Proctalgia Fugax: Definition and historical overview

Definition:

Proctalgia fugax is a disorder characterized by sudden, extremely painful cramps in the anal area. These cramps are short-lived, episodic and usually occur without warning. The clinical picture is well defined, but the diagnosis can only be made on the basis of the patient's medical history, as there are no specific clinical tests.

Historical background:

First description: The syndrome was first described by Myrtle in 1883.

Terminology: The term "proctalgia fugax" was coined in 1935 by the Danish physician Thaysen, who published a detailed description of the typical symptoms. Thaysen's work contributed significantly to the recognition and definition of the clinical picture.

Outdated synonyms:

With the introduction of the term "proctalgia fugax" by Thaysen, several older terms became obsolete. These include:

• Perineal neuralgia
• Perineal spasm
• Spasm of the anal sphincter
• Nervous rectalgia
• Neuralgia pudendo-analis
• Paroxysmal proctalgia

Frequency and epidemiology of proctalgia fugax

• Frequency: Proctalgia fugax is not a rare disease. Due to the short duration and sudden relief of the pain, many sufferers do not regard the symptoms as requiring treatment or as an illness. Nevertheless, targeted studies show that the syndrome is more common than generally assumed.
• Prevalence in clinical and healthy populations: Ibrahim found that 4% of his proctologic patients suffered from proctalgia fugax.Thompson even reports a prevalence of 14% in "healthy" control subjects.

Demographic characteristics:

• Age: The condition rarely occurs before puberty and reaches its peak incidence between the ages of 40 and 50, with an average age of manifestation of 44 years.Gender: Women are affected twice as often as men.

Course and duration:

• Repeated occurrence: The recurrent attacks of Proctalgia fugax extend on average over a period of 11 years.Frequency, intensity and duration of attacks: The frequency, intensity and duration of pain attacks decrease with increasing age.

Associations:

• Gastrointestinal diseases: There is no evidence of an association between Proctalgia fugax and gastrointestinal diseases.

etiopathogenesis of proctalgia fugax

The aetiopathogenesis of proctalgia fugax is complex and multifactorial, with various possible triggers and mechanisms being discussed:

1. Muscular spasms: sphincter and pelvic floor muscles: spasms of these muscles and in the area of the rectosigmoid junction are considered possible triggers.Intraluminal pressure measurements: Harvey was able to demonstrate increased contractions in the rectosigmoid in two patients during an attack.
2. Colonic mucosa and mucus secretion: S tenosingedema: Marti observed stenosing edema of the colonic mucosa in some patients during a seizure, combined with increased mucus secretion and concluded a congestion due to hypervascularization.
3. Genetic factors: Autosomal dominant myopathy: There is evidence that proctalgia fugax occurs more frequently in patients with an autosomal dominant inherited myopathy of the internal sphincter.
4. Resting pressure and sphincter spasm: Increased resting pressure: Eckhardt and coworkers found a slightly increased resting pressure in 18 patients and suspect that the seizures are triggered by spasms of the internal sphincter.
5. Therapeutic approaches: Hemorrhoidal therapy: Lans showed in 11 cases that symptom relief can be achieved by hemorrhoidal therapy using sclerotherapy or elastic ligation.
6. Psychosomatic factors: Psychological disposition: There is a high incidence of proctalgia fugax in anxious and perfectionist individuals who express their anxiety somatically in the rectum and anus.Trigger factors: Additional trigger factors such as dreams with erotic content, coitus (especially after prolonged abstinence), frustrated attempts at defecation and distension of the rectum by gases or stool masses can trigger attacks.

Symptoms of proctalgia fugax

Proctalgia fugax is characterized by recurrent attacks of pain in the anus and rectal area, which can be divided into day and night attacks:

1. Daytime attacks:

Pain character: the pain occurs suddenly without warning and is felt as a cramp-like pulling, stabbing-cutting or dull pressure.Pain localization: it is localized in the anus and anal canal area and may radiate to the rectum and lower abdomen.Pain intensity and course: The pain may be continuous or undulating, lasting from a few minutes to an hour.Accompanying symptoms: Severe attacks may be accompanied by dizziness, sweating, nausea, nausea and even collapse.

2. Night attacks:

Occurrence: These usually occur in the early hours of the morning and rouse the patient from sleep.Pain intensity: The nocturnal attacks are described as less intense and less painful compared to the daytime attacks.

3. Interval:

Recurrence: Proctalgia fugax recurs at irregular intervals of weeks or months.

Diagnosis:

The diagnosis of proctalgia fugax is based solely on the patient's description of the symptoms. Typically, patients report a sudden onset of severe pain in the anal area that lasts only a few seconds to minutes. These reports are often very similar, although the exact description of the pain varies due to the individual vocabulary of the patients.

Differential diagnosis

First and foremost, the differential diagnosis must include anal fissure, anogenital syndrome and
inflammatory intramural processes must be excluded.

Treatment of proctalgia fugax

The treatment of proctalgia fugax includes various approaches, from drug therapy to physical interventions. Here are some of the most common and successful methods:

Drug therapy:

• Clonidine
• Nifedipine: Successful use: Babb achieved positive results with nifedipine, a calcium channel blocker, in the treatment of proctalgia fugax.
• Treatment of hemorrhoids
• Nitroglycerin : The sublingual or anal application of nitroglycerin is recommended to reduce the tone of the internal sphincter muscle.
• Salbutamol : Inhalation of the sympathomimetic salbutamol can also help to reduce sphincter tone.

Physical interventions:

• Pressure on the perineum: Pressure with the fist on the perineum can help to relieve pain.
• Heat application / sphincter relaxation: Heat applications, such as warm sitz baths, can help to relax the sphincter muscle.
• Sphincter stretching
• Enema: An enema can help to empty the bowel and relax the sphincter.

Challenges of therapy: Verification of successful drug therapy is often difficult, as the seizure usually subsides spontaneously before the medication has taken full effect. Therefore, a combination of drug and physical interventions is often used to effectively relieve symptoms.

Summary:

Proctalgia fugax is a well-defined but very painful disorder characterized by its characteristic seizure-like episodes of anal pain. Despite the intense pain symptoms, diagnosis is only possible with a careful medical history. Understanding this condition and naming it correctly is crucial for the appropriate care and treatment of patients. Historically, the work of Myrtle and Thaysen has contributed significantly to the definition and recognition of this syndrome.