Proctalgia fugax

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Proctalgia fugax
Specialty General surgery

Proctalgia fugax, a variant of levator ani syndrome , is a severe, episodic pain in the regions of the rectum and anus. [1] It can be caused by cramping of the levator ani muscle, particularly in the pubococcygeal part. [2]

Contents

Signs and symptoms

It most often occurs in the middle of the night [3] and lasts from seconds to minutes; [4] pain and aching lasting twenty minutes or longer would likely be diagnosed instead as levator ani syndrome. In a study published in 2007 involving 1809 patients, the attacks occurred in the daytime (33 percent) as well as at night (33 percent) and the average number of attacks was 13. Onset can be in childhood; however, in multiple studies the average age of onset was 45. Many studies showed that women are affected more commonly than men, [5] but this can be at least partly explained by men's reluctance to seek medical advice concerning rectal pain. [6] Data on the number of people affected vary, but prevalence may be as high as 8–18%. [4] [7] It is thought that only 17–20% of patients consult a physician, so obtaining accurate data on occurrence presents a challenge. [4]

During an episode, the patient feels spasm-like, sometimes excruciating, pain in the rectum or anus, often misinterpreted as a need to defecate. To be diagnosed as proctalgia fugax, the pain must arise de novo (meaning the absence of clear cause). As such, pain associated with constipation (either chronic, or acute), penetrative anal intercourse, trauma (such as tears or fissures of the rectal sphincter or anal canal), side-effects of some medications (particularly opiates), or rectal foreign body insertion preclude this diagnosis. The pain episode subsides by itself as the spasm disappears on its own, but may reoccur. [4]

Because of the high incidence of internal anal sphincter thickening with the disorder, it is thought to be a disorder of that muscle or that it is a neuralgia of pudendal nerves. It is not known to be linked to any disease process.

Prevention

High-voltage pulsed galvanic stimulation (HGVS) has been shown to be of prophylactic benefit, to reduce the incidence of attacks. The patient is usually placed in the left lateral decubitus position and a sterile probe is inserted into the anus. The negative electrode is used and the stimulator is set with a pulse frequency of 80 to 120 cycles per second. The voltage (intensity) is started at 0, progressively raised to a threshold of patient discomfort, and then is decreased to a level that the patient finds comfortable. As the patient's tolerance increases, the voltage can be gradually increased to 250 to 350 Volts. Each treatment session usually lasts between 15 and 60 minutes. Several studies have reported short-term success rates that ranged from 65 to 91%. [8] [9] [10] [11]

A low dose of oral diazepam taken at night may be of benefit for frequent or disabling attacks. [12]

Treatment

For milder cases, simple reassurance and topical treatment with a calcium channel blocker such as diltiazem, or nifedipine ointment, salbutamol inhalation and topical nitroglycerine. For persistent cases, local anesthetic blocks, clonidine or botulinum toxin injections can be considered. [13] [14] Supportive treatments directed at aggravating factors include high-fiber diet, withdrawal of drugs which have gut effects (e.g., drugs that provoke or worsen constipation including narcotics and oral calcium channel blockers; drugs that provoke or worsen diarrhea including quinidine, theophylline, and antibiotics), warm baths, rectal massage, perineal strengthening exercises, anticholinergic agents, non-narcotic analgesics, sedatives or muscle relaxants such as diazepam. In patients who have frequent, severe, prolonged attacks, inhaled salbutamol has been shown in some studies to reduce their duration. [15]

Traditional remedies have ranged from cannabis suppositories, warm baths (if the pain lasts long enough), warm to hot enemas, [16] and relaxation techniques. [17]

Related Research Articles

<span class="mw-page-title-main">Defecation</span> Expulsion of feces from the digestive tract

Defecation follows digestion, and is a necessary process by which organisms eliminate a solid, semisolid, or liquid waste material known as feces from the digestive tract via the anus or cloaca. The act has a variety of names ranging from the common, like pooping or crapping, to the technical, e.g. bowel movement, to the obscene (shitting), to the euphemistic, to the juvenile. The topic, usually avoided in polite company, can become the basis for some potty humor.

<span class="mw-page-title-main">Pudendal nerve</span> Main nerve of the perineum

The pudendal nerve is the main nerve of the perineum. It is a mixed nerve and also conveys sympathetic autonomic fibers. It carries sensation from the external genitalia of both sexes and the skin around the anus and perineum, as well as the motor supply to various pelvic muscles, including the male or female external urethral sphincter and the external anal sphincter.

<span class="mw-page-title-main">Constipation</span> Bowel dysfunction

Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement. Complications from constipation may include hemorrhoids, anal fissure or fecal impaction. The normal frequency of bowel movements in adults is between three per day and three per week. Babies often have three to four bowel movements per day while young children typically have two to three per day.

<span class="mw-page-title-main">Levator ani</span> Broad, thin muscle group, situated on either side of the pelvis

The levator ani is a broad, thin muscle group, situated on either side of the pelvis. It is formed from three muscle components: the pubococcygeus, the iliococcygeus, and the puborectalis.

<span class="mw-page-title-main">Rectal prolapse</span> Medical condition

A rectal prolapse occurs when walls of the rectum have prolapsed to such a degree that they protrude out of the anus and are visible outside the body. However, most researchers agree that there are 3 to 5 different types of rectal prolapse, depending on whether the prolapsed section is visible externally, and whether the full or only partial thickness of the rectal wall is involved.

<span class="mw-page-title-main">Colorectal surgery</span> Field in medicine for disabilities in the rectum

Colorectal surgery is a field in medicine dealing with disorders of the rectum, anus, and colon. The field is also known as proctology, but this term is now used infrequently within medicine and is most often employed to identify practices relating to the anus and rectum in particular. The word proctology is derived from the Greek words πρωκτός proktos, meaning "anus" or "hindparts", and -λογία -logia, meaning "science" or "study".

<span class="mw-page-title-main">Anal canal</span> Functional segment of the large intestine

The anal canal is the part that connects the rectum to the anus, located below the level of the pelvic diaphragm. It is located within the anal triangle of the perineum, between the right and left ischioanal fossa. As the final functional segment of the bowel, it functions to regulate release of excrement by two muscular sphincter complexes. The anus is the aperture at the terminal portion of the anal canal.

Proctitis is an inflammation of the anus and the lining of the rectum, affecting only the last 6 inches of the rectum.

<span class="mw-page-title-main">Internal anal sphincter</span> Ring of smooth muscle that surrounds part of the anal canal

The internal anal sphincter, IAS, or sphincter ani internus is a ring of smooth muscle that surrounds about 2.5–4.0 cm of the anal canal. It is about 5 mm thick, and is formed by an aggregation of the smooth (involuntary) circular muscle fibers of the rectum. It terminates distally about 6 mm from the anal orifice.

<span class="mw-page-title-main">Anorectal abscess</span> Medical condition

Anorectal abscess is an abscess adjacent to the anus. Most cases of perianal abscesses are sporadic, though there are certain situations which elevate the risk for developing the disease, such as diabetes mellitus, Crohn's disease, chronic corticosteroid treatment and others. It arises as a complication of paraproctitis. Ischiorectal, inter- and intrasphincteric abscesses have been described.

Pruritus ani is the irritation of the skin at the exit of the rectum, known as the anus, causing the desire to scratch. The intensity of anal itching increases from moisture, pressure, and rubbing caused by clothing and sitting. At worst, anal itching causes intolerable discomfort that often is accompanied by burning and soreness. It is estimated that up to 5% of the population of the United States experiences this type of discomfort daily.

<span class="mw-page-title-main">Levator ani syndrome</span> Medical condition

Levator ani syndrome is a condition characterized by burning pain or tenesmus of the rectal or perineal area, caused by spasm of the levator ani muscle. The genesis of the syndrome is unknown; however, inflammation of the arcus tendon is a possible cause of levator ani syndrome.

Lateral internal sphincterotomy is an operation performed on the internal anal sphincter muscle for the treatment of chronic anal fissure. The internal anal sphincter is one of two muscles that comprise the anal sphincter which controls the passage of feces. The procedure helps by lowering the resting pressure of the internal anal sphincter, which improves blood supply to the fissure and allows faster healing. The procedure has been shown to be very effective, with 96% of fissures healing at a median of 3 weeks in one trial.

<span class="mw-page-title-main">Human anus</span> External opening of the rectum

In humans, the anus is the external opening of the rectum located inside the intergluteal cleft. Two sphincters control the exit of feces from the body during an act of defecation, which is the primary function of the anus. These are the internal anal sphincter and the external anal sphincter, which are circular muscles that normally maintain constriction of the orifice and which relax as required by normal physiological functioning. The inner sphincter is involuntary and the outer is voluntary. Above the anus is the perineum, which is also located beneath the vulva or scrotum.

Rectal pain is the symptom of pain in the area of the rectum. A number of different causes (68) have been documented.

<span class="mw-page-title-main">Anorectal manometry</span> Medical functional test of the anus and rectum

Anorectal manometry (ARM) is a medical test used to measure pressures in the anus and rectum and to assess their function. The test is performed by inserting a catheter, that contains a probe embedded with pressure sensors, through the anus and into the rectum. Patients may be asked to perform certain maneuvers, such as coughing or attempting to defecate, to assess for pressure changes. Anorectal manometry is a safe and low risk procedure.

Rectal discharge is intermittent or continuous expression of liquid from the anus. Normal rectal mucus is needed for proper excretion of waste. Otherwise, this is closely related to types of fecal incontinence but the term rectal discharge does not necessarily imply degrees of incontinence. Types of fecal incontinence that produce a liquid leakage could be thought of as a type of rectal discharge.

<span class="mw-page-title-main">Anismus</span> Medical condition

Anismus or dyssynergic defecation is the failure of normal relaxation of pelvic floor muscles during attempted defecation. It can occur in both children and adults, and in both men and women. It can be caused by physical defects or it can occur for other reasons or unknown reasons. Anismus that has a behavioral cause could be viewed as having similarities with parcopresis, or psychogenic fecal retention.

<span class="mw-page-title-main">Neurogenic bowel dysfunction</span> Human disease involving inability to control defecation

Neurogenic bowel dysfunction (NBD) is the inability to control defecation due to a deterioration of or injury to the nervous system, resulting in faecal incontinence or constipation. It is common in people with spinal cord injury (SCI), multiple sclerosis (MS) or spina bifida.

Low anterior resection syndrome is a complication of lower anterior resection, a type of surgery performed to remove the rectum, typically for rectal cancer. It is characterized by changes to bowel function that affect quality of life, and includes symptoms such as fecal incontinence, incomplete defecation or the sensation of incomplete defecation, changes in stool frequency or consistency, unpredictable bowel function, and painful defecation (dyschezia). Treatment options include symptom management, such as use of enemas, or surgical management, such as creation of a colostomy.

References

  1. ↑ Alberts, Daniel (2012). Dorland's illustrated medical dictionary (32nd ed.). Philadelphia, PA: Saunders/Elsevier. p. 1521. ISBN   978-1-4160-6257-8.
  2. ↑ Olden, Kevin W. (1996). Handbook of functional gastrointestinal disorders. New York: M. Dekker. p. 369. ISBN   0-8247-9409-5.
  3. ↑ Takano M (2005). "Proctalgia fugax: caused by pudendal neuropathy?". Dis. Colon Rectum. 48 (1): 114–20. doi:10.1007/s10350-004-0736-3. PMID   15690667. S2CID   792567.
  4. 1 2 3 4 Whitehead WE, Wald A, Diamant NE, Enck P, Pemberton JH, Rao SS (September 1999). "Functional disorders of the anus and rectum". Gut. 45 (Suppl 2): II55–9. doi:10.1136/gut.45.2008.ii55. PMC   1766682 . PMID   10457046.
  5. ↑ de Parades V, Etienney I, Bauer P, Taouk M, Atienza P (2007). "Proctalgia fugax: demographic and clinical characteristics. What every doctor should know from a prospective study of 54 patients". Dis. Colon Rectum. 50 (6): 893–8. doi:10.1007/s10350-006-0754-4. PMID   17164968. S2CID   11697730.
  6. ↑ Brannon, Linda; Feist, Jess (2009-03-19). Health Psychology: An Introduction to Behavior and Health. Cengage Learning. p. 54. ISBN   978-0495601326.
  7. ↑ Jeyarajah, Santhini; Purkayastha, Sanjay (2013-03-19). "Proctalgia fugax". Canadian Medical Association Journal. 185 (5): 417. doi:10.1503/cmaj.101613. ISSN   1488-2329. PMC   3602260 . PMID   23184844.
  8. ↑ Sohn N, Weinstein MA, Robbins RD. The levator syndrome and its treatment with high-voltage electrogalvanic stimulation. Am J Surg. 1982;144(5):580-582.
  9. ↑ Oliver GC, Rubin RJ, Salvati EP, Eisenstat TE. Electrogalvanic stimulation in the treatment of levator syndrome. Dis Colon Rectum. 1985;28(9):662-663.
  10. ↑ Nicosia JF, Abcarian H. Levator syndrome: A treatment that works. Dis Colon Rectum. 1985;28(6):406-408.
  11. ↑ Morris L, Newton RA. Use of high voltage pulsed galvanic stimulation for patients with levator ani syndrome. Phys Ther. 1987;67(10):1522-1525
  12. ↑ Pfenninger JL, Zainea GG (2001). "Common anorectal conditions: Part I. Symptoms and complaints". Am Fam Physician. 63 (12): 2391–8. PMID   11430454.
  13. ↑ Jeyarajah S, Chow A, Ziprin P, Tilney H, Purkayastha S (September 2010). "Proctalgia fugax, an evidence-based management pathway". Int J Colorectal Dis. 25 (9): 1037–46. doi:10.1007/s00384-010-0984-8. PMID   20556402. S2CID   8635926.
  14. ↑ Wollina U, Konrad H, Petersen S (2005). "Botulinum toxin in dermatology - beyond wrinkles and sweat". Journal of Cosmetic Dermatology. 4 (4): 223–7. doi:10.1111/j.1473-2165.2005.00195.x. PMID   17168867. S2CID   11333698.
  15. ↑ Eckardt VF, Dodt O, Kanzler G, Bernhard G (1996). "Treatment of proctalgia fugax with salbutamol inhalation". Am. J. Gastroenterol. 91 (4): 686–9. PMID   8677929.
  16. ↑ Olsen B (2007). "Proctalgia fugax - a nightmare drowned in enema". Colorectal Disease. 10 (5): 522–3. doi:10.1111/j.1463-1318.2007.01399.x. PMID   17949444. S2CID   45958437.
  17. ↑ Carrington EV, Popa SL, Chiarioni G (June 2020). "Proctalgia Syndromes: Update in Diagnosis and Management". Curr Gastroenterol Rep. 22 (7): 35. doi:10.1007/s11894-020-00768-0. PMID   32519087.
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