Pain-in-the- ...er, rear. Proctalgia fugax?

Dear Reader, 

It can be hard to confess to experiencing nightly pain in the rear even in a circle of friends, let alone to a health care provider. However, it can be a relief to know that you aren’t alone. It’s also worth noting  that the pain you and your buddies are experiencing may or may not be caused by the same issues. Anal cramping and pain can be caused by many physical conditions, as well as mental health conditions, such as anxiety or depression. Proctalgia fugax is a condition that is caused by spasms in the muscles of the pelvic floor, anal sphincter, and rectum, which leads to pain in the lower rectal area or in the anus. Some factors that may increase someone's risk for proctalgia fugax include constipation, high stress, or sexual intercourse. It’s typically more common for people with internal genitalia to experience proctalgia fugax, therefore, it is not just a “guy’s issue.” However, without a visit to your health care provider, there’s no way to confirm if you have this condition. Some common health issues that can also cause anal pain include: 

• Hemorrhoids 
• Infection 
• Neuropathy (isolated nerve pain) 
• Disorder of the blood vessels in that area 
• Anal or rectal cancer 
• Crohn’s disease 
• Anal fissures 
• Spasms around the anus 
• Perianal abscess 
• Inflammation 
• Trauma 

To determine the possible cause of anal pain, your health care provider may recommend an anorectal exam, which can include a rectal examination, colonoscopy, and fecal blood testing. Most likely, your provider will start with a rectal examination to rule out some of the more common causes of anal pain, such as hemorrhoids and anal fissures. During the exam, patients are asked to lie down on their side with their knees up to their chest, as this is the easiest position for the doctor or nurse to examine the rectum. After examining the outside of your rectum with gloves on, the doctor or nurse will then lubricate their finger with gel before gently inserting it into your rectum to check for any abnormalities. They may also ask you to squeeze their finger so they can assess how well the rectal muscles are functioning. While this process should not be painful, it can be a little uncomfortable. Consider talking with your provider before the exam to discuss any accommodations that may help you feel more comfortable. 

Depending on the results of the examination, your health care provider will determine a course of treatment if necessary. If your doctor does determine that your anal cramping is due to proctalgia fugax, treatment usually consists of lifestyle changes and physical therapy. There are a few things you can do at home to reduce pain and discomfort, including sitz baths, enemas, and self-release with tools specifically designed to massage the pelvic floor. Other treatments that have been found to reduce pain or discomfort include: 

• Biofeedback: helps train parts of your conscious mind to take control over bodily functions that typically are controlled by the autonomic nervous system and to respond to chronic pain in ways that minimize the sensation 
• Nerve blocks: anesthesiologist places a small needle into the person’s back and injects a solution that numbs the nerves in the pelvic area 
• Natural vegetable powder: these powders help produce large, soft bowel movements that can stretch out the muscles and prevent spasms 
• Electrical stimulation: uses an anal probe to send low voltage vibrating current through the spastic muscles for 30 minutes to encourage the spasming muscles to relax 
• Pelvic muscle restraining: training voluntary muscles to relax through special exercises

Another possible cause of your symptoms is a similar condition called levator ani syndrome. The levator ani muscles hold up the bladder, descending rectum, prostate in people with external genitalia, and uterus and vagina in people with internal genitalia. This condition is characterized by pain and cramping in the levator ani muscles in the rectum or on the pelvic floor. Levator ani syndrome can cause pain during, or after, sex, frequent or incomplete urination, constipation, bowel issues, including pain and rectal burning, excessive discomfort or relief after a bowel movement, and a “flickering” or “vibrating” sensation in the perineum, vagina, or rectum. The main difference between proctalgia fugax and levator ani syndrome is the length of time that the pain lasts. Both conditions most commonly occur overnight; however, proctalgia fugax typically lasts between five seconds to several minutes, though it can last up to 90 minutes.  Proctalgia fugax is considered chronic if the pain lasts for more than 20 minutes. However, it is common for pain and cramping caused by levator ani syndrome to last up to 20 minutes. Both conditions are also episodic and can occur daily, weekly, or once every few months. 

Both proctalgia fugax and levator ani syndrome can occur randomly, meaning they don't always have a specific cause, and only a small portion of people experience proctalgia fugax as a result of an underlying disease. 

Here’s to hoping you can get the pain resolved so you don’t have to spend your nights with your mind on your behind.