Proctalgia Fugax

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Definition/Description

Proctalgia fugax, acute proctalgia, or functional recurrent anorectal pain, 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 may repeats for weeks with no pain between episodes. 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. The pain is localized to the lower rectum and anus and unrelated to defecation. While chronic proctalgia is a dull ache or pressure-like sensation in the rectum that is worse with sitting than standing.

Clinically Relevant Anatomy

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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%and is more common among women than men between 30 and 60 years most affected age.

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. Anxiety, stressful conditions, and irritable bowel syndrome in addition to an abscess, anal fissure, or hypertrophy of the internal anal sphincter.

Characteristics/Clinical Presentation

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. Symptoms like; nausea, vomiting, sweating, and dizziness are rare. Episodes occur at irregular intervals and are unpredicted. In a study the intervals range from 1-18o times/ year, another study demonstrated the recurrence of proctalgia fugax less than 5 times/ year in 51% of patients.

Differential Diagnosis

• Levator ani syndrome.
• Chronic proctalgia.
• Chronic benign prostatitis.
• Urogenital abnormalities.

Diagnostic Procedures

Rome III diagnostic criteria for proctalgia fugax include the following:

• 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.
• 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.

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.

Medical Management

sitz bath

The episodes of pain are brief and infrequent and usually they don’t need treatment for those patients reassurance and explanation of the disorder to the patient or advice them with a hot sitz bath are recommended. 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.

Physical Therapy Management

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. There are no definite recommended treatment protocol for proctalgia fugax 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 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.