A 43-year-old woman with no significant medical history comes to the physician with episodic rectal pain for the past 8 months. About once a month she has severe rectal pain that lasts for minutes and resolves without intervention. She has no fever, diarrhea, anal trauma, rectal bleeding, or weight loss. She has 1 formed bowel movement every 3 days without any straining and does not associate the pain with bowel movements. She takes no medications.
Her blood pressure is 110/60 mm Hg, pulse is 76/min, and respirations are 14/min. Physical examination reveals a soft, nontender abdomen with normal bowel sounds. There is no hepatomegaly or splenomegaly. Rectal examination shows normal tone, no external hemorrhoids, and guaiac-negative brown stool. Pelvic examination is also unremarkable.
Laboratory results are as follows:

Colonoscopy is notable for small internal hemorrhoids and mild diverticulosis.
Which of the following is the most likely cause of this patient's symptoms?

Question

A 43-year-old woman with no significant medical history comes to the physician with episodic rectal pain for the past 8 months.  About once a month she has severe rectal pain that lasts for minutes and resolves without intervention.  She has no fever, diarrhea, anal trauma, rectal bleeding, or weight loss.  She has 1 formed bowel movement every 3 days without any straining and does not associate the pain with bowel movements.  She takes no medications.
Her blood pressure is 110/60 mm Hg, pulse is 76/min, and respirations are 14/min.  Physical examination reveals a soft, nontender abdomen with normal bowel sounds.  There is no hepatomegaly or splenomegaly.  Rectal examination shows normal tone, no external hemorrhoids, and guaiac-negative brown stool.  Pelvic examination is also unremarkable.
Laboratory results are as follows:

Colonoscopy is notable for small internal hemorrhoids and mild diverticulosis.
Which of the following is the most likely cause of this patient's symptoms?

Quizplus · Accepted Answer

This patient's presentation suggests proctalgia fugax, a benign self-limited condition of recurrent and severe rectal pain occurring in up to 15% of the population. Proctalgia fugax is a functional disorder, and the diagnosis requires exclusion of other gastrointestinal causes of anal or rectal pain (eg, hemorrhoids, cryptitis, ischemia, intramuscular abscess, anal fissures, rectoceles, or malignancy). The pathophysiology is possibly due to anal sphincter spasm/hypertrophy, pudendal nerve compression or neuralgia, or psychological factors. Patients usually present with attacks of severe rectal pain lasting a few seconds to 2 hours. Anorectal and pelvic examination shows no abnormalities. Anorectal manometry may be normal or show elevated internal anal sphincter pressure. Colonoscopy is usually performed to exclude other diseases and is frequently normal. The proposed diagnostic Rome Criteria for proctalgia fugax include: Recurrent episodes of anal or rectal painEpisodes lasting seconds to minutesAbsence of pain between episodes Recurrent episodes of anal or rectal pain Episodes lasting seconds to minutes Absence of pain between episodes Proctalgia fugax must also be differentiated from chronic proctalgia, which presents with chronic rectal pain (usually worse with sitting) lasting at least 20 minutes and not due to other diseases that cause rectal pain. Symptoms of chronic proctalgia must be present for at least 6 months prior to diagnosis. Patients with mild proctalgia fugax require no specific treatment except reassurance and explanation of the condition. Patients with more debilitating symptoms may benefit from warm baths. Those with psychological dysfunction should be treated appropriately. (Choice A) Endometriosis usually presents with chronic pelvic and/or lower back pain (mild to severe and crampy in nature), dysmenorrhea, dyspareunia, and bowel or bladder dysfunction (eg, bloating, constipation or diarrhea, hematuria). (Choice B) Fibromyalgia typically presents with tenderness in multiple soft-tissue areas of the body accompanied by musculoskeletal pain, fatigue, and mood disturbances. (Choice C) Irritable bowel syndrome usually presents with chronic abdominal pain and altered bowel motility (constipation, diarrhea, or both). In addition, irritable bowel syndrome patients typically have decreased abdominal discomfort with defecation. (Choice E) Somatization usually presents with a history of chronic, unexplained physical symptoms that are unrelated to physical examination findings and have no exacerbating or alleviating factors. These patients often have a history of psychiatric disorders. Educational objective: Proctalgia fugax usually presents with severe and episodic rectal pain lasting seconds to minutes that is unrelated to bowel movements. Patients are usually asymptomatic between episodes. Diagnosis is made after excluding other gastrointestinal causes of anal and rectal pain. __________ References: Proctalgia fugax, an evidence-based management pathway. (http://www.ncbi.nlm.nih.gov/pubmed/20556402) Proctalgia fugax: demographic and clinical characteristics. what every doctor should know from a prospective study of 54 patients. (http://www.ncbi.nlm.nih.gov/pubmed/17164968) Patient characteristics and treatment outcome in functional anorectal pain. (http://www.ncbi.nlm.nih.gov/pubmed/21654255)

A 43-Year-Old Woman with No Significant Medical History Comes to the Physician