II. Pathophysiology

  1. Functional Rectal Pain has no clear etiology and is diagnosed after other rectal conditions are excluded
  2. Functional Rectal Pain is divided into three distinct conditions (based on Rome Criteria as below)
    1. Levator Ani Syndrome
    2. Unspecified Functional Anorectal Pain
    3. Proctalgia Fugax
      1. May be related to spasm of anal sphincter

III. Symptoms: Proctalgia Fugax

  1. Anorectal Pain
    1. Sudden onset
    2. Variable character: Sharp, gripping, or cramp-like
    3. No radiation
  2. Spontaneous relief
    1. Seconds to minutes
    2. Rarely lasts hours
  3. Recurs several times each year
    1. Often occurs at night
    2. May occur as often as 3 to 4 times weekly
  4. Associated Symptoms
    1. Urge to defecate but no stool passed
    2. Onset with orgasm

IV. Diagnosis: Proctalgia Fugax (ROME IV Criteria - all must be present for diagnosis)

  1. Recurrent episodic Rectal Pain, unrelated to Defecation
  2. Episode duration seconds to minutes (<30 minutes)
  3. No Anorectal Pain between episodes
  4. Other organic causes of Rectal Pain are excluded

V. Diagnosis: Levator Ani Syndrome (ROME IV Criteria - all must be present for diagnosis)

  1. Chronic or recurrent Rectal Pain or ache
  2. Episode duration >30 minutes
  3. Pain on posterior traction (against puborectalis muscle) on rectal exam
  4. Other organic causes of Rectal Pain are excluded

VI. Diagnosis: Unspecified Functional Anorectal Pain (ROME IV Criteria - all must be present for diagnosis)

  1. Chronic or recurrent Rectal Pain or ache
  2. Episode duration >30 minutes
  3. NO Pain on posterior traction (against puborectalis muscle) on rectal exam
    1. Differentiates this condition from Levator Ani Syndrome
  4. Other organic causes of Rectal Pain are excluded

VII. Differential Diagnosis

VIII. Associated Conditions

  1. More common in those with Irritable Bowel Syndrome
  2. Potential food associations
    1. Artificial Sweeteners
    2. Caffeine

IX. Management: General to consider in all Functional Rectal Pain

  1. Exclude organic causes of Rectal Pain
  2. Sit in tub of hot water
  3. Fiber supplementation (e.g. 20-30 grams/day) with 64 ounces non-caffeinated fluid
  4. Biofeedback
  5. Topical Diltiazem or topical Glyceryl Trinitrate
    1. See Anal Fissure for dosing
  6. Tricyclic Antidepressants

X. Management: Proctalgia Fugax

  1. No proven Management
  2. Medications with anecdotal success (no proven efficacy)
    1. Albuterol MDI
    2. Catapres 0.1 mg bid
    3. Cardizem 80 mg PO bid
    4. Diazepam (Valium) at bedtime (not recommended)
  3. Procedures that have been studied with varying success
    1. Onabotulinumtoxin A injection
    2. Sacral nerve stimulation
    3. Pudendal Nerve Block
  4. Maneuvers that anecdotally interrupt spasm
    1. Sit in tub of hot water
    2. Apply ice to peri-anal area
    3. Finger placed inside Rectum
    4. Rectal suppository (e.g. Preparation H)
    5. Inhaled Salbutamol (not available in U.S.)

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Related Studies

Ontology: Levator syndrome (C0423738)

Definition (NCI) Recurrent episodes of pain localized to the anus or lower rectum which lasts seconds to minutes. There is no pain between episodes.(NICHD)
Concepts Disease or Syndrome (T047)
MSH C535890
ICD10 K59.4
SnomedCT 155788009, 270534003, 279087002, 62647006
English proctalgia fugax, proctalgia fugax (diagnosis), Levator ani syndrome, Levator syndrome, Levator ani spasm syndrome, fugax proctalgia, levator syndrome, Proctalgia fugax (& anal spasm): disorder or observation, Proctalgia fugax (& anal spasm): disorder or observation (disorder), Anal spasm/pain, Painful spasm of anus (finding), Proctalgia fugax - anal spasm, Proctalgia Fugax, Anorectal spasm, Paroxysmal proctalgia, Proctalgia fugax, Painful spasm of anus, Painful spasm of anus (disorder), fugax; proctalgia, proctalgia; fugax, proctalgia; spasmodic, spasmodic; proctalgia
Spanish Síndrome del elevador del ano, Proctalgia fugaz, espasmo anorrectal, espasmo doloroso del ano (trastorno), espasmo doloroso del ano, proctalgia fugaz (trastorno), proctalgia fugaz, proctalgia paroxística, síndrome del elevador
Dutch levator-syndroom, proctalgia fugax, fugax; proctalgie, proctalgie; fugax, proctalgie; spasmodisch, spasmodisch; proctalgie
Italian Proctalgia fugace, Sindrome di Levator
German Levatorsyndrom, Proctalgia fugax
French Coccydynie, Proctalgie fugace
Portuguese Síndrome do Elevador, Proctalgia fugaz
Czech Bolest konečníku přechodná, Syndrom zdvihače
Japanese コウモンキョキンショウコウグン, イッカセイチョクチョウツウ, 一過性直腸痛, 肛門挙筋症候群
Hungarian Levator syndroma, Proctalgia fugax