W.R.Lans

Proctalgia fugax - curable after all?

Summary. In a retrospective examination of twelve patients who had attended a proctology clinic in Veenendaal with symptoms of proctalgia fugax, the anal lesions and the results of therapy were recorded. A mucous colitis was diagnosed in eleveen patients and haemorrhoids also in eleven patients. After treatment of the intra-anal congestion and all other anal lesions which were detected, all patients were free of symptoms. This suggests that reassurance of the patient and symptomatics advice ignores the fact that proctalgia fugax is a symprom and that there is a causal and effective therapy possible to treat lesions which lead to this symptom.

(Keywords: Proctalgia fugax, haemorrhoids, mucous colitis)

Résumé. Dans le cadre d`un examen rétrospecif, on été notés les lésions anales et les résultats thérapeutiques de 12 patients, admis à la clinique proctologique de Veenendaal avec les symptômes d'une proctalgie fugax. Chez 11 patients, on abservait aussi des colites mucomembraneuses et des hémorroïdes. Le traitement de la congestion intra-anale et des autres lésions anales présentes a permis de faire disparaître les symptômes chez tousa les patients. Ce résultat indique qu'en apaisant le patient et en lui donnant des conseils symptomatique, on oublie que la proctalgie fugax représente un symptôme et qu'une thérapie causale et efficace pour traiter la lésion qui fait apparaître ce symptôme est possible.

(Mots clés: Proctalgie fugax, hémorroïdes, colite muco-membraneuse)

PROCTALGIA FUGAX, curable after all

One of the most neglected proctological syndromes is proctalgia fugax There is little known of the aetiology, but the conclusion of Van Tongeren (who quoted Douthwaite) that proctalgia fugax "harmless, unpleasant and incurable" (1) is no longer true.

Reassurance of the patient (1,2,3), shoud be supplemented by symptomatic measures such as warmth (bath, hotwater bottle, autodigitation, pressure on the perineum (fist), clysma, kneeelbow position, oral medication (spasmolitica, neuroleptica or nitrobate sublingual) 4,5). Some of these treatments take a longer prepare than the duration of the attack itself! A dismal prospect for those whose well-being (often at night) is severely dis-turbed by the attacks.

In recent years we have seen a number of patients in our surgery with proctalgia fugax. The fact that these persons all became complaint-free was an indication to focus attention on this syndrome.

As is often the case in science, lack of knowledge produces synonyms. Since the first description by Myrtle (6) they have been numerous. The most common is that of Thaysen (7) (proctalgia = pain of the anus, fugax = temporary, passing), as well as: anorectal neuralgia, perineal spasms, perineal neuralgia, sphincter spasms, paroxysmal proctalgia , neuralgia pudendalis.

The proctalgia fugax attacks occur mostly at night (proctalgia fugax noctura) but also during daytime. Total incidence is estimated at about 4% of proctological patients (4), with a male:female ratio of 1:2.

Diff.Diagnosis Complaints
Coccygodynia Pain in the regio sacralis/os coccygis:sharp pain after pressure from sitting or straining during defaecation
Proctitis Continued, often dull pain with blood and mucus by defaecation
Anal fissura Pain starts during defaecation and lasting afterwards.Occasionally blood
Cryptitis Nagging pain that begins shortly after defaecation and slowly fading away
Thrombosis Dull continuing pain when sitting with a perceptible swelling on the anus
Abcess Continuous pain, independant of defaecation. Often general malaise
Table 1, the differential diagnosis of the Proctalgia fugax

Symptomatology

The clinical manifestations are severe, sudden, spasmodic pain mostly confined to the anal region. The pain can however spread to the abdomen and the pelvis and can be accompanied by agitation, anxiety, vomitus, sweating, dizziness and even collapse. The bouts of pain occur suddenly and last between 30 sec. and 30 min. (rarely longer).

Diagnosis

In practice this is made solely on the basis of the characteristic case history. With a well-formulated case history no problems arise as regards the differential diagnosis. Accordingly other causes of pain can usually be ruled out. (Tab 1). Possibly non-proctological syndrome such as chronic prostatitis or parametritis should be considered.

Proctological examination (in our case inspection, digital rectal examination, proctos-copy, anal speculum examination, and rectoscopy), rules out the possibility of tumours. The diagnosis coccygodyny is often made by pal-pation of the os coccygis itself and the joint between the os coccygis and the sacrum (8). Here I would emphasise that haemorrhoids do not belong in the differential diagnosis. The plexus haemorrhoidalis superior is proximal to the dentate line and therefore has no sensible innervation. In other words, every patient with anal pain must be taken seriously, he may have haemorrhoids but by definition there is something else. Moreover, haemorrhoids are not palpable by digital rectal examination.

This suggests that proctalgia fugax is a diagnosis per exclusionum by examination. In my opinion, in it is more accurate to refer to a symptom (comparable for example with pain and fever) rather than a disease.

Patients and methods

We treated twelve persons with proctalgia fugax nine woman and three men. The duration of the anal complaints varied from 30 years to 3 weeks (patient 12). The last patient experienced her proctalgia fugax complaints only after a single sclerotherapy forhaemorrhoids. In only five patients (all women) proctalgia fugax was the only complaint. For two patients it was their single main complaint (tab. 2).

Pat. Age
yrs
m/f Complaint Sub-
complaint
Proct.
anamnesis
Time
yrs
Exam.
results
Diagnosis
1 56 m -pruritus
-blood
-pain dur. def.
-PF -<flatulence 7 -perianal rhagads
-RB, H
-mucus/faeces
-MC
-H
-PF
2 35 f -PF -tenesmus
-pruritus
-twinges
-flatulence
-swollen abdomen
-fatigue
15 -scar lateral
-sphincterotomy
-RB, H
-exessive folding
-MC
-H
-PF
3 44 f -PF -pruritus
-blood
-tenesmus
-fatigue 25 -RB, H
-malodorous faeces
-MK
-H
-PF
4 34 f -pruritus -Fissures - 18 -perianal rhagads
-anodermal defects
-candida
-RB, H
-MC
-H
-recurring tromboses
-candida infection
-PF
5 63 f -PF
-blood
-PF -abdominal pain
-flatulence
20 -fistula
-RB, H
-fistula
-MC
-H
-PF
6 73 f -constipation -PF -abdominal pain
-weight loss
-fatigue
30 -RB -MC
7 55 f -pain dur. def. -burning -blood/mucus
-flatulence
3 -anodermal defects
-hypertone sphincter
-RB, H
-MC
-H
-PF
8 48 f -perianal irritation
-PF
- -borborygmia 1,5 -RB, H
-papillohypertrophy
-fibroma
-MC
-H
-papillohypertrophy
-PF
9 56 m -pressure in anus
-prolapse
-PF
-constipation
-flatulence 30 -anal prolapse
-spincter hypotomy
-RB, H
-MC
-H, prolapse
-PF
10 39 m -pain dur. def.
-blood
-PF -flatulence 10 -anodermal defects
-sentinel pile
-papillohypertrophy
-RB, H
-MC
-H
-PF
11 49 f -PF
-swollen abdomen
-prolapse
-blood
-mucus
-flatulence 10 -anal prolapse
-RB, oedema, H
-MC
-H, prolapse
-PF
12 57 f -pain dur. def. -PF after
sclerosis
-flatulence
-borborygmia
10 -H -H
-PF

Tabel 2/3 Case histories / Examination and diagnosis

RB = red bowel mucosa
H = haemerroids
MC = mucous colitis
PF = proctalgia fugax

In our clinic, examination is always performed in the first instance without preparation of the bowel by means of laxativs, enemas or the like. One should normally see a healthy pink bowel without mucus and faeces. Any form of cleaning of the bowel always causes irritation of the bowel mucosa (as reactive hyperaemia) and can be considered be a minor medical fault. Mucous colitis (9) can no longer be diagnosed after cleaning (tab 3).

Rectoscopy showed no anomalies in any patients (except the mucous colitis. Neither did X-ray of the colon (patients 6,7,11 and 12) depict any abnormalities. There appeared to be an mucous colitis by all patients (except no. 11,female). Only one patient (male no.8) had no haemorrhoids. Treatment of the mucous colitis comprised a temporary colonsparing diet according to Truelove (10) supplemented with vitamin B complex forte and magnesium peroxide.

Where necessary sodium sulphate was given as a hygroscopic laxans. The haemorrhoids were treated either with by sclerotherapy with 3% hydroxypolidocanol according to Blond or with Barron ligatures. A cylindrical anal dilatator was given (patients 1,2,9 and 10) to improve sphincter function, and also appeared to have a fast symptomatic effect on perianal rhagaden and anal fisures (11). Hypertrophic papillae and fibromas were removed under local anaesthetic.

In patient no.6 (female) the proktalgia fugax had greatly decreased in frequency and intensitity after four months. After neural therapy according to Huneke with 1% lidocaine on scars on the abdomen (uterus extirpaty and appendectomy) the attacks disappeared completely. Patient no.2 (female) had an identical pattern. Almost all complaints were over after six weeks and the proktalgia fugax was also reduced. Infiltration of anal scars (lateral sphincterotomy) resulted in complete cure.

The course of the proktalgia fugax is shown in Table 4. The duration is registered from the first consultation to the confirmation of cessation of attacks. There were sometimes many months between consultations. In all patients the proktalgia fugax did not recur for a year or more. In most patients frequency and intensity diminished gradually.

Discussion

The aetiology of the proktalgia fugax has in the course of time lead to many hypotheses, including spasms of the sphincters, of the levators, of the pelvic floor musculature or vasospasm in the anal region (8). During digital examination of the rectum of ten medical doc-tors suffering from proktalgia fugax, however, no spasm of the sphincter ani was evident (1).

The fact that all patients except one had an mucous colitis with haemorrhoids points principally towards congestion (hypervascularisation).

If this congestion disappears (which can be observed in the normal pink aspect of the bowel mucosa), the haemorroidal plexus is reduced to normal proportions and other leasions such as papillas are removed, the attacks seem to cease. If the proktalgia fugax attacks cease when the anal region is completely treated, that would indicate that we should speak of a proctological warning mechanism, rather than of a proctological syndrome.

Pat. Frequency Duration Day/Night Cure Period
1 1 x p week 15 min. N 1 month
2 several x p d 15-20 min. D/N 5 months
3 1-2 x p week 3-30 min. N 1 months
4 daily seconds N 3 months
5 2 x p day seconds D 2 months
6 1-2 x p month 30 min. N 9 months
7 3-4 x p week 30 min. D/N 1 month
8 1 x p month seconds N 1 month
9 1 x p month 5 min. N 7 months
10 3 x p year 30 min. N 2 months
11 2-3 x p week 10 min. N 5 months
12 2 x p week 5 min. N 9 weeks

Table 4: Course of the Proctalgia fugax

Conclusion

Proktalgia fugax is a symptom which demands close examination of all anal abnormalities and in particular of evidence of anal conges-tion (including haemorrhoids). The treatment of these abnormalities led to the cessation of complaints in all our patients. This would suggest that apart from all symtomatic treatment, there is an effective causal therapy for proktalgia fugax. To simply reassure patient is to deny the anal symptom.

In view of this new information, I would be in favour of an amendment to Van Tongeren's quotation, as follows: Proctalgia fugax is "harmless, unpleasant but curable"!

References:

  1. Tongeren van JHM, Proctalgia fugax. NTvG 1976; 120: 280 to 281.
  2. Brühl W.,Differentialdiagnose proktologischer Erkrankun-gen. Bad Salzuflen: Institut für Proktologie, 1992
  3. Knoch H-G. Afterbeschwerden. Berlin: Sport und Gesundheit Verlag GmbH, 1992
  4. Stein E. Proktologie, Lehrbuch und Atlas. Berlin. Springer-Verlag, 1990
  5. Wienert V. Proctalgia Fugax. Colo-Proktologie 1987; 2: 122
  6. Myrtle A.S. Some commen affections of the anus often neglected by medical men and patients. Br Med. Journal 1883; 1: 1061
  7. Hess Thyasen ThE. Proctalgia fugax. Lancet 1935; 2: 243-6
  8. Vogt H.J., Proctalgia fugax/Kozygodynie. Phlebologie und Proktologie 1986; 15: 201-2
  9. White BV, Jones CM. Mucous colitis: a delineation of the syndrome with certain observations on its mechanism and on the role of emotional tension as a precipitating factor. Ann Int Med 1940; 14: 854-72
  10. Treulove SC. Trial of various diets. Br Med Journal 1961; 1: 154
  11. Klug W, Knoch H-G. Objectivierung der Wirksamkeit des therapeutischen Dilatators bei der Behandlung der akuten Analfissur. Colo-Proktologie 1993; 1: 22-8

W. R. Lans, M.D.
Stationssingel 50
3901 XK Veenendaal
The Netherlands

BRON: Coloproctology Volume 16 (1994), 128-132 o.2, March/April.