Proctalgia Fugax: Causes, Symptoms, Treatment, Home Remedies, Pathophysiology

Proctalgia fugax is a harmless condition where a person experiences sudden, severe and sharp rectal and anal pain, which is transient in nature, i.e. it lasts for a few seconds to a few minutes. The pain is sudden and sharp in nature, occurs in episodes and is felt like a cramp. The pain of proctalgia fugax is recurrent and occurs at irregular intervals. The exact cause for why proctalgia fugax occurs is not clear and it does not seem to be related to any type of organic disease. One of the causes of proctalgia fugax is thought to be spasms in the anal sphincter. Other contributing causes include stress and anxiety.

The pain of proctalgia fugax is fleeing in nature and commonly occurs when the patient has gone to bed for the night and is felt for only a few seconds to a few minutes and subsides, as abruptly as it starts. Proctalgia fugax tends to get relieved with time. Proctalgia fugax commonly affects individuals who are aged between 30 to 60 years. This condition tends to decline after the age of 45.

The differentiating factor between proctalgia fugax and levator ani syndrome is that proctalgia fugax tends to occur in the middle of the night. The duration of the pain of proctalgia fugax can last from a few seconds to a few minutes; whereas, the pain in levator ani syndrome lasts for around 20 minutes or more.

The proctalgia fugax is transient and sporadic in nature which makes it difficult to determine its underlying pathophysiology. However, some of the causes for Proctalgia Fugax include: Anal sphincter spasm, compression or neuropathy of the pudendal nerve and psychological issues. The pressure of anus and rectum is normal when the patient is asymptomatic, but there is occurrence of motor abnormalities in the smooth muscle of the anus during an episode of proctalgia fugax. According to a study, there was a slight increase in the resting anal pressures when an anorectal manometry was done, but without any differences in sphincter relaxation, rectal compliance, squeeze pressure or in the thickness of the external and internal anal sphincter. Association of autosomal dominant inherited myopathy of the internal anal sphincter was also seen with proctalgia fugax. In two cases, the symptoms of proctalgia fugax were triggered from anorectal manometry. Relation was seen between increasing duration of pain with an increase in slow wave amplitude and anal resting tone.

• As mentioned previously, the precise cause of proctalgia fugax is not clear. The pain of proctalgia fugax is believed to occur due to spasm in the smooth muscles of anal canal and the anal sphincter.
• A problem in the pudendal nerve causes transmission of wrong signals to the anal muscles, which results in their contraction causing proctalgia fugax.
• Proctalgia fugax is thought to be neuralgia of pudendal nerve. Pudendal nerve controls the functions of the bladder, rectum and genitals.
• Proctalgia fugax is also thought to occur as a result of a disorder of the internal anal sphincter.
• Another contributing cause of proctalgia fugax is excessive anxiety and stress. Constipation, irritable bowel syndrome and sexual activities can also trigger an episode of proctalgia fugax; however, it can also occur without any triggers.
• Decreased levels of potassium can also affect the smooth muscles present in the anal region causing proctalgia fugax.
• A person can also experience proctalgia fugax after sudden explosive bowel movement, straining at stool or ejaculation.
• Some medical procedures, such as vaginal hysterectomy or sclerotherapy for hemorrhoids can also cause proctalgia fugax.

• Pain of excruciating nature is felt in the anus or lower rectum, which lasts for a few seconds or a few minutes and then completely resolves.
• The pain is severe and cramping in type.
• Patient experiences frequent bouts of pain in proctalgia fugax, but the time interval between them is not definite.
• The episodes of proctalgia fugax are recurrent in nature and the patient is completely pain-free between the episodes.
• The episodes of proctalgia fugax can also occur in clusters, i.e. patient can have them daily and then it abates for a prolonged period of time.
• The pain and spasm felt in proctalgia fugax primarily occurs in the middle of the night when the patient is in bed. Thus proctalgia fugax also causes sleep disturbance for the patient.
• Patient feels an urge to defecate. As there is stimulation of the autonomic nervous system, male patients may also have erection along with the pain of Proctalgia Fugax.

The diagnosis of proctalgia fugax is made upon the symptoms of the patient and after ruling out other causes of the pain. There is no specific test to diagnose proctalgia fugax. Other common painful conditions of rectum and anus need to be excluded before coming to the conclusion of proctalgia fugax. Some of other anal and rectal conditions, which cause similar pain include: cryptitis, hemorrhoids, abscess, ischemia, rectocele, fissure and cancer.

Abdominal and digital rectal examination helps in assessment of the anal pain. Proctoscopy/anoscopy can also be done. If it is felt necessary, then gynecological or scrotal examination should also be carried out. Further tests, such as colonoscopy or sigmoidoscopy can also be done for excluding pathological causes of proctalgia fugax. Blood tests should be done if the patient is having rectal or anal bleeding to look for anemia.

As the cause of proctalgia fugax is not known, there is no known cure for proctalgia fugax. It is important to reassure the patient that proctalgia fugax is not a serious condition and it subsides on its own. This condition is not known to be associated with other medical conditions.

The episode of pain and spasm of proctalgia fugax subsides on its own; however, it can recur. Medicines are mostly not required, as proctalgia fugax is transient and fleeting in nature and it subsides spontaneously before the patient has had time to take medicines or other steps to relieve it.

According to some studies, the use of pudendal nerve block, botulinum toxin and calcium channel blockers help in relieving proctalgia fugax. Topical treatments can also be done.

• Using botulinum toxin acts as an analgesic and relieves pain of proctalgia fugax.
• Taking low dose of diazepam at bedtime helps in preventing further episodes of proctalgia fugax.
• Clonidine also helps in relaxing the anal sphincter and relieving an episode of proctalgia fugax.
• Inhaling salbutamol helps in reducing the duration of the attack of proctalgia fugax, especially in those patients who experience frequent, prolonged and severe attacks of proctalgia fugax.
• Nerve blocks and topical glyceryl nitrate helps in relieving the spasm of proctalgia fugax by relaxing the anal sphincter.
• If the patient is suffering from psychological issues then they should also be treated, as psychological problems, such as stress and anxiety can also cause proctalgia fugax.

• Applying pressure on the anal region helps in reducing or relieving the pain associated with proctalgia fugax. This can also be done by sitting on a hard surface.
• Foods, which are rich in potassium, should be consumed, as potassium deficiency is thought to be a potential cause for Proctalgia Fugax. Some of the foods which are rich in potassium include banana, raisins and avocado.
• Warm baths where the patient can sit and relax in a tub of warm water helps in relaxing the anal sphincter and reducing the spasm and pain of proctalgia fugax.
• Warm to hot enemas can also be given for relief from proctalgia fugax.
• Patient should practice relaxation techniques, such as meditation, deep breathing exercises and yoga to relieve anxiety and stress, as these can trigger an episode of proctalgia fugax.