Chronic Proctalgia Replaced by Its Subtype Syndromes

Chronic proctalgia is a term that has been discontinued. In the past, it was defined as a condition in which a person experiences recurrent rectal pain of at least 20-minute duration, with no identifiable structural or associated health condition to account for the pain.

This term was in use until it was eliminated in the Rome IV Criteria for Colorectal Disorders in 2016. However, it can still be seen in diagnoses and classifications that use older criteria. Learn what was meant by the term and how it has been replaced.

Changes to the Definition of Chronic Proctalgia

Under the Rome III criteria, chronic proctalgia was distinguished from proctalgia fugax by the duration of symptoms. Proctalgia fugax had been defined as sudden sharp anorectal pain that lasts less than 20 minutes. Chronic proctalgia was further subdivided into levator ani syndrome, characterized by sensitivity of the levator muscle during a healthcare provider's rectal examination, and unspecified functional anorectal pain syndrome if there was no tenderness.

When research didn't find distinct clusters of symptoms for proctalgia fugax and chronic proctalgia, the term chronic proctalgia was eliminated in Rome IV. However, Rome IV includes the two subtypes that were under chronic proctalgia as their own syndromes.

Current definitions:

• Levator ani syndrome: Pain episodes in levator ani syndrome last for at least 30 minutes. The pain tends to be worse in a sitting position than when standing or laying down. Tenderness is felt on the puborectalis (muscle within your pelvis) when it is touched during a healthcare provider's rectal examination.
• Unspecified functional anorectal pain: This condition is diagnosed if you have symptoms of levator ani syndrome, without tenderness on the puborectalis when it is touched during a rectal examination.
• Proctalgia fugax: The Rome IV classification made changes to the definition of this term. The maximum duration of pain is 30 minutes (it used to be 20 minutes) and the location is in the rectum (it used to be in the lower rectum or anus).

The underlying mechanisms and choices of treatment differ for these syndromes.

Symptoms

The symptoms of these syndromes are typically described as a prolonged dull ache or pressure-like sensation in the rectum—often felt more toward the top of the rectum. It may worsen when you are sitting for a prolonged period of time and may ease when you stand up or lie down. Discomfort may increase as the day wears on, but rarely occurs at night.

The pain may be felt more often during the following times:

• Following sexual intercourse
• Following a bowel movement
• During times of stress.
• During long-distance travel

Diagnosis

Healthcare providers will make a diagnosis based on symptoms according to the Rome IV criteria:

• Chronic or recurring rectal pain or aching
• Discomfort must last for at least 30 minutes
• Other causes of rectal pain (structural or systemic) must be ruled out
• Symptoms must be present for at least three months with onset at least six months prior.

Your healthcare provider is likely to perform a rectal examination to test for tenderness. Diagnostic tests may be administered to rule out other health problems.

Causes

The exact reason behind these conditions is currently unknown. In the past, it was hypothesized that they resulted from chronic tension or inflammation of the muscles within the pelvic floor, although research support for this theory has been limited. Some emerging research points to the possible role of ​dyssynergic defecation, a condition in which the muscles of the pelvic floor do not operate as they should.

Factors that may increase a person's risk of developing these syndromes include:

• Anal surgery
• Childbirth
• Pelvic surgery
• Spinal surgery

There is also an association between chronic rectal pain and higher rates of depression and anxiety disorders. However, it is unknown if these emotional symptoms increase the risk of chronic rectal pain or result from chronic rectal pain.

Treatment

Biofeedback is now the preferred treatment for levator ani syndrome after being shown by research to be the most effective compared with electrical stimulation of the anal canal and massage of the levator muscles.

Electrical stimulation has been shown to be beneficial and may be used if biofeedback is not available.

Digital massage of the levator ani muscle, muscle relaxants, and the use of sitz baths, all showed limited effectiveness and are not used for treatment. Surgery is not considered to be an effective treatment.