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]

Causes

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.

In one study of 68 people with proctalgia fugax, 55 had tenderness along the course of the pudendal nerve. Pudendal nerve block relieved symptoms completely in 65% of the participants and reduced symptoms in 25%. This suggests that a major cause of proctalgia fugax may be pudendal neuralgia. [8]

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%. [9] [10] [11] [12]

A low dose of oral diazepam taken at night may be of benefit for frequent or disabling attacks. [13]

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. [14] [15] 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. [16]

Traditional remedies have ranged from cannabis suppositories, warm baths (if the pain lasts long enough), warm to hot enemas, [17] and relaxation techniques. [18]

Related Research Articles

<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">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents — including flatus (gas), liquid stool elements and mucus, or solid feces. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. Reported prevalence figures vary: an estimated 2.2% of community-dwelling adults are affected, while 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

<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.

Pudendal nerve entrapment (PNE) is an uncommon, chronic pelvic pain condition in which the pudendal nerve is entrapped and compressed. There are several different anatomic locations of potential entrapment. Pudendal nerve entrapment is an example of nerve compression syndrome.

<span class="mw-page-title-main">Rectal prolapse</span> Protrusion of the walls of the rectum outside the body

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 or anusitis 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.

<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.

<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.

An enterocele is a herniation of a peritoneum-lined sac containing small intestine through the pelvic floor, between the rectum and the vagina. Enterocele is significantly more common in females, especially after hysterectomy.

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> Failure to relax the pelvic floor muscles during defecation

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.

Obstructed defecation syndrome is a major cause of functional constipation, of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week. Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools, and the colonic transit time may be normal, but delayed in the rectum and sigmoid colon.

<span class="mw-page-title-main">Ahmed Shafik (surgeon)</span> Egyptian researcher (1933–2007)

Ahmed Shafik was an Egyptian surgeon and prolific researcher, best known for his groundbreaking work in colorectal and pelvic floor surgery, as well as his contributions to sexual health research. Shafik's dedication to advancing surgical techniques and understanding human physiology made him a prominent figure in the medical field.

Transanal irrigation is medical procedure in which water is used to evacuate feces from the rectum and descending colon via the anus.

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. ↑ Steele SR, Hull TL, Hyman N, Maykel JA, Read TE, Whitlow CB (20 November 2021). The ASCRS Textbook of Colon and Rectal Surgery (4th ed.). Cham, Switzerland: Springer Nature. ISBN   978-3-030-66049-9.
  9. ↑ 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.
  10. ↑ Oliver GC, Rubin RJ, Salvati EP, Eisenstat TE. Electrogalvanic stimulation in the treatment of levator syndrome. Dis Colon Rectum. 1985;28(9):662-663.
  11. ↑ Nicosia JF, Abcarian H. Levator syndrome: A treatment that works. Dis Colon Rectum. 1985;28(6):406-408.
  12. ↑ Morris L, Newton RA. Use of high voltage pulsed galvanic stimulation for patients with levator ani syndrome. Phys Ther. 1987;67(10):1522-1525
  13. ↑ Pfenninger JL, Zainea GG (2001). "Common anorectal conditions: Part I. Symptoms and complaints". Am Fam Physician. 63 (12): 2391–8. PMID   11430454.
  14. ↑ 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.
  15. ↑ 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.
  16. ↑ 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.
  17. ↑ 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.
  18. ↑ 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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