Proctalgia fugax

Proctalgia means pain around the back passage area. Fugax means fugitive or fleeting. So, it is described as a short-lasting pain in the back passage.
Proctalgia fugax refers to the sudden onset of severe episodic pain in the regions of the rectum and anus. This pain is usually caused by sudden tightening (spasming) of smooth muscles in the anal canal, pelvic floor (pubococcygeal part) and the anal sphincter.
This pain in the anorectal region is benign, intermittent, recurring, periodical and self-limiting.
The pain generally remains localized within the rectum, and occasionally the pain may radiate into the gluteal or perineal region. The condition is also known as functional recurrent anorectal pain.
Patients may describe the pain as sharp or gripping, stabbing, twisting, cramping, or lancinating in nature.
The pain or spasm that appears suddenly, may be severe and may occur on several occasions over a few weeks, and each time lasting only seconds or minutes.
In exceptional cases, the pain may last for days. It often occurs in the middle of the night and it may wake up in the night. It can also occur during the day.
Proctalgia fugax does not cause any bleeding and usually it is not a long-term problem.
Proctalgia occurs worldwide and affects men and women of all races and socioeconomic status

Pathophysiology

The exact cause of the Proctalgia fugax is unclear. The pain is a short, stabbing pain in the rectum and it is accompanied by a lower abdominal cramp like pain. The pain is first felt in the rectum late at night and awakens the patient from sleep. This pain is not particularly severe, so the patient falls asleep, and next morning the attack is forgotten.
A month later a severe attack occurs and is repeated for four or five times. The next severe attack awakens the patient from sleep and this time the attack lasts 10 to 15 minutes and ends by the passage of the gas. The patient may be forced to lie flat on the floor until the attack passes. The patients get such attacks during defecation.
Patients who get attacks during night time, may later develop attacks following defecation or spontaneously in the daytime and also during their afternoon nap and the  time  periods between spasms may be long.
It may be caused by an issue with the pudendal nerve which is the  main nerve of the perineum that runs from the back of the pelvis to near the base of penis or vagina,
It may also occur after an injection procedure for hemorrhoids called sclerotherapy, or after a vaginal hysterectomy.
The frequency and intensity of attacks of proctalgia fugax may be increased due to the stress and sitting for prolonged periods.
Depression often accompanies the pain of proctalgia fugax but is not thought to be the primary cause.
Patients often feel an urge to defecate with the onset of the attack of pain
The symptoms of proctalgia fugax can be so severe as to limit the patient’s ability to perform activities of daily living.
The pain will usually stop on its own and patients with proctalgia fugax may not feel any anal pain between spasms.
Triggers of the pain may be sexual activity, menstruation, constipation, stress, poor posture, chronic anxiety, mental fixation on the rectal area, and misalignment of coccyx or other bones comprising the pelvic bowl.

Diagnosis

Proctalgia fugax is normally diagnosed after other possible causes of anal pain and spasms, like conducting a physical exam, asking questions about the pain severity, duration, etc.
Checking for hemorrhoids, fissures, an abscess, and other diseases or conditions that might cause anal pain, have been ruled out.
Once other conditions have been ruled out as the cause of the pain, the doctor will be able to diagnose proctalgia fugax.
Diagnosis involves a thorough medical examination, including of the genital region, blood tests and an endoscopy test to look at the lining of the bowel.

Diet and Personal care

Proctalgia fugax is not life-threatening but causes more discomfort than anything.
Some effective pain reliever options, as well as lifestyle changes can prevent future attacks.
Proctalgia fugax may be caused by Potassium deficiency and it can be avoided by taking potassium rich Bananas, raisins, and avocados.
Vegetables, whole grains, help with bowel movements as they contain more fiber which    reduces straining of the anal muscles. .

There are certain home remedies that may help to relax the anal muscles and keep them from spasming. Some natural treatment remedies that people can try to help relieve the pain are,

• By doing special exercises, to get voluntary muscles of the pelvis relax.
• Taking warm baths and enemas of warm water.
• Applying a cold-pressed castor oil pack to rectal muscles, and then applying heat.
• Taking a stool softener or bulking agent.
• Changing from seated toilet position to squat position (knees higher than hips)
• Applying counter-pressure and gently massaging rectum and rectal muscles
• In mild cases, over-the-counter creams and pain relievers can be used.
• Taking pain-relieving drug (Topical glyceryl nitrate), nerve blockers, muscle relaxers, hemorrhoid creams may provide relief from pain. nerve blockers can numb nerves
• If stress is the cause of pain, then counseling may help.
• Stress relievers such as meditation, deep-breathing exercises, and yoga may help to relieve anxiety and stress.
• To get symptomatic relief, the local application of heat and cold and the use of bland rectal suppositories may also help.

Alternative therapy

If the pain and spasms are due to an increase in stress or depression, counseling or alternative therapy may be recommended.
If the proctalgia fugax does not respond to the current treatments, as an alternative therapeutic option, Botulinum A toxin injection is suggested. Botulinum A toxin injection is a promising option with minimal morbidity which can reduce internal anal sphincter pressure, and provides relief of symptoms.
It can provide a high rate of healing and low recurrence, even in cases that are untreatable with other existing measures.
Botulinum A toxin injection does not cause general side effects.