Proctalgia fugax is a functional anorectal disorder characterized by severe, intermittent episodes of rectal pain that are self-limited.
PATHOPHYSIOLOGY
The sporadic and transient nature of proctalgia fugax has limited efforts to determine the underlying pathophysiologic basis, but spasm of the anal sphincter, pudendal nerve compression, and neuropathy have been implicated.
CLINICAL MANIFESTATIONS
- Recurrent attacks of severe anorectal pain
- Each episode may last from a few seconds to minutes, but the duration does not exceed 30 minutes
- The attacks are usually infrequent, occurring less than five times per year in approximately one-half of patients, but wide ranges have been reported (1 to 180 attacks per year)
DIAGNOSIS
Rome IV criteria A diagnosis of proctalgia fugax requires all of the following criteria to be fulfilled for the past three months, with symptom onset at least six months prior to diagnosis
- Recurrent episodes of pain localized to the rectum and unrelated to defecation
- Episodes last from seconds to minutes, with a maximum duration of 30 minute
- Absence of anorectal pain between episodes
DIFFERENTIAL DIAGNOSIS
MANAGEMENT
Initial treatment
- Reassurance and explanation
- The episodes of pain are typically brief, and prevention is not possible.
For patients who experience severe or frequent symptoms, sitz baths and treatment with topical antispasmodics may be helpful.
Topical antispasmodics
- Topical therapy with nitroglycerin (0.2 percent) or topical diltiazem gel (2 percent) has been used to treat proctalgia fugax at the onset of symptoms by decreasing internal anal sphincter pressure
Subsequent therapy and evaluation
- Rectal endoscopic ultrasound or magnetic resonance imaging of the abdomen and pelvis, if not performed as part of the initial evaluation
- If no alternative etiology is found, we suggest Biofeedback therapy for patients with severe or frequent symptoms who do not respond to initial therapy.