Proctalgia fugax


Proctalgia fugax

Description, Causes and Risk Factors:

Proctalgia fugax is a sharp fleeing pain felt in the rectum that lasts from 30 seconds to 30 minutes. In rare cases the pain can last up to several hours. The pain is localized and usually occurs spontaneously during the night. The rectum is the last 6 to 8 inches of the large intestine. It expands to store solid waste, and when full its muscular walls contract, forcing waste through the anorectal canal to the anus; where it is expelled from the body.

The pathophysiology of proctalgia is unknown, although it likely represents a spastic condition of the smooth muscle of the anal canal. There is a limited amount of data to support spasm of the rectosigmoid as a cause, while some clinicians and researchers believe that proctalgia develops due to spasm of the levator ani muscles (primarily the pubococcygeus). Physiologic studies using anorectal manometry and endoanal ultrasound have shown that proctalgia patients are similar to healthy controls during pain-free episodes, although one study demonstrated that anal canal resting pressures were higher in patients with proctalgia than normal volunteers. One study found that, during episodes of pain, patients with proctalgia have increased anal canal pressures and an increase in the frequency of slow waves in the anal canal. Patients frequently ask about precipitating factors, although no clear-cut precipitating event has been identified. Some patients report that straining at stool, stress, or intercourse may provoke an attack. Contrary to what has been written in many textbooks, proctalgia is not more likely to occur in patients with irritable bowel syndrome (IBS).

The pain is triggered by sexual intercourse, masturbation, psychophysical stress, evacuations, menstruation, excess alcohol use, but often a trigger factor cannot be identified. Preventative measures of eating a diet high in fiber and drinking plenty of fluids may help decrease the frequency of episodes by keeping stools soft.

Symptoms:

    Recurrent episodes of sudden, severe cramping pain localized to the anus or lower rectum.

  • Last from seconds to minutes and resolves completely.

  • The patient is entirely pain-free between the episodes.

  • Symptoms often occur at night and may wake the sufferer. Attacks are infrequent (<5 times yearly in 51% of patients).

  • Attacks may come in clusters (occurring daily) then abate for long periods.

Diagnosis:

The diagnosis of proctalgia fugax can be made based on the clinical history.A careful examination of the perianal region is imperative. Fissures, thrombosed hemorrhoids, masses, prolapse, and lichenification associated with chronic pruritus ani can all be quickly identified. Sensation can be quickly assessed, as can tone and strength of the external anal sphincter. Internal examination can identify a large rectocele, prolapse, or the taut muscle associated with levator ani syndrome (nearly always on the patient's left side). Although the history is diagnostic, patients are frequently worried about cancer because of the unpredictable and fleeting nature of the pain. In the current medico-legal climate, flexible sigmoidoscopy with careful retroflexion in the rectum should be performed.

Proctoscopy and pelvic MRI may be necessary for the differential diagnosis. The anorectal ultrasound may provide information on the thickness of the muscles of the anal sphincter. Finally, the Neurophysiological (electromyography of the pelvic floor muscles, the study of bulbo-cavernous reflex and the measurement of the latency of the pudendal nerve) may influence the medical and surgical treatment to be performed.

Treatment:

Treating patients with proctalgia fugax can be difficult because symptoms have usually completely resolved by the time the patient can initiate medical therapy. In addition, because the majority of patients have very infrequent episodes, most clinicians are reticent to treat a patient with a daily medication in order to prevent a single, brief monthly episode. After carefully explaining the nature of the condition to the patient and reassuring him or her that it is a benign disorder, conservative therapy is generally the best recommendation. A warm sitz bath or even a warm water enema at the start of the attack can be very useful. Longer lasting episodes can be treated with short-acting benzodiazepines, smooth muscle antispasmodics (i.e., sublingual hyoscyamine), sublingual nitroglycerin, or topical (perianal) nitroglycerin. One prospective, double-blind study demonstrated that an inhaled beta-agonist, salbuterol, shorted the length of each episode. Patients with frequent episodes may benefit from the use of a calcium channel blocker, long-acting nitrates, or even botulinum toxin injection of the anal canal. Some patients and physicians have resorted to myotomy of the anal canal as a last resort; however, that is generally not necessary, even in the most severe patients.

NOTE: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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