[14]. There are no definite recommended treatment protocol for proctalgia fugax[2] but there are small studies found that biofeedback, galvanic electrical stimulation, and massage for levator muscles were effective and biofeedback was more effective than galvanic stimulation and the massage for levator muscles[14] as for levator ani syndrome.

Biofeedback is used to reduce the tension of pelvic floor muscles, Galvanic Electrical Stimulation GES with a low-frequency current is used to break the cycle of spasm[2].

References[edit | edit source]

  1. 1.0 1.1 Jeyarajah S, Purkayastha S. Proctalgia fugax. CMAJ. 2013 Mar 19;185(5):417-.
  2. 2.0 2.1 2.2 2.3 Carrington EV, Popa SL, Chiarioni G. Proctalgia syndromes: update in diagnosis and management. Current Gastroenterology Reports. 2020 Jul;22(7):1-7.
  3. 3.0 3.1 3.2 3.3 Bharucha AE, Trabuco E. Functional and chronic anorectal and pelvic pain disorders. Gastroenterology Clinics of North America. 2008 Sep 1;37(3):685-96.
  4. Shafik A, El-Sibai O. Effect of levator ani muscle contraction on urethrovesical and anorectal pressures and role of the muscle in urination and defecation. Urology. 2001 Aug 1;58(2):193-6.
  5. Drossman DA, Li Z, Andruzzi E, Temple RD, Talley NJ, Thompson WG, et al. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci. 1993;38(9):1569–80
  6. 6.0 6.1 6.2 Bharucha AE, Wald A, Enck P, Rao S. Functional anorectal disorders. Gastroenterology. 2006 Apr 1;130(5):1510-8.
  7. Celik AF, Katsinelos P, Read NW, Khan MI, Donnelly TC. Hereditary proctalgia fugax and constipation: report of a second family. Gut. 1995 Apr 1;36(4):581-4.
  8. 8.0 8.1 de Parades V, Etienney I, Bauer P, Taouk M, Atienza P. Proctalgia fugax: demographic and clinical characteristics. What every doctor should know from a prospective study of 54 patients. Diseases of the colon & rectum. 2007 Jun;50(6):893-8.
  9. 9.0 9.1 Simren M, Palsson OS, Whitehead WE. Update on Rome IV criteria for colorectal disorders: implications for clinical practice. Current gastroenterology reports. 2017 Apr;19(4):1-8.
  10. Shih DQ, Kwan LY. All roads lead to Rome: update on Rome III criteria and new treatment options. The gastroenterology report. 2007;1(2):56.
  11. Be Healthy. How Proctalgia Fugax Is Diagnosed Short Attacks Health Tips . Available from:[last accessed 25/5/2022]
  12. Knowles CH, Cohen RC. Chronic anal pain: A review of causes, diagnosis, and treatment. Cleveland Clinic journal of medicine. 2022 Jun 1;89(6):336-43.
  13. Jeyarajah S, Chow A, Ziprin P, Tilney H, Purkayastha S. Proctalgia fugax, an evidence-based management pathway. International journal of colorectal disease. 2010 Sep;25(9):1037-46.
  14. 14.0 14.1 Chiarioni G, Asteria C, Whitehead WE. Chronic proctalgia and chronic pelvic pain syndromes: new etiologic insights and treatment options. World Journal of Gastroenterology: WJG. 2011 Oct 28;17(40):4447.