Proctalgia Fugax and Levator Spasm

Dr. Weyrich's Naturopathic Proctology Notebook

Overview

Proctalgia fugax and Levator spasm are similar pain syndromes of the pelvic, rectal, and perianal areas. Attacks may last about 20 minutes, building to an intolerable crescendo and then gradually abating.

The constriction of the anal muscles makes the patient more susceptible to formation of anal fissures, both by reducing blood supply to the area, making the tissue less healthy and more friable, and simultaneously exacerbating the mechanical stress caused by passage of hard stools.

The pain from anal fissures may lead to spasm of the levator ani muscles, resulting in a vicious cycle.

Signs and Symptoms

Proctalgia Fugax:

• More common in young men.
• Brief episodic pain may last about 20 minutes.
• Sensation as if a knife were inserted up the rectum.
• May awaken patient at night.

Levator Spasm:

• More common in women.
• Episodic spasm of the levator ani muscle.
• Pain tends to be left-sided, may radiate into gluteal region.
• Sensation as if sitting on a ball, or as a dull ache high in the rectum.
• Levator sling tenderness upon transanal palpation.

Etiology

Physical examination is usually found to be normal. Onset may be associated with the following:

• Spasm of levator ani or ischiococcygeal muscles.
• Irritable bowel syndrome.
• Anismus.
• Previous pelvic surgery.
• Disordered defecation syndromes
• Episodes may be triggered by a variety of factors (often painful stimuli that provoke a reflex muscle spasm) such as:
  • Sitting
  • Emotional factors
  • Sexual activity
  • Fatigue
  • Low back pain
  • Anal fissures
  • Abscesses
  • Gas distention of the lower bowel
  • Prostate disorders
  • Structural deviations of the lumbosacral junction, sacroiliac junction, or coccyx
  • Structural deviations of the supporting pelvic floor

Diagnosis

• History, Physical exam, DRE
• Male or female exam.
• CBC
• Examination of axial spine and bony pelvis.
• Sigmoidoscopy
• Radiology: Plain film X-ray, CT Scan, MRI, Ultrasound
• Transrectal ultrasound
• Electromyelography (EMG - paradoxical puborectalis contraction)
• Nerve conduction
• Barium enema X-Ray
• Cinedefography
• Anorectal manography (EMG may be more sensitive)

Differential Diagnosis

• Proctalgia fugax (stabbing pain)
• Levator spasm (left-sided, as if sitting on ball)
• Coccygodynia (tenderness elicited by coccygeal motion)
• Inflammatory diseases:
  • Anal fistula
  • Inflammatory bowel disease (Crohn's, Ulcerative colitis)
  • Abscess (including tubo-ovarian, cryptoglandular)
  • Proctitis (infectious or radiation)
  • Diverticulitis
  • Prostatitis
  • Endometriosis/Endometritis (cyclic)
  • Pelvic appendicitis
• Anal fissure
• Rectal prolapse (incomplete)
• Constipation
• Paradoxical puborectalis contraction.
• Pelvic floor hernia
• Cauda equina syndrome (S2 to S4) or pudendal nerve disorder
• Descending perineum syndrome/laxity of the pelvic floor causing nerve traction
• Ectopic pregnancy
• Ovarian torsion
• Rectocele
• Retrovaginal intussusception
• Neoplastic diseases
• Multiple sclerosis
• Peripheral neuritic/degenerative disease
• Depression/anxiety (possibly secondary)
• Chronic idiopathic rectal pain (if none of the above).

Treatment

• Find and treat the exacerbating cause.
• Massage of levator ani muscle
• Digital stretching of the ischiococcygeus to relax it
• Anal sphincter massage under regional or general anesthesia
• Warm sitz baths may relax the anal sphincter muscles and promote blood flow.
• Muscle relaxant (beta-blocker, calcium channel blocker)
• Analgesic
• Local anesthetic
• Nerve block
• Botox
• Diathermy
• Electrogalvonic muscle stimulation of the lower rectum (Sohn, 1982 - results variable)
• Manipulation of axial spine and bony pelvis, especially the SI joint
• Biofeedback to learn to control muscle tone may be helpful

Pathophysiology

Spasm and ischemia of the muscles of the pelvic floor are implicated, including the striated muscles:

• levator ani
• puborectalis
• pubococcygeus
• iliococcygeus

and the smooth muscle of the internal anal sphincter.

ICD-9 Codes

ICD9-Code	Description	Comments

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References

Unless specifically noted above, references used in the construction of this web page include the following:

[FDM] Lecture notes from Functional Medicine University.

[SCNM] Lecture notes from Southwest College of Naturopathic Medicine.

[UT] Lecture notes from the University of Tennessee graduate programs in Chemistry and Biochemistry.

[Shackelford2007] Charles Yeo et al. Shackelford's Surgery of the Alimentary Tract, 6th Edition. Philadelphia: Saunders-Elsevier (2007).

[Shacket2009] www.hemorrhoid.net/fissure.php

[Shacket2009] www.hemorrhoid.net/levator.php

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