What is Proctalgia Fugax
Proctalgia fugax is a condition that involves very short episodes of intense pain in the rectum. The rectum is the last part of the large intestine. The pain can last from seconds to minutes.
Episodes often occur during the night and awaken the person from sleep. This condition is not a sign of cancer, but your health care provider may want to rule out a number of other conditions.
Proctalgia fugax is a disease of unknown cause characterized by paroxysms of rectal pain with pain-free periods between attacks. The pain-free periods between attacks can last seconds to minutes. Similar to cluster headache, spontaneous remissions of the disease occur and may last weeks to years.
Proctalgia fugax is more common in women and occurs with greater frequency in patients with irritable bowel syndrome.
The pain of proctalgia fugax is sharp or gripping and severe. Similar to other urogenital focal pain syndromes, such as vulvodynia and prostadynia, the causes remain obscure.
Stress and sitting for prolonged periods often increase the frequency and intensity of attacks of proctalgia fugax.
Patients often feel an urge to defecate with the onset of the paroxysms of pain. Depression often accompanies the pain of proctalgia fugax but is not thought to be the primary cause. The symptoms of proctalgia fugax can be so severe as to limit the patient’s ability to perform activities of daily living.
What are the causes?
The cause of this condition is not known. One possible cause may be spasm of the pelvic muscles or of the lowest part of the large intestine.
What are the symptoms?
The only symptom of this condition is rectal pain.
- The pain may be intense or severe.
- The pain may last for only a few seconds or it may last up to 30 minutes.
- The pain may occur at night and wake you up from sleep.
The physical examination of a patient with proctalgia fugax is usually normal. The patient may be depressed or appear anxious. Rectal examination is normal, although deep palpation of the surrounding musculature may trigger paroxysms of pain. The patient often reports that he or she can abort the attack of pain by placing a finger in the rectum. Rectal suppositories also may interrupt the attacks.
How is this diagnosed?
This condition may be diagnosed by ruling out other problems that could cause the pain. Diagnosis may include:
- Medical history and physical exam.
- Various tests, such as:
- Anoscopy. In this test, a lighted scope is put into the rectum to look for abnormalities.
- Barium enema. In this test, X-rays are taken after a white chalky substance called barium is put into the colon. The barium makes it easier to see problems because it shows up well on the X-rays.
- Blood tests to rule out infections or other problems.
Similar to the physical examination, testing in patients with proctalgia fugax is usually normal. Because of the risk for overlooking rectal malignancy that may be responsible for pain that may be attributed to a benign cause, by necessity proctalgia fugax is a diagnosis of exclusion.
Rectal examination is mandatory in all patients thought to have proctalgia fugax. Sigmoidoscopy or colonoscopy is strongly recommended in such patients. Testing of the stool for occult blood is indicated. Screening laboratory studies, consisting of a complete blood cell count, automated chemistries, and erythrocyte sedimentation rate, should be performed.
Magnetic resonance imaging (MRI), ultrasound imaging, or computed tomography (CT) of the pelvis should be considered in all patients with proctalgia fugax to rule out occult pathology. If psychological problems are suspected or the patient has a history of sexual abuse, psychiatric evaluation is indicated concurrently with laboratory and radiographic testing.
As mentioned previously, because of the risk for overlooking serious pathology of the anus and rectum, proctalgia fugax must be a diagnosis of exclusion.
The clinician first must rule out rectal malignancy to avoid disaster. Proctitis can mimic the pain of proctalgia fugax and can be diagnosed on sigmoidoscopy or colonoscopy.
Hemorrhoids usually manifest with bleeding associated with pain and can be distinguished from proctalgia fugax on physical examination. Prostadynia sometimes may be confused with proctalgia fugax, but the pain is more constant, duller, and aching.
How is this treated?
There is no specific treatment to cure this condition. Treatment options may include:
- Warm baths.
- Relaxation techniques.
- Gentle massage of the painful area.
Initial treatment of proctalgia fugax should include a combination of simple analgesics and nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 (COX-2) inhibitors.
If these medications do not control the symptoms adequately, a tricyclic antidepressant or gabapentin should be added. Traditionally, tricyclic antidepressants have been a mainstay in the palliation of pain secondary to proctalgia fugax. Controlled studies have shown the efficacy of amitriptyline for this indication.
Other tricyclic antidepressants, including nortriptyline and desipramine, also have been shown to be clinically useful. This class of drugs is associated with significant anticholinergic side effects, including dry mouth, constipation, sedation, and urinary retention. These drugs should be used with caution in patients with glaucoma, cardiac arrhythmia, and prostatism.
To minimize side effects and encourage compliance, the primary care physician should start amitriptyline or nortriptyline at a 10-mg dose at bedtime. The dose can be titrated upward to 25 mg at bedtime, as side effects allow.
Upward titration of dosage in 25-mg increments can be done each week as side effects allow. Even at lower doses, patients generally report a rapid improvement in sleep disturbance and begin to experience some pain relief in 10 to 14 days. If the patient does not experience any improvement in pain as the dose is being titrated upward, the addition of gabapentin alone or in combination with nerve blocks of the intercostal nerves with local anesthetics, steroid, or both is recommended. Selective serotonin reuptake inhibitors, such as fluoxetine, also have been used to treat the pain of diabetic neuropathy; although better tolerated than the tricyclic antidepressants, they seem to be less efficacious.
If antidepressant compounds are ineffective or contraindicated, gabapentin is a reasonable alternative. Gabapentin should be started with a 300-mg dose at bedtime for 2 nights. The patient should be cautioned about potential side effects, including dizziness, sedation, confusion, and rash. The drug is increased in 300-mg increments, given in equally divided doses over 2 days, as side effects allow, until pain relief is obtained or a total dose of 2400 mg daily is reached. At this point, if the patient has experienced partial pain relief, blood values are measured, and the drug is carefully titrated upward using 99-mg tablets. More than 3600 mg daily rarely is required.
Local application of heat and cold also may be beneficial to provide symptomatic relief of the pain of proctalgia fugax. The use of bland rectal suppositories may help provide symptomatic relief. For patients who do not respond to these treatment modalities, injection of the perineal nerves or caudal epidural nerve block using a local anesthetic and steroid may be a reasonable next step. Ultrasound guidance may improve the accuracy of needle placement and decrease the incidence of needle-related complications. Anecdotal reports indicate that calcium channel blockers, topical nitroglycerin, low-dose intravenous lidocaine, and inhalation of albuterol provide symptomatic relief of the pain of proctalgia fugax.
The major problem in the care of patients thought to have proctalgia fugax is the failure to identify potentially serious pathology of the anus or rectum secondary to primary tumor or invasion of these structures by pelvic tumor. Although uncommon, occult rectal infection remains a possibility, especially in an immunocompromised patient with cancer. Early detection of infection is crucial to avoid potentially life-threatening sequelae.
Proctalgia fugax is a distressing disease for patients. The paroxysms of pain may occur without warning and make the patient afraid to leave the house. The main focus of the clinician caring for a patient with proctalgia fugax is to ensure that occult malignancy has not been overlooked. Given the psychological implications of pain involving the genitals and rectum, the clinician should not overlook the possibility of psychological abnormality in patients with pain in the rectum.
Follow these instructions at home:
- Take over-the-counter and prescription medicines only as told by your health care provider.
- Follow instructions from your health care provider about diet.
- Follow instructions from your health care provider about rest and physical activity.
- Try warm baths, massaging the area, or progressive relaxation techniques as told by your health care provider.
- Keep all follow-up visits as told by your health care provider. This is important.
Contact a health care provider if:
- You develop new symptoms.
- Your pain does not get better as soon as it usually does.