The pain of proctalgia fugax is characteristically described as a
sudden, sharp or gripping, cramp-like pain in the anorectal area. The
pain does not radiate. Spontaneous relief occurs within seconds to
minutes, although rarely the pain can be present for hours. Onset
occurs after puberty and disappears by the age of 70. It occurs in
both males and females. The pain can occur at any time but has a
predilection for the nocturnal hours. Frequency is variable but, in
most affected persons, episodes of pain occur several times a year. A
brief review has been posted:
Friday, October 3, 2008
Proctalgia Fugax
Proctalgia fugax is a common cause of pain in the rectum. Symptoms consistent
with proctalgia fugax occur in 13 to 19 percent of the general population.
Proctalgia fugax is underrepresented in the medical literature, and many
physicians are unaware of its existence. Lack of familiarity on the part of the
physician can result in unnecessary diagnostic evaluation. Contributing to the
relative lack of familiarity is the fact that most patients with proctalgia
fugax do not seek medical attention because the pain is usually brief and often
infrequent. Patients may also be reluctant to disclose the symptoms because
they fear potentially painful diagnostic procedures or the possibility of a
serious condition
* Anorectal pain is a relatively common symptom first described by the
Romans.
* 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:
o Proctalgia fugax (PF) (fugax=fugitive/fleeting in Greek) and
o 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.
Aetiology
* They are thought to occur due to spasm of the anal sphincter (PF) or
pelvic floor muscles (LAS) but are something of an enigma.
* They may be associated with irritable bowel syndrome. The two affected
muscles are anatomically contiguous so the two conditions may co-exist, or be
different manifestations of the same underlying dysfunction.
* 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.
* May be associated with low-fibre diet and irritable bowel syndrome. More
than half of affected patients are aged 3060 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.
Epidemiology
* PF is estimated to affect 818% of the population in the developed world,
and LAS around 6%.
* LAS seems to affect women more than men.
* It is thought that only 2030% of sufferers of these conditions consult a
healthcare practitioner.
Differential diagnosis
* Irritable bowel syndrome
* Haemorrhoids ± thrombosis
* Anal fissure (usually causes intense localised pain associated with and
following defecation) should be visible on proctoscopy.
* Solitary chronic rectal ulcer
* Rectal carcinoma
* Perirectal abscess or fistula; hydradentis suppuritiva
* Proctitis (especially gonococcal/chlamydial infection)
* Crohn's/Ulcerative colitis.
* Rectal foreign body
* Pruritus ani.
* Diverticular disease
* Rectal prolapse
* Coccygodynia (neuralgic pain around the region of the coccyx)
* Retrorectal cysts
* Condylomata acuminata (anogenital warts)
* Testicular carcinoma
* Prostatitis
* Cystitis
* Psychological cause (some hypothesise that these conditions are
psychological rather than physical in origin)
* Alcock's canal syndrome (pudendal neuralgia due to entrapment, may
present similarly to PF/be aetiologically relevant)
* Hereditary anal sphincter myopathy
* Bilateral internal iliac artery occlusion
Proctalgia fugax
Presentation
* Symptoms:
o Recurrent episodes of sudden, severe cramping pain localised to the
anus or lower rectum.
o Last from seconds to minutes and resolves completely.
o The patient is entirely pain free between the episodes.
o Symptoms often occur at night and may wake the sufferer. Attacks
are infrequent (<5>
o Attacks may come in clusters (occurring daily) then abate for long
periods.
* Signs:
o PF has no signs and the diagnosis is made on the basis of
characteristic symptoms and the absence of signs of other pathology.
o Abdominal and digital rectal examination should constitute the
minimum assessment of anal pain.
o Ideally, anoscopy/proctoscopy should be carried out.
o Consider gynae/scrotal examination if relevant.
o Further examination with a sigmoidoscope or colonoscope may be
necessary in selected patients where there is suspicion of pathology higher in
the colon.
o It is worth checking for signs of anaemia if GI 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.
* Clonidine and amylnitrate have also been used but no evidence exists for
their efficacy.
Posted by jitendraagrawal2000 at 2:28 PM
http://www.surgerysearch.blogspot.com/
Dr. Jitendra Agrawal, Kanpur, India.
