Proctalgia

Proctalgia is pain in the rectum or anal region in the absence of an identifiable structural cause, comprising proctalgia fugax and chronic proctalgia (levator ani syndrome and unspecified functional anorectal pain).

• Proctalgia fugax affects 8 to 18 percent of adults, more in women, usually between ages 30 and 60 years.
• Chronic proctalgia affects about 6 percent of the community and is linked to levator ani spasm, pelvic floor tension, previous surgery, prolonged sitting and psychological stress.
• Both are diagnosed only after excluding organic disease.

Proctalgia fugax: sudden severe cramping or stabbing rectal pain lasting seconds to 20 minutes, often at night, resolving spontaneously, with long pain-free intervals; triggers include defecation, sexual activity, stress.

• Levator ani syndrome: chronic or recurrent vague dull aching or pressure high in the rectum lasting 30 minutes or longer, worse on sitting, relieved by standing, with tenderness on traction of the puborectalis (more often left side).
• Unspecified functional anorectal pain: no tenderness of the levator ani.
• Differential diagnosis: anal fissure, thrombosed haemorrhoid, perianal abscess, fistula, proctitis, rectal cancer, coccydynia, pudendal neuralgia, prostatitis, endometriosis, sacral nerve root pathology, pelvic floor dyssynergia, inflammatory bowel disease.
• Complications: sleep disturbance, psychological distress, sexual dysfunction, impaired quality of life, repeated unnecessary investigation.

Clinical, based on symptom duration and character, with digital rectal examination (assess puborectalis tenderness, sphincter tone, fissure, mass).

• Proctosigmoidoscopy or colonoscopy; anorectal manometry and balloon expulsion test if dyssynergia is suspected.
• MRI pelvis or endoanal ultrasound if abscess, fistula or a mass is suspected; spine imaging if neurological signs.
• Urinalysis, prostate or gynaecological review when relevant.

Supportive: reassurance about benign nature; warm sitz baths for 15 minutes; avoid prolonged sitting; stress reduction; heat to the perineum.

Pharmacological

• Proctalgia fugax: inhaled salbutamol 200 microgram (2 puffs) at the onset of pain; topical glyceryl trinitrate 0.2 percent ointment to the anal verge, or diltiazem 2 percent gel; for frequent attacks, nifedipine 10 to 20 mg at night or clonidine 0.1 mg at night.
• Levator ani syndrome: diazepam 5 mg at night (short course) or cyclobenzaprine 5 to 10 mg at night; amitriptyline 10 to 25 mg at night increasing to 50 mg; gabapentin 300 mg daily increasing to 900 to 1800 mg daily in divided doses; pregabalin 75 mg twice daily increasing to 150 mg twice daily.
• Trigger point injection of lidocaine 1 percent with or without methylprednisolone 40 mg into the levator.

Procedures

• Biofeedback pelvic floor retraining, 6 sessions, is the most effective treatment for levator ani syndrome.
• Digital levator massage by a trained physiotherapist, 3 times weekly.
• Botulinum toxin A 100 to 150 units into the puborectalis, electrogalvanic stimulation, and sacral neuromodulation for refractory pain.

Special groups: psychological comorbidity (cognitive behavioural therapy), older men (exclude prostatic cause), women (exclude gynaecological disease).

Red flags: rectal bleeding, weight loss, change in bowel habit, fever, progressive pain, neurological signs, inflammatory bowel disease.

Follow-up: review at 6 to 8 weeks; refer to a pelvic pain specialist if persistent for more than 3 months.