Proctalgia fugax

Background

Anatomy of the anus.

• Exact pathophysiology unclear, however may include anal sphincter spasm and hypertrophy
• Frequently brought on by stress
• Prevalence 8-18%, does not favor one sex
• Should be considered a diagnosis of exclusion

Clinical Features

• Spasm-like, sometimes excruciating, pain in the anus, often misinterpreted as a need to defecate
• Episodic pain (women, patients < 45yo)
• Brief, usually only seconds to minutes in duration
• Incontinence
• Urgency

Differential Diagnosis

Anorectal Disorders

• Anal fissure
• Anal fistula
• Anal malignancy
• Anal tags
• Anorectal abscess
• Coccydynia
• Colorectal malignancy
• Condyloma acuminata
• Constipation
• Crohn's disease
• Cryptitis
• GC/Chlamydia
• Fecal impaction
• Hemorrhoids
  • Internal hemorrhoid
  • External hemorrhoid
• Levator ani syndrome
• Pedunculated polyp
• Pilonidal cyst
• Proctalgia fugax
• Proctitis
• Pruritus ani
  • Enterobius (pinworms)
• Rectal foreign body
• Rectal prolapse
• Syphilitic fissure

Non-GI Look-a-Likes

• Prostatitis

Evaluation

• Diagnosis is largely clinical, and one of exclusion
• Digital rectal examination should be performed, with special attention and care noted to assess the external areas for contributing sources of pain
  • This includes a prostate examination in men
  • Women should also have pelvic examination to assess for pelvic etiology masking as rectal complaint
• Laboratory evaluation, including ESR and CRP, may be obtained though are frequently normal
• If febrile or leukocytosis present, consider advanced imaging to assess for deeper infections or process not easily evaluated by physical examination

Rome IV Criteria

• The Rome IV criteria are meant to differentiate and assist in the diagnosis of functional gastrointestinal disorders (FGID)
• For the diagnosis of proctalgia fugax, the following should be present

1. Recurrent episodes of pain unrelated to defecation
2. Episode duration no longer than 30 minutes (>30 minutes suggest levator ani syndrome)
3. Absence of pain between episodes
4. Exclusion of other causes

Management

• In majority of cases, reassurance and explanation of process is sufficient
  • This is due to brief duration of episodes and difficulty in both treating and preventing
• Referral to gastroenterology if symptoms severe
  • Some research into inhaled beta agonists and topical anti-spasmodics, but best provided and managed by GI

Disposition

• Can be safely discharged home when emergent causes excluded
• Provide GI follow up information

See Also

• Anorectal Disorders