This is an accepted version of this page
| Proctalgia fugax | |
|---|---|
| Specialty | General surgery |
Proctalgia fugax, a variant oflevator ani syndrome, is a severe, episodic pain in the regions of therectum andanus.[1] It can be caused bycramping of thelevator ani muscle, particularly in thepubococcygeal part.[2]
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 aslevator 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 therectum oranus, often misinterpreted as a need to defecate. To be diagnosed as proctalgia fugax, the pain must arisede novo (meaning the absence of clear cause). As such, pain associated withconstipation (either chronic, or acute), penetrative anal intercourse, trauma (such as tears or fissures of the rectalsphincter or anal canal), side-effects of some medications (particularlyopiates), 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 ofinternal anal sphincter thickening with the disorder, it is thought to be a disorder of that muscle or that it is a neuralgia ofpudendal 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 bepudendal neuralgia.[8]
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 lateraldecubitus position and a sterile probe is inserted into the anus. The negative electrode is used and thestimulator 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 oraldiazepam taken at night may be of benefit for frequent or disabling attacks.[13]
For milder cases, simple reassurance and topical treatment with acalcium channel blocker such asdiltiazem, ornifedipine ointment,salbutamol inhalation and topicalnitroglycerine. For persistent cases, local anesthetic blocks,clonidine orbotulinum 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 includingquinidine,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]
Other remedies have ranged from cannabis suppositories, warmbaths (if the pain lasts long enough), warm to hotenemas,[17] and relaxation techniques.[18]