II. Pathophysiology
- Functional Rectal Pain has no clear etiology and is diagnosed after other rectal conditions are excluded
- Functional Rectal Pain is divided into three distinct conditions (based on Rome Criteria as below)
- Levator Ani Syndrome
- Unspecified Functional Anorectal Pain
- Proctalgia Fugax
- May be related to spasm of anal sphincter
III. Symptoms: Proctalgia Fugax
-
Anorectal Pain
- Sudden onset
- Variable character: Sharp, gripping, or cramp-like
- No radiation
- Spontaneous relief
- Seconds to minutes
- Rarely lasts hours
- Recurs several times each year
- Often occurs at night
- May occur as often as 3 to 4 times weekly
- Associated Symptoms
- Urge to defecate but no stool passed
- Onset with orgasm
IV. Diagnosis: Proctalgia Fugax (ROME IV Criteria - all must be present for diagnosis)
- Recurrent episodic Rectal Pain, unrelated to Defecation
- Episode duration seconds to minutes (<30 minutes)
- No Anorectal Pain between episodes
- Other organic causes of Rectal Pain are excluded
V. Diagnosis: Levator Ani Syndrome (ROME IV Criteria - all must be present for diagnosis)
- Chronic or recurrent Rectal Pain or ache
- Episode duration >30 minutes
- Pain on posterior traction (against puborectalis Muscle) on Rectal Exam
- Other organic causes of Rectal Pain are excluded
VI. Diagnosis: Unspecified Functional Anorectal Pain (ROME IV Criteria - all must be present for diagnosis)
- Chronic or recurrent Rectal Pain or ache
- Episode duration >30 minutes
- NO Pain on posterior traction (against puborectalis Muscle) on Rectal Exam
- Differentiates this condition from Levator Ani Syndrome
- Other organic causes of Rectal Pain are excluded
VII. Differential Diagnosis
- See Rectal Pain
VIII. Associated Conditions
- More common in those with Irritable Bowel Syndrome
- Potential food associations
IX. Management: General to consider in all Functional Rectal Pain
- Exclude organic causes of Rectal Pain
- Sit in tub of hot water
- Fiber supplementation (e.g. 20-30 grams/day) with 64 ounces non-caffeinated fluid
- Biofeedback
- Topical Diltiazem or topical Glyceryl Trinitrate
- See Anal Fissure for dosing
- Tricyclic Antidepressants
X. Management: Proctalgia Fugax
- No proven Management
- Medications with anecdotal success (no proven efficacy)
- Procedures that have been studied with varying success
- Onabotulinumtoxin A injection
- Sacral nerve stimulation
- Pudendal Nerve Block
- Maneuvers that anecdotally interrupt spasm
- Sit in tub of hot water
- Apply ice to peri-anal area
- Finger placed inside Rectum
- Rectal suppository (e.g. Preparation H)
- Inhaled Salbutamol (not available in U.S.)