Proctalgia fugax

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

• Levator ani
• External hemorrhoid
• Anal fissure
• Rectal prolapse
• Constipation
• Fecal impaction
• Prostatitis
• Proctitis
• Prolapsed internal hemorrhoid
• Anorectal abscess
• Coccydynia

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