Learning Objectives
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Learn the common causes of rectal pain.
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Develop an understanding of the anatomy of the nerves of the rectum and pelvis.
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Develop an understanding of the etiology of proctalgia fugax.
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Learn the clinical presentation of proctalgia fugax.
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Learn how to use physical examination to rule out pathology and other urogenital pain syndromes that may mimic proctalgia fugax.
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Develop an understanding of the treatment options for proctalgia fugax.
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Learn the appropriate testing options to help diagnose proctalgia fugax.
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Learn to identify red flags in patients who present with rectal pain.
Carrie Matheson
Carrie Matheson is a 30-year-old graphic designer with the chief complaint of, “I’ve got shooting pain in my rectum that just won’t go away.” Carrie went on to say that the rectal pain came on suddenly about 6 months ago. She was unable to identify any antecedent rectal or pelvic trauma or abnormalities associated with the onset of her pain, but did volunteer that she had been under a lot of stress at work. Carrie denied any urinary tract or vaginal infections or any gastrointestinal disturbance, constipation, or change in bowel habits. Carrie described the pain as sudden, excruciating, shooting pains located deep in her rectum that came on suddenly and went away just as quickly. I asked her to rate her rectal pain on a scale of 1 to 10, with 10 being the worst pain she had ever had, and she said this pain was a “20. Doc, this is worse than anything I have ever had. It’s worse than when I slammed my hand in the car door. It’s worse than having a baby. It’s killing me! I just can’t go on like this.”
I asked Carrie if she had any fever or chills since her pain began, and she shook her head no. She also denied rectal bleeding, abnormal vaginal bleeding or discharge, or pelvic pain and also denied urinary or fecal incontinance. Her last menstrual period was 1 week ago. She admitted that she quit taking her birth control pills because with this rectal pain, sex was out of the question.
I asked Carrie if she ever had anything like this before, and she shook her head no. I asked what she was doing to manage the pain and she said, “Nothing really works.” She had tried Preparation H, thinking she might have a hemorrhoid, a donut pillow her friend gave her, and sitz baths without any significant diminution of symptoms. She went on to say, “Doctor, this may sound nuts, but sometimes when the shooting pain just won’t stop, if I insert my finger into my rectum, I can get some relief.” I said, “This is useful information and a good clue as to what might be causing your pain.”
I asked Carrie to point with one finger to show me where it hurt the most. She pointed to her anus and said, “Doc, you can’t see anything. There is nothing there. It’s down deep inside. I’m really scared that it’s something really bad.” I reassured Carrie that we would figure out what was going on and that I would do everything I could to get her better. She gave me a weak smile and said that she hoped so, because she was really worn out getting up 50 times a night to try to go to the bathroom. “Carrie, since this pain has been so hard on you, I have a couple of questions and I want you to really think before answering because they are so important.” She said, “Okay, Doc, I will do my best.” I said that I knew she would and asked, “Carrie, have you ever felt like life just isn’t worth living?” She seemed shocked and then answered, “Doc, if you are asking if this pain makes me want to kill myself, the answer is absolutely not. I have a lot to live for, my boyfriend, my dog Buffy, my job. You don’t have to worry about that.” “Okay, that’s good, Carrie, but I want you to know that you can tell me anything. I make no judgments, no criticism. I’m always here to help.” She smiled and said that she really appreciated the concern. “So, next question. Do you feel like you have an excess of worry or stress? You mentioned that there was a lot going on a work.” Carrie thought for a moment and admitted that she had been pretty stressed out, but quickly went on to say, “Doctor, the pain is not in my head. It’s in my butt.” “Okay, that’s good to know,” I responded. “One last question. Are you being hurt or abused, or have you been hurt and abused in a past relationships or by a stranger or loved one?” Carrie shook her head no, but looked away, making me wonder if something might be going on. “Carrie, this is a place where you can always talk. You can always come for help.” She nodded yes and said, “Doctor, just get my tush better and all will be right with the world!”
On physical examination, Carrie was afebrile. Her respirations were 16. Her pulse was 72 and regular. Her blood pressure (BP) was normal at 118/74. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her thyroid examination. Her cardiopulmonary examination was negative. Her abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Her lower extremity neurologic examination was completely normal.
I asked Carrie to lie back on the examination table with her knees bent so we could inspect her groin. Inspection of the groin revealed no obvious abnormal mass or inguinal hernia. I again asked Carrie to use one finger to point to the spot that hurt, and she carefully pointed to her anus and again said that the pain was down deep. I asked Carrie if it was okay to do a pelvic and rectal exam and she said that I could do whatever I needed to if it would help get rid of the pain. Visual inspection of the skin and muscosa of the perineum, anus, and external genitalia was normal, with no evidence of trauma or lesions suggestive of herpes or other sexually transmitted diseases. Her rectal and pelvic exam were completely normal, with the stool guaiac negative. Specifically, there were no hemorrhoids, rectal fissures, evidence of trauma, abnormal masses, or rectal prolapse on Valsalva. With deep palpation of the levator ani muscles, the paroxysms of pain were triggered, and Carrie asked me to stop. I told Carrie that I had good news. “I didn’t find anything bad on the rectal exam.” And I had more good news. “I think I know what is wrong and have a pretty good idea of how to fix it.” She smiled and said, “Thank God!”
Key Clinical Points—What’s Important and What’s Not
The History
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A history of recent onset of paroxysmal shooting pains deep in the rectum
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No history of gastrointestinal symptoms related to the pain
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No history of gynecologic symptoms related to the pain
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Sleep disturbance
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Admits to increased stress at work
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Pain is localized to the rectum
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No fever or chills
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Denies suicidal ideation
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Denies domestic violence or abuse, but an index of suspicion
The Physical Examination
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The patient is afebrile
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Normal visual inspection of the anus, perineum, external genitalia
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Normal rectal examination
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Stool was guaiac negative
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Normal pelvic examination
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No evidence of rectal prolapse on Valsalva
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Deep palpation of the levator ani muscles triggers the paroxysms of pain
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The neurologic examination is within normal limits
Other Findings of Note
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Normal BP
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Normal HEENT examination
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Normal cardiopulmonary examination
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Normal abdominal examination
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No peripheral edema
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No rectal mass or inguinal hernia
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No CVA tenderness
What Tests Would You Like to Order?
The following tests were ordered:
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Magnetic resonance imaging (MRI) of the pelvis with special attention to the rectal area
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Colonoscopy with special attention to the rectum
Test Results
MRI of the pelvis is within normal limits. Colonoscopy is completely within normal limits with no evidence of proctitis or other abnormality of the distal colon and rectum.
Clinical Correlation—Putting It All Together
What is the diagnosis?
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Proctalgia fugax
The Science Behind the Diagnosis
Anatomy of The Symphysis Pubis
The rectum is the terminal part of the colon, interposed between the sigmoid colon and anus ( Figs. 13.1 and 13.2 ). It connects with the sigmoid colon at the level of S3. The rectum plays an important role in electrolyte and water resorption and as well as a key role in defecation and maintaining fecal continence, as the rectum serves as a terminal reservoir for fecal material. The rectum has a sacral and perineal flexure and has three rectal folds: the superior, middle, and inferior. Blood is supplied to the rectum via the superior, middle, and inferior rectal arteries. Stretch receptors in the rectal walls stimulate the desire to defecate ( Fig. 13.3 ).
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