A 32-year-old woman comes to the office with rectal pain. The pain is crampy and episodic, occurring at least once every week and lasting about 5 minutes each time before completely resolving. It is not associated with defecation, sexual intercourse, sitting, or standing. The patient reports no rectal bleeding, pruritus, constipation, diarrhea, fecal or urinary incontinence, or unexplained weight loss. She is sexually active. Vital signs are normal. Conjunctival pallor is absent, and mucous membranes are moist. Heart and lung sounds are normal. The abdomen is nontender and nondistended. Pelvic and rectal examinations show no abnormalities. Which of the following is the most likely diagnosis?

Question

A 32-year-old woman comes to the office with rectal pain.  The pain is crampy and episodic, occurring at least once every week and lasting about 5 minutes each time before completely resolving.  It is not associated with defecation, sexual intercourse, sitting, or standing.  The patient reports no rectal bleeding, pruritus, constipation, diarrhea, fecal or urinary incontinence, or unexplained weight loss.  She is sexually active.  Vital signs are normal.  Conjunctival pallor is absent, and mucous membranes are moist.  Heart and lung sounds are normal.  The abdomen is nontender and nondistended.  Pelvic and rectal examinations show no abnormalities.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d223_ef68_bc81_075179b51433_MD0003_00 This patient with recurrent episodes of rectal pain most likely has proctalgia fugax (PF). PF is a functional anorectal disorder characterized by recurrent, brief episodes (seconds to minutes) of rectal pain unrelated to defecation. Patients are pain-free between episodes. Attacks may be precipitated by stress, sexual intercourse, and/or sitting but often occur without an obvious stimulus, as in this patient. Although the pathophysiology is poorly understood, it likely involves uncontrolled spasms of the anal sphincter and possibly intermittent pudendal nerve compression. Women are affected more commonly than men; other risk factors include functional pathologies (eg, irritable bowel syndrome) and anxiety disorders. PF is a diagnosis of exclusion; abnormalities in the physical examination (eg, digital rectal, prostate, pelvic) or laboratory evaluation (eg, complete blood count, electrolytes, inflammatory markers) suggest an alternate diagnosis. Most patients can be reassured of the benign nature of this condition. Because symptoms are often brief and no preventive measure is effective, most patients do not require specific treatment. Topical nitroglycerin or biofeedback therapy may be useful for frequent or prolonged symptoms. (Choice A) Coccydynia (pain at the coccyx) is most commonly diagnosed in women with obesity and often results from traumatic injury. The pain is exacerbated by sitting, and a rectal examination elicits tenderness of the coccyx bone during palpation. (Choice B) Endometriosis sometimes presents with rectal pain but is cyclical typically and related to the menstrual cycle. In addition, it usually causes dyspareunia and dysmenorrhea. (Choice C) Fibromyalgia causes widespread musculoskeletal pain as well as fatigue and sleep disruption. This is unlikely in this patient because her pain is limited to the rectum. (Choice D) Irritable bowel syndrome causes recurrent abdominal pain related to defecation as well as constipation and/or diarrhea. This patient's isolated rectal pain unrelated to defecation is more consistent with PF. (Choice F) Compression of the sacral nerves S2-S4 can lead to sacral and buttock pain; however, pain often radiates down the leg. Urinary and fecal incontinence and sexual dysfunction are common. In addition, symptoms would not be expected to occur intermittently. Educational objective: Proctalgia fugax is a functional anorectal disorder characterized by recurrent episodes of rectal pain unrelated to defecation. Attacks may be precipitated by stress, sexual intercourse, and/or sitting but often occur without an obvious stimulus. Proctalgia fugax is a diagnosis of exclusion; physical examination (eg, digital rectal, prostate, pelvic) and laboratory analysis are normal. References: Functional anorectal disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27144630)

A 32-Year-Old Woman Comes to the Office with Rectal Pain