Proctalgia Syndromes: Update in Diagnosis and Management

Abstract

Purpose of Review Functional anorectal pain syndromes are a neglected yet often disabling clinical entity resulting in significant economic and psychological burden to the patient. The aim of this review is to update the practicing gastroenterologist/ coloproctologist on the diagnosis and management of these complicated disorders. Recent Findings The updated Rome foundation diagnostic criteria (Rome IV) for functional anorectal pain subgroups chronic proctalgia (levator ani syndrome and unspecified functional anorectal pain) and acute proctalgia (proctalgia fugax) on the basis of symptom duration and digital rectal examination findings. Chronic proctalgia is thought to be secondary to paradoxical pelvic floor contraction in many patients and biofeedback to improve the defecation effort has proven effective for over 90% in the short term. Unfortunately, management of proctalgia fugax remains challenging and treatment outcomes modest at best. Summary A number of therapies to relax the pelvic floor may be employed to improve symptoms in functional anorectal pain syndromes; however, only biofeedback to improve defaecatory dynamics in patients with levator ani syndrome has proven effectiveness in a randomized setting. Further investigation of treatment approaches in proctalgia fugax is required.

Diagnosis and Management of Functional Pouch Disorders: A Systematic Review

“…These involve centrally mediated pain pathways and pelvic floor dysfunction such as paradoxical contraction or nonrelaxation of the levator ani and puborectalis muscles. 10,12,13 In patients with an intact colon, dyssynergic defecation is comorbid with proctalgia in 87% of those diagnosed with levator ani syndrome. 15…”

“…For example, proctalgia fugax is described as chronic recurrent painful episodes lasting from several seconds to <30 minutes, whereas levator ani syndrome or unspecified functional anorectal pain is defined by recurrent episodes lasting >30 minutes. 11,12…”

“…These involve centrally mediated pain pathways and pelvic floor dysfunction such as paradoxical contraction or nonrelaxation of the levator ani and puborectalis muscles. 10,12,13 In patients with an intact colon, dyssynergic defecation is comorbid with proctalgia in 87% of those diagnosed with levator ani syndrome. 15 The most recent guidelines from the American College of Gastroenterology recommend the use of anorectal manometry and balloon expulsion testing in patients with chronic proctalgia and suspected levator ani dysfunction to identify those who may benefit from biofeedback therapy.…”

Spectrum of Diagnoses in Female Patients With Proctologic Symptoms Presenting to the Surgery Unit of a Tertiary Care Center

“…Anorectal diseases are associated with significant morbidity. Unluckily, patients avoid reporting the symptoms, and the disease worsens with time [6,7]. With time, the underlying disease becomes chronic, and patients get complications [6].…”

Optimal management of functional anorectal pain: a systematic review and network meta-analysis

“…First-line management strategies comprise conservative options, including modification of toilet habits, pelvic floor physical therapy, analgesic medications and muscle relaxants [10]. Management strategies for medication-refractory functional anorectal pain are diverse and include electrogalvanic stimulation (EGS), biofeedback sessions, injection of botulinum toxin A (Botox), sacral neuromodulation (SNM) or injection of steroids [11,12]. Despite divergent management strategies across specialist centres, a quantitative synthesis of reported outcomes has not yet been performed.…”