Proctalgia fugax is a disorder characterised by the sudden onset at irregular intervals of severe anorectal pain that usually lasts a few minutes and resolves without sequelae

The clinical condition necessary to be able to speak of proctalgia fugax is that there is an absence of painful pelvic pathologies such as fissures, abscesses, thrombized haemorrhoids, chronic inflammatory diseases in the flare-up phase, prostatitis, endometriosis, tumours, etc.

What triggers proctalgia fugax?

Pain can be triggered by evacuations, stressful psycho-physical events, menstruation, alcohol intake and sexual intercourse, but often no trigger factor can be identified.

Although formerly described as typically nocturnal, recent studies have found that the pain can appear at any time of day.

Is proctalgia fugax a frequent condition?

The prevalence in the general population ranges between 4 and 18 per cent and affects more women.

What causes proctalgia fugax?

Pathogenic hypotheses include spasm of the sphincter musculature, increased intraluminal pressure of the sigma, abnormal contractile activity of the internal anal sphincter influenced by sympathetic nervous activity and thus by psycho-physical stress, and, finally, pudendal nerve pain.

It is most often present in subjects with an irritable colon, in patients undergoing sclerotherapy for the treatment of haemorrhoids and in women who have undergone transvaginal hysterectomy.

Finally, a rare genetic-based familial form with autosomal dominant transmission has been described, which is associated with constipation and marked thickening of the internal anal sphincter.

How is it diagnosed?

The anamnestic history together with a clinical examination to exclude the absence of other painful pelvic pathologies may be sufficient to make a diagnosis of proctalgia fugax.

However, rectoscopy and pelvic nuclear magnetic resonance imaging (MRI) may be necessary for differential diagnosis.

Anorectal ultrasound is helpful in providing information on the thickness of the anal sphincter musculature.

In addition, anorectal manometry can reveal abnormalities of sphincter tone at rest by detecting characteristic ‘slow waves of increased amplitude’.

Finally, the neurophysiological study of the perineum (electromyography of the pelvic floor muscles, the study of the bulbo-cavernous muscle reflex and the measurement of the latency time of the pudendal nerve) can orientate on the medical or surgical treatment to be performed.

How is it treated?

Since a strong anxiety component is often present, the first attempt at treatment should make use of reassurance and orally administered benzodiazepines together with the advice to perform half-cups with warm water in the ano-genital region.

However, in the event of failure, drugs that alleviate the painful spasm of the ano-rectum, to be applied locally (diltiazem or nitroglycerin 2%) or taken by mouth (nifedipine), are resorted to.

To this end, the use of botulinum toxin type A injections has also been proposed.

In cases where pudendal compression is documented, pharmacological blockade or surgical decompression of the nerve may be useful. Good therapeutic results through anaesthetic blockade of the superior hypogastric plexus are also reported in the literature.

Finally, in the rare familial forms or in all those cases in which there is a thickening of the internal anal sphincter of more than 3.5 cm, the surgical procedure of internal lateral sphincterotomy may be indicated.

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Web MD

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