Proctalgia Fugax and Anal Pain

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Synonyms: functional anorectal pain, chronic proctalgia, pyriformis syndrome, pelvic tension myalgia, levator ani syndrome

  • Anorectal pain is a relatively common symptom first described by the Romans.[1]
  • Patients will often delay consulting a healthcare practitioner about this problem due to embarrassment and fear of a sinister diagnosis, tolerating disturbing symptoms for long periods.
  • There are two functional anorectal pain syndromes:
  • Proctalgia fugax (PF) (fugax = fugitive/fleeting in Latin) and
  • Levator ani syndrome (LAS)
  • They are both characteristic, benign anorectal-pain syndromes of uncertain aetiology.
  • Despite their benign nature, they can cause severe distress to the sufferer. There is even an account of marital disharmony caused by proctalgia fugax.[2]
  • They are thought to occur due to spasm of the anal sphincter - proctalgia fugax (PF)[3] or pelvic floor muscles - levator ani syndrome (LAS) but are something of an enigma.[4]
  • They may be associated with irritable bowel syndrome (IBS). The two affected muscles are anatomically contiguous so the two conditions may coexist, or be different manifestations of the same underlying dysfunction.[5]
  • The diagnosis of these conditions can usually be made on the basis of the symptoms.
  • However, more serious diagnoses can present similarly. Thus, it is essential to conduct a thorough clinical assessment to exclude other pathology before offering reassurance.
  • It may be associated with low-fibre diet and IBS. More than half of affected patients are aged 30-60 years and prevalence declines after age 45.[6]
  • It has been associated with a variety of other pathologies which may have aetiological significance; for example, pudendal nerve neuralgia.[7]

Save time & improve your PDP on Patient.co.uk

  • Notes Add notes to any clinical page and create a reflective diary
  • Track Automatically track and log every page you have viewed
  • Print Print and export a summary to use in your appraisal
Click to find out more »
  • Proctalgia fugax (PF) is estimated to affect 8-18% of the population in the developed world, and levator ani syndrome (LAS) around 6%.
  • LAS seems to affect women more than men.[8]
  • It is thought that only 20-30% of sufferers of these conditions consult a healthcare practitioner.[8][6]

Presentation

  • Symptoms:
    • Recurrent episodes of sudden, severe cramping pain localised to the anus or lower rectum.
    • Last from seconds to minutes and resolves completely.
    • The patient is entirely pain-free between the episodes.
    • Symptoms often occur at night and may wake the sufferer. Attacks are infrequent (<5 times yearly in 51% of patients).
    • Attacks may come in clusters (occurring daily) then abate for long periods.[6]
  • Signs:
    • Proctalgia fugax (PF) has no signs and the diagnosis is made on the basis of characteristic symptoms and the absence of signs of other pathology.
    • Abdominal and digital rectal examination should constitute the minimum assessment of anal pain.
    • Ideally, anoscopy/proctoscopy should be carried out.[13]
    • Consider gynaecological/scrotal examination if relevant.
    • Further examination with a sigmoidoscope or colonoscope may be necessary in selected patients where there is suspicion of pathology higher in the colon.
    • It is worth checking for signs of anaemia if gastrointestinal bleeding is suspected.

Management

  • Once the diagnosis is made, reassurance is usually sufficient.
  • The symptoms are so transient that drug therapy is rarely needed.
  • In patients who suffer frequent, severe, prolonged attacks, inhaled salbutamol has been shown to reduce their duration.[14]
  • Clonidine and amyl nitrite have also been used but no evidence exists for their efficacy.
  • Pudendal nerve blocks have been used and claims are made on the basis of subsequent pain relief that a neuralgia is the cause of pain.[7]

Presentation

  • Symptoms:
    • Vague, aching or pressure sensation high in the rectum often worsened by sitting or lying, and relieved by walking.
    • Pain tends to recur regularly.
    • Lasts from hours to days.
    • To satisfy diagnostic criteria the symptoms must be present for 12 weeks in the preceding year (need not be consecutive) with episodes lasting <20 minutes.
    • Other causes of similar pain (see Differential diagnosis section) must have been excluded.[6]
  • Signs:
    • In levator ani syndrome (LAS), posterior traction on the puborectalis reveals tight levator ani muscles and tenderness or pain.
    • Tenderness may be predominantly left-sided and massage of the puborectalis muscle may elicit the characteristic discomfort.

Management

  • Many treatments have been tried including pulsed galvanic stimulation, Sitz baths, massage, muscle relaxants such as methocarbamol and diazepam, and biofeedback (which appears effective subjectively at reducing pain).
  • Calcium channel blockers have been suggested.[15]
  • Botulinum toxin injections have been tried successfully, but more studies are needed to prove efficacy.[16]
  • Psychotherapeutic interventions have long been suggested for many functional gastrointestinal disorders, but evidence of efficacy in proctalgia fugax (PF) and levator ani syndrome (LAS) is so far lacking.[17]
  • There have been no reliable RCTs testing the efficacy of these treatments.[6]
  • No investigations help to make the diagnoses of proctalgia fugax (PF) or levator ani syndrome (LAS).
  • If other conditions, such as rectal carcinoma, are suspected then tests to confirm or refute these - eg FBC, colonoscopy - should be considered.
  • When examining the anogenital area ensure that the patient is fully informed about what to expect and the reasons why the examination is necessary.
  • An appropriate chaperone should be offered and be in attendance for intimate examinations.
  • Document the presence of a chaperone and their identity along with the examination findings.
  • Ensure patient privacy and dignity, and discontinue the examination if at any time you or the patient are unhappy or uncomfortable with the situation.
  • Do not assume that because you are the same sex as the patient, that a chaperone isn't needed.
  • For further information, see separate article Rectal Examination.

Further reading & references

  • Vincent C; Anorectal pain and irritation: anal fissure, levator syndrome, proctalgia fugax, Prim Care. 1999 Mar;26(1):53-68.
  • Pfenninger JL, Zainea GG; Common anorectal conditions: Part I. Symptoms and complaints. Am Fam Physician. 2001 Jun 15;63(12):2391-8.
  • Pfenninger JL, Zainea GG; Common anorectal conditions: Part II. Lesions. Am Fam Physician. 2001 Jul 1;64(1):77-88.
  1. Proctalgia Fugax, A pain in the butt; Gihealth.com
  2. Mountifield JA; Proctalgia fugax: a cause of marital dysharmony. CMAJ. 1986 Jun 1;134(11):1269-70.
  3. Rao SS, Hatfield RA; Paroxysmal anal hyperkinesis: a characteristic feature of proctalgia fugax. Gut. 1996 Oct;39(4):609-12.
  4. Peery WH; Proctalgia fugax: a clinical enigma. South Med J. 1988 May;81(5):621-3.
  5. Mazza L, Formento E, Fonda G; Anorectal and perineal pain: new pathophysiological hypothesis. Tech Coloproctol. 2004 Aug;8(2):77-83.
  6. Whitehead WE, Wald A, Diamant NE, et al; Functional disorders of the anus and rectum. Gut. 1999 Sep;45 Suppl 2:II55-9.
  7. Takano M; Proctalgia fugax: caused by pudendal neuropathy? Dis Colon Rectum. 2005 Jan;48(1):114-20.
  8. 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 Jun;50(6):893-8.
  9. Manavi K, McMillan A, Young H; The prevalence of rectal chlamydial infection amongst men who have sex with men attending the genitourinary medicine clinic in Edinburgh. Int J STD AIDS. 2004 Mar;15(3):162-4.
  10. Singer MA, Cintron JR, Martz JE, et al; Retrorectal cyst: a rare tumor frequently misdiagnosed. J Am Coll Surg. 2003 Jun;196(6):880-6.
  11. de la Portilla F, Borrero JJ, Rafel E; Hereditary vacuolar internal anal sphincter myopathy causing proctalgia fugax and constipation: a new case contribution. Eur J Gastroenterol Hepatol. 2005 Mar;17(3):359-61.
  12. Snooks SJ, Croft RJ; 'Defaecation claudication': a cause of rectal pain? J R Soc Med. 1989 Jun;82(6):371-2.
  13. Pfenninger JL, Zainea GG; Common anorectal conditions: Part I. Symptoms and complaints. Am Fam Physician. 2001 Jun 15;63(12):2391-8.
  14. Eckardt VF, Dodt O, Kanzler G, et al; Treatment of proctalgia fugax with salbutamol inhalation. Am J Gastroenterol. 1996 Apr;91(4):686-9.
  15. Babb RR; Proctalgia fugax: would you recognize it? Postgrad Med. 1996 Apr;99(4):263-4.
  16. Katsinelos P, Kalomenopoulou M, Christodoulou K, et al; Treatment of proctalgia fugax with botulinum A toxin. Eur J Gastroenterol Hepatol. 2001 Nov;13(11):1371-3.
  17. Drossman DA, Creed FH, Olden KW, et al; Psychosocial aspects of the functional gastrointestinal disorders. Gut. 1999 Sep;45 Suppl 2:II25-30.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Richard Draper
Current Version:
Last Checked:
19/02/2010
Document ID:
2667 (v21)
© EMIS