Proctalgia fugax

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Background

  • 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

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 imagining to assess for deeper infections or process not easily evaluated by physical examination

Rome IV Criteria[1]

  • 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

References

  1. Rao SSC, Bharucha AE, Chiarioni G, et al. Anorectal Disorders. Gastroenterology. March 2016:S0016-5085(16)00175-X 10.1053/j.gastro.2016.02.009. doi:10.1053/j.gastro.2016.02.009., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5035713/