Proctalgia Fugax: Difference between revisions

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== Definition/Description ==
== Definition/Description ==
Proctalgia fugax or functional recurrent anorectal pain, a spasm of pelvic floor muscles, anal sphincter muscles, or rectal muscles causing episodes of severe stabbing anal pain in the absence of an organic disorder to explain pain, lasting for a few seconds or minutes, and repeats for weeks with no pain between episodes. The severity can be severe enough to wake the patient from sleep. The pain is localized to the lower rectum and anus<ref>Jeyarajah S, Purkayastha S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3602260/ Proctalgia fugax.] CMAJ. 2013 Mar 19;185(5):417-.</ref>. While chronic proctalgia is a dull ache or pressure-like sensation in the rectum that worse with sitting than standing<ref name=":0">Bharucha AE, Trabuco E. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2676775/ Functional and chronic anorectal and pelvic pain disorders.] Gastroenterol Clin North</ref>.
[[File:Digital rectal exam nci-vol-7136-300.jpg|thumb|200x200px]]
Proctalgia fugax or [[Functional Anorectal Pain|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 the pain.<ref name=":6" /> The severity can be severe enough to awaken the patient from sleep. The patient describes the symptoms as a blunt knife inserted into the rectum<ref name=":3">Carrington EV, Popa SL, Chiarioni G. [https://link.springer.com/article/10.1007/s11894-020-00768-0 Proctalgia syndromes: update in diagnosis and management.] Current Gastroenterology Reports. 2020 Jul;22:1-7.</ref>. The pain is localized to the lower rectum and anus<ref name=":6">Jeyarajah S, Purkayastha S. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3602260/ Proctalgia fugax.] CMAJ. 2013 Mar 19;185(5):417-.</ref> and unrelated to defecation. <ref name=":0">Bharucha AE, Trabuco E. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2676775/ Functional and chronic anorectal and pelvic pain disorders]. Gastroenterology Clinics of North America. 2008 Sep 1;37(3):685-96.</ref>  


== Clinically Relevant Anatomy  ==
== Clinically Relevant Anatomy  ==
 
[[File:Medical Animation Levator Ani structure.jpg|thumb|levator ani muscles]]
add text here
The levator ani muscles are a component of the pelvic floor diaphragm, in addition to their role as a supportive structure and keeping visceral and internal organs in place. Contraction of the levator ani muscle assists in the process of evacuation by lowering the urethral and anal pressures. Abnormalities in muscle contraction cause defecation disorders<ref>Shafik A, El-Sibai O. [https://www.sciencedirect.com/science/article/pii/S0090429501011967 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.</ref>. 
[[File:Human anus-en.svg.png|thumb|250x250px|External, and Iinternal sphincter in red.]]
The anal sphincter consists of the internal and external anal sphincters; the internal anal sphincter is a ring of muscles that contract at rest and relax during defecation, and the external anal sphincter is a skeletal muscle fiber adherent to the skin that controls defecation.


== Epidemiology /Etiology  ==
== Epidemiology /Etiology  ==


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''%''<ref>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</ref>and is more common among women than men with 30 and 60 years most affected age<ref name=":0" />.
It is a transitory disorder that usually does not need further investigations and can be treated by a primary 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''%''<ref>Drossman DA, Li Z, Andruzzi E, Temple RD, Talley NJ, Thompson WG, et al. U.S. [https://link.springer.com/article/10.1007/BF01303162 householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact.] Dig Dis Sci. 1993;38(9):1569–80</ref>and is more common among women than men between 30 and 60 years old age<ref name=":0" />.


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.
Abnormal smooth muscle contraction and the increase in anal pressure were suggested to be the cause of pain sensation because the intermittent, infrequent, and short duration of the pain associated with proctalgia fugax make identifying its mechanism difficult. The definite causes of proctalgia are still unclear but first, the exclusion of any pelvic or anorectal pathophysiology is important. Proctalgia fugax is common after vaginal [[hysterectomy]], sclerotherapy for hemorrhoids, and intramuscular abscess<ref name=":1">Bharucha AE, Wald A, Enck P, Rao S. [https://www.gastrojournal.org/article/S0016-5085(06)00516-6/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F#secd23675761e389 Functional anorectal disorders.] Gastroenterology. 2006 Apr 1;130(5):1510-8.</ref>. Anxiety, stressful conditions, and [[Irritable Bowel Syndrome|irritable bowel syndrome]] in addition to an abscess, anal fissure, or hypertrophy of the internal anal sphincter<ref>Celik AF, Katsinelos P, Read NW, Khan MI, Donnelly TC. [https://gut.bmj.com/content/36/4/581.short Hereditary proctalgia fugax and constipation: report of a second family.] Gut. 1995 Apr 1;36(4):581-4.</ref>.
 
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<ref name=":1">Bharucha AE, Wald A, Enck P, Rao S. [https://www.gastrojournal.org/article/S0016-5085(06)00516-6/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F#secd23675761e389 Functional anorectal disorders.] Gastroenterology. 2006 Apr 1;130(5):1510-8.</ref>. Anxiety, stressful conditions, and irritable bowel syndrome in addition to an abscess, anal fissure, or hypertrophy of internal anal sphincter<ref>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.</ref>.  


== Characteristics/Clinical Presentation  ==
== Characteristics/Clinical Presentation  ==


add text here <br>  
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<ref name=":1" />. Symptoms like;  nausea, vomiting, sweating,  and dizziness are rare. Episodes occur at irregular intervals and are unpredicted<ref name=":3" />. In a study the intervals range from 1-18o times/ year<ref name=":4">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.</ref>, another study demonstrated the recurrence of proctalgia fugax less than 5 times/ year in 51% of patients.


== Differential Diagnosis  ==
== Differential Diagnosis  ==
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== Diagnostic Procedures  ==
== Diagnostic Procedures  ==


add text here related to medical diagnostic procedures
Rome III diagnostic criteria for proctalgia fugax include the following:
 
== Outcome Measures ==
 
add links to outcome measures here (also see [[Outcome Measures|Outcome Measures Database]]) 
 
== Examination  ==
 
add text here related to physical examination and assessment<br>
 
== Medical Management <br>  ==
 
add text here <br>
 
== Physical Therapy Management <br>  ==
 
add text here <br>


== Key Research  ==
* Reporting symptoms 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<ref name=":2">Simren M, Palsson OS, Whitehead WE. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5378729/ Update on Rome IV criteria for colorectal disorders: implications for clinical practice]. Current gastroenterology reports. 2017 Apr;19(4):1-8.</ref>.
* No anorectal pain between episodes.


add links and reviews of high quality evidence here (case studies should be added on new pages using the [[Template:Case Study|case study template]])<br>  
In research, it is important for symptoms to be checked for 3 months while in clinical practice proctalgia can be diagnosed before three months<ref name=":2" /><ref>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.
</ref>.


== Resources <br>  ==
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<ref name=":4" />.
== Medical Management  ==
[[File:Sitz or hip bath.jpeg|thumb|sitz bath]]
The symptoms of proctalgia fugax are rare and last for a short time, thus making its diagnosis and finding treatment options challenging<ref>Knowles CH, Cohen RC. [https://www.ccjm.org/content/89/6/336.long Chronic anal pain: A review of causes, diagnosis, and treatment.] Cleveland Clinic journal of medicine. 2022 Jun 1;89(6):336-43.</ref>. 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<ref name=":0" />. For patients suffering from long, frequent symptoms:


add appropriate resources here <br>  
* Oral diazepam( short-term course) as a [[Muscle Relaxant|muscle relaxant.]]
* Topical treatment with glyceryl trinitrate, or diltiazem.
* Inhalation of β<sub>2</sub> adrenergic agonist salbutamol.
* Local anesthetic blocks, clonidine, or botox injections can be considered after clarification of risk and benefit<ref>Jeyarajah S, Chow A, Ziprin P, Tilney H, Purkayastha S. [https://pubmed.ncbi.nlm.nih.gov/20556402/ Proctalgia fugax, an evidence-based management pathway.] International journal of colorectal disease. 2010 Sep;25(9):1037-46.</ref>.


== Clinical Bottom Line ==
== Physical Therapy Management ==
 
add text here <br>


Overactive or spasm of the pelvic floor muscles is common in most pelvic floor disorder syndromes from this, we can find different disorders may respond to the same treatment approach<ref name=":5">Chiarioni G, Asteria C, Whitehead WE. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3218134/ Chronic proctalgia and chronic pelvic pain syndromes: new etiologic insights and treatment options]. World Journal of Gastroenterology: WJG. 2011 Oct 28;17(40):4447.</ref>. There is no definite recommended treatment protocol for proctalgia fugax<ref name=":3" /> but there are small studies that 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<ref name=":5" /> 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<ref name=":3" />. 
== References  ==
== References  ==
see [[Adding References|adding references tutorial]].


<references />  
<references />  


[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Vrije_Universiteit_Brussel_Project]]
[[Category:Conditions]]
[[Category:Womens Health]]
[[Category:Womens Health]]
[[Category:Mens Health]]
[[Category:Mens Health]]
[[Category:Pelvic Health]]
[[Category:Pelvic Health]]
[[Category:Pelvis - Conditions]]
[[Category:Pelvis - Conditions]]

Latest revision as of 20:20, 26 June 2023

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 the pain.[1] The severity can be severe enough to awaken 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 are a component of the pelvic floor diaphragm, in addition to their role as a supportive structure and keeping visceral and internal organs in place. Contraction of the levator ani muscle assists in the process of evacuation by lowering the urethral and anal pressures. Abnormalities in muscle contraction cause defecation disorders[4].

External, and Iinternal sphincter in red.

The anal sphincter consists of the internal and external anal sphincters; the internal anal sphincter is a ring of muscles that contract at rest and relax during defecation, and the external anal sphincter is a skeletal muscle fiber adherent to the skin that controls defecation.

Epidemiology /Etiology[edit | edit source]

It is a transitory disorder that usually does not need further investigations and can be treated by a primary 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 old 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 short duration of the pain associated with proctalgia fugax make identifying its mechanism difficult. The definite causes of proctalgia are still unclear but first, the 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 symptoms 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[11]. 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[12].

Physical Therapy Management[edit | edit source]

Overactive or spasm of the pelvic floor muscles is common in most pelvic floor disorder syndromes from this, we can find different disorders may respond to the same treatment approach[13]. There is no definite recommended treatment protocol for proctalgia fugax[2] but there are small studies that 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[13] 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;22:1-7.
  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. 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.
  12. 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.
  13. 13.0 13.1 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.