Chronic Proctalgia Has Been Replaced by Its Subtype Syndromes

Chronic proctalgia is a term that has been discontinued. It referred to a condition in which a person experiences the 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 the Rome IV Criteria for Colorectal Disorders eliminated it in 2016.

However, it is likely to still be seen in diagnoses and classifications until medical professionals begin to apply the new 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 by the length of time of its symptoms from proctalgia fugax, which is marked by 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 when it is touched during a doctor'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, the underlying mechanisms and choices of treatment differ for these syndromes and Rome IV include the subtypes that were under chronic proctalgia as their own syndromes.

• Levator ani syndrome: In this form of chronic proctalgia, people experience tenderness on the puborectalis (muscle within your pelvis) when it is touched during a doctor's rectal examination.
• Unspecified functional anorectal pain: This form of chronic proctalgia is diagnosed if you feel no such 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. Now the maximum duration is 30 minutes rather than 20 minutes and the location is in the rectum rather than in the lower rectum or anus.

Symptoms

The symptoms of these syndromes are typically experienced as a prolonged dull ache or pressure-like sensation in the rectum—often experienced 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

For the syndromes that were subtypes of chronic proctalgia, functional gastrointestinal disorder (FGD), diagnostic tests will only be administered to rule out other health problems. Otherwise, doctors will make a diagnosis based on symptoms according to the Rome IV criteria for FGDs:

• 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.

In order to identify the presence of levator ani syndrome, your doctor is likely to perform a rectal examination to test for tenderness.

Causes

The exact reason behind these conditions is currently unknown. In the past, it was hypothesized that the condition was the result of 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 proctalgia and higher rates of depression and anxiety disorders. However, it is unknown if these emotional symptoms increase the risk of, or are the result of, experiencing chronic rectal pain symptoms.

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 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. These treatments replace the traditional ones used, which included digital massage of the levator ani muscle, muscle relaxants, and the use of sitz baths, which all showed limited effectiveness. Surgery is not considered to be an effective treatment for chronic proctalgia.

_Sources:

Chiarioni G, Asteria C, Whitehead W. Chronic proctalgia and chronic pelvic pain syndromes: New etiologic insights and treatment options" World Journal of Gastroenterology 2011 17:4447-4455.

Schmulson MJ, Drossman DA. What Is New in Rome IV? Journal of Neurogastroenterology and Motility. 2017;23(2):151-163. doi:10.5056/jnm16214.