- Amy Barto, MD
Amy Barto, MD
- Lahey Clinic Medical Center
- Burlington, MA
- Kristen M Robson, MD, MBA, FACG
Kristen M Robson, MD, MBA, FACG
- Assistant Professor
- Tufts University School of Medicine
Proctalgia fugax is a functional anorectal disorder characterized by severe, intermittent episodes of rectal pain that are self-limited. The diagnosis of proctalgia fugax requires exclusion of other causes of rectal or anal pain.
This topic will review the epidemiology, clinical manifestations, diagnosis, and management of proctalgia fugax. Other functional gastrointestinal disorders and disorders that affect the anus or rectum are discussed separately. (See "Clinical manifestations and diagnosis of irritable bowel syndrome in adults" and "Perianal abscess: Clinical manifestations, diagnosis, treatment" and "Anal fissure: Clinical manifestations, diagnosis, prevention" and "Hemorrhoids: Clinical manifestations and diagnosis" and "Perianal complications of Crohn disease" and "Clinical manifestations, diagnosis, and prognosis of ulcerative colitis in adults" and "Clinical presentation, diagnosis, and staging of colorectal cancer" and "Clinical features, staging, and treatment of anal cancer".)
Proctalgia fugax is estimated to affect 4 to 18 percent of the general population [1-7]. However, only 17 to 20 percent of patients report their symptoms to their physicians. Although proctalgia has been reported in patients ranging from 10 to 87 years of age, it usually affects individuals between 46 and 58 years [1,8-13]. Proctalgia fugax has a higher prevalence in women as compared with men (58 to 84 percent) [1,5,6,9,10,12,14].
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, neuropathy, and psychological factors have been implicated.
Muscle spasm/hypertrophy — Patients with proctalgia fugax have normal anorectal pressures when asymptomatic, but exhibit motor abnormalities of the anal smooth muscle during an acute attack [9,13,15,16]. In one study that included 18 patients with proctalgia fugax, anorectal manometry demonstrated slightly increased resting anal pressures, but no differences in squeeze pressure, sphincter relaxation, rectal compliance, or internal and external anal sphincter thickness . In two patients, anorectal manometry provoked symptoms of proctalgia fugax. Furthermore, increasing duration of pain was associated with an increase in anal resting tone and slow wave amplitude. An autosomal dominant inherited myopathy of the internal anal sphincter has also been associated with proctalgia fugax [17,18].
- Thompson WG, Heaton KW. Proctalgia fugax. J R Coll Physicians Lond 1980; 14:247.
- Drossman DA, Li Z, Andruzzi E, et al. U.S. householder survey of functional gastrointestinal disorders. Prevalence, sociodemography, and health impact. Dig Dis Sci 1993; 38:1569.
- Whitehead WE, Wald A, Diamant NE, et al. Functional disorders of the anus and rectum. Gut 1999; 45 Suppl 2:II55.
- IBRAHIM H. Proctalgia fugax. Gut 1961; 2:137.
- Boyce PM, Talley NJ, Burke C, Koloski NA. Epidemiology of the functional gastrointestinal disorders diagnosed according to Rome II criteria: an Australian population-based study. Intern Med J 2006; 36:28.
- Thompson WG. Proctalgia fugax in patients with the irritable bowel, peptic ulcer, or inflammatory bowel disease. Am J Gastroenterol 1984; 79:450.
- Bharucha AE, Wald A, Enck P, Rao S. Functional anorectal disorders. Gastroenterology 2006; 130:1510.
- de Parades V, Etienney I, Bauer P, et al. Proctalgia fugax: demographic and clinical characteristics. What every doctor should know from a prospective study of 54 patients. Dis Colon Rectum 2007; 50:893.
- Eckardt VF, Dodt O, Kanzler G, Bernhard G. Anorectal function and morphology in patients with sporadic proctalgia fugax. Dis Colon Rectum 1996; 39:755.
- Takano M. Proctalgia fugax: caused by pudendal neuropathy? Dis Colon Rectum 2005; 48:114.
- Pilling LF, Swenson WM, Hill JR. The psychologic aspects of proctalgia fugax. Dis Colon Rectum 1965; 8:372.
- Gracia Solanas JA, Ramírez Rodríguez JM, Elía Guedea M, et al. Sequential treatment for proctalgia fugax. Mid-term follow-up. Rev Esp Enferm Dig 2005; 97:491.
- KARRAS JD, ANGELO G. Proctalgia fugax. Am J Surg 1951; 82:616.
- DOUTHWAITE AH. Proctalgia fugax. Br Med J 1962; 2:164.
- Harvey RF. Colonic motility in proctalgia fugax. Lancet 1979; 2:713.
- Rao SS, Hatfield RA. Paroxysmal anal hyperkinesis: a characteristic feature of proctalgia fugax. Gut 1996; 39:609.
- Kamm MA, Hoyle CH, Burleigh DE, et al. Hereditary internal anal sphincter myopathy causing proctalgia fugax and constipation. A newly identified condition. Gastroenterology 1991; 100:805.
- Celik AF, Katsinelos P, Read NW, et al. Hereditary proctalgia fugax and constipation: report of a second family. Gut 1995; 36:581.
- Shafik A. Pudendal canal syndrome and proctalgia fugax. Dis Colon Rectum 1997; 40:504.
- Salas LR, Whitehead WE, Schuster MM. Psychological symptoms in patients with levator ani and proctalgia fugax (abstract). Gastroenterology 1992; 102:508A.
- Thompson WG. Proctalgia fugax. Dig Dis Sci 1981; 26:1121.
- Atkin GK, Suliman A, Vaizey CJ. Patient characteristics and treatment outcome in functional anorectal pain. Dis Colon Rectum 2011; 54:870.
- Rao SS, Bharucha AE, Chiarioni G, et al. Functional Anorectal Disorders. Gastroenterology 2016; 54:1430.
- Lacy BE, Weiser K. Common anorectal disorders: diagnosis and treatment. Curr Gastroenterol Rep 2009; 11:413.
- Jeyarajah S, Chow A, Ziprin P, et al. Proctalgia fugax, an evidence-based management pathway. Int J Colorectal Dis 2010; 25:1037.
- Lowenstein B, Cataldo PA. Treatment of proctalgia fugax with topical nitroglycerin: report of a case. Dis Colon Rectum 1998; 41:667.
- Clayton MR. Therapy for proctodynia. Med J Aust 1985; 143:532.
- Schuster MM. Constipation and anorectal disorders. Clin Gastroenterol 1977; 6:643.
- Boquet J, Moore N, Lhuintre JP, Boismare F. Diltiazem for proctalgia fugax. Lancet 1986; 1:1493.
- Swain R. Oral clonidine for proctalgia fugax. Gut 1987; 28:1039.
- Katsinelos P, Kalomenopoulou M, Christodoulou K, et al. Treatment of proctalgia fugax with botulinum A toxin. Eur J Gastroenterol Hepatol 2001; 13:1371.
- Wald A. Functional anorectal and pelvic pain. Gastroenterol Clin North Am 2001; 30:243.
- Peleg R, Shvartzman P. Low-dose intravenous lidocaine as treatment for proctalgia fugax. Reg Anesth Pain Med 2002; 27:97.
- Mao J, Chen LL. Systemic lidocaine for neuropathic pain relief. Pain 2000; 87:7.
- Eckardt VF, Dodt O, Kanzler G, Bernhard G. Treatment of proctalgia fugax with salbutamol inhalation. Am J Gastroenterol 1996; 91:686.
- Guy RJ, Kamm MA, Martin JE. Internal anal sphincter myopathy causing proctalgia fugax and constipation: further clinical and radiological characterization in a patient. Eur J Gastroenterol Hepatol 1997; 9:221.
- Muscle spasm/hypertrophy
- Nerve compression
- Psychologic factors
- CLINICAL MANIFESTATIONS
- DIFFERENTIAL DIAGNOSIS
- Initial treatment
- - Topical antispasmodics
- Biofeedback therapy
- - Oral antihypertensives
- - Botulinum toxin and nerve blocks
- - Psychologic treatment
- - Other
- SUMMARY AND RECOMMENDATIONS