What is proctalgia fugax

Proctalgia fugax is a medical term to describe the sensation of pain due to rectal muscle spasm. Proctalgia fugax causes episodes of sudden, severe anal pain that last for a few minutes at a time. Proctalgia fugax is a functional recurrent anorectal pain that is part of a spectrum of functional gastrointestinal disorders ¹. A functional bowel disorder is diagnosed by characteristic symptoms for at least 12 weeks during the preceding 12 months in the absence of a structural or biochemical explanation ². Functional gastrointestinal disorders are disorders of gut–brain interaction ³. Functional bowel disorder is a group of disorders classified by gastrointestinal symptoms related to any combination of the following: motility disturbance, visceral hypersensitivity, altered mucosal and immune function, altered gut microbiota, and altered central nervous system (CNS) processing ⁴.

The term “functional” is generally applied to disorders where the body’s normal activities in terms of the movement of the intestines, the sensitivity of the nerves of the intestines, or the way in which the brain controls some of these functions is impaired. However, there are no structural abnormalities that can be seen by endoscopy, x-ray, or blood tests. Thus it is identified by the characteristics of the symptoms and infrequently, when needed, limited tests.

Proctalgia fugax is defined by the Rome III diagnostic criteria 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 ⁵. There is no diurnal variation. There are numerous precipitants including sexual activity, stress, constipation, defecation and menstruation, although proctalgia fugax can occur without a trigger. Proctalgia fugax should be differentiated from chronic proctalgia, a functional anorectal pain disorder with a vague, dull ache or pressure sensation high in the rectum, often worse when sitting than when standing or lying down, and lasts at least 20 minutes ⁵.

The prevalence of proctalgia fugax in the general population may be as high as 8%–18% ⁶. Many patients present to primary health care physicians and often do not require further consultation because the symptoms are fleeting ⁷. This condition is more common among women than among men ⁷ and usually affects patients between 30 and 60 years of age ⁸.

Depending on the cause of your anal pain, there are some measures you can try at home to get relief. They include:

• Eating more fruits, vegetables and whole grains, exercising daily, and taking stool softeners, if needed, to facilitate bowel movements, reduce straining and ease pain
• Sitting in a tub of hot water up to your hips — known as a sitz bath — several times a day to ease the pain of hemorrhoids, anal fissures or rectal muscle spasms
• Applying over-the-counter hemorrhoid cream for hemorrhoids or hydrocortisone cream for anal fissures
• Taking an over-the-counter pain reliever such as acetaminophen (Tylenol, others), aspirin or ibuprofen (Advil, Motrin IB, others)

Proctalgia fugax causes

Although the cause of proctalgia fugax is unclear, spasm of the anal sphincter is commonly implicated ⁹. The condition may be more likely to occur after sclerotherapy for hemorrhoids and vaginal hysterectomy. There are also associations with other functional pathologies, such as irritable bowel syndrome and anxiety ⁹.

Other causes of anorectal pain (e.g., hemorrhoids, cryptitis, ischemia, abscess, fissure, rectocele and malignant disease) must be excluded before the diagnosis of proctalgia fugax can be made ¹⁰.

Other causes of anal pain include:

• Anal cancer
• Anal fissure (a small tear in the lining of the anal canal)
• Anal itching (pruritus ani)
• Anal sex
• Anorectal fistula (an abnormal channel between the anus or rectum usually to the skin near the anus)
• Coccydynia or coccygodynia (tailbone pain)
• Constipation
• Crohn’s disease
• Diarrhea causing anal irritation
• Fecal impaction (a mass of hardened stool in the rectum due to chronic constipation)
• Hemorrhoids (swollen and inflamed veins in your anus or rectum)
• Levator ani syndrome (spasm in the muscles that surround the anus)
• Perianal abscess (pus in the deep tissue around the anus)
• Perianal hematoma (a collection of blood in the perianal tissue caused by a ruptured vein, sometimes called an external hemorrhoid)
• Proctitis (inflammation of the lining of the rectum)
• Solitary rectal ulcer syndrome (ulcer of the rectum)
• Thrombosed hemorrhoid (blood clot in a hemorrhoid)
• Trauma
• Ulcerative colitis (a type of inflammatory bowel disease)
• Ulcerative proctitis (a type of inflammatory bowel disease)

Figure 1. Proctalgia fugax diagnostic pathway

[Source ¹¹ ]

Proctalgia fugax symptoms

Rome III criteria for proctalgia fugax ¹²:

1. Recurrent episodes of pain localized to the anus or lower rectum
2. Episodes last from seconds to minutes
3. There is no anorectal pain between episodes.

Proctalgia fugax treatment

Most treatments for proctalgia fugax (e.g., oral diltiazem, topical glyceryl nitrate, nerve blocks) act by relaxing the anal sphincter spasm, but the effectiveness of these treatments are supported only by case reports or case series, with the exception of a single randomized controlled trial of salbutamol ¹³, making the value of most treatment options, including salbutamol, difficult to judge ¹¹.

Summary of recommended treatment modalities for proctalgia fugax ¹¹:

• Tap/hot water enema – there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial ¹⁴
• Hot baths – there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial ¹⁵
• Oral diltiazem – there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial ¹⁶
• Glyceryl trinitrate (nitroglycerin) – there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial ¹⁷
• Clonidine – there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits ¹⁸
• Botulinum toxin injection – there is high certainty that the net benefit is substantial ¹⁹
• Salbutamol inhalation – there is high certainty that the net benefit is substantial ²⁰
• Pudendal nerve block – there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits ²¹
• Superior hypogastric plexus block – there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits ²²

References

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