A REAL PAIN IN THE ARSE
Published New Zealand GP Weekly 19 February, 1997.
First described late last century but identified as a particular malady by T E Thansen in 1935, Proctalgia Fugax remains somewhat of an enigma today. Incurable and benign it is of consequence only to those who suffer its most acute symptoms.
Thansen, in describing it as 'a fleeting pain in the rectum' had obviously never suffered from the affliction. The pain, colloquially known as 'anal cramp', can persist for as long as an hour with some victims experiencing nausea and cold sweats - fainting attacks have been recorded. The cessation of pain brings a feeling of well-being akin to the removal of an abscessed tooth.
D M Nidorf and E R Jamison in the December, 1995 edition of the American Family Physician describe Proctalgia Fugax as 'a fairly common but little known cause of rectal pain. It is a benign condition that has no known etiology'. They go on to say that 'Several treatments have been tried and found anecdotally to be effective, although reassurance is the most useful therapeutic option'.
This latter observation is surprising given that the same authors describe the ailment as 'Doctor's Disease - the disease of the perfectionist male physician'. One would have expected at least one of the varied treatments tried by these suffering doctors to have been accepted as a standard remedy.
Fugax 2
Research by Nidorf and Jamison using random sampling showed that about 15% of the population have experienced symptoms but few seek medical help due to its transitory and embarrassing nature. The embarrassment comes from attacks often being associated with orgasm. Gastroenterologist, W G Thompson, reported that of 2000 patients only 6 visited because of Proctalgia Frugax. Apparently men and women are equally affected. A H Douthwaite [British Medical Journal, July 1962] records that he had no spontaneous complaints from women but attributes that to women accepting it as a pain associated with the reproductive process and a normal part of life's difficulties. In men the attacks are usually at night but in women day-time attacks are more prevalent.
Douthwaite's conclusion is that 'Proctalgia Fugax is a pain which does not arise in the rectum but is occasioned by segmental cramp of the pubococcygeus muscle. It is harmless, unpleasant and incurable'.
Douthwaite records that coitus is not a provocative in females. However J A Mountfield [Canadian Medical Association Journal, 1986] in an article questioning the benign status of Proctalgia Fugax, reports a case of a woman who experienced attacks after every orgasm. His prescription of valium as a
possible preventative was refused and her marriage, and presumably all sexual activity, ceased.
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Many causes have been postulated ranging from chronic constipation, hypertension and stress to neuroticism and anal fixation. The few random studies however show that these conditions are equally present in non-sufferers.
Prescribed treatments are just as varied. Anelgesics do not work fast enough to be of any value.
Amyl nitrate, quinine, chloroform, phenobarbital, nifedipine, valium, ropantheline, oral clonidine and diltiazem have been tried without wide acceptance. Self anal-dilation has been used successfully by some doctors but is impracticable for most sufferers. Dr Eckert conducted a double-blind, cross-over trial in Germany [American Journal of Gastroenterology] with sixteen patients. He found that 'two puffs of Salbutamol [.2 mg aerosol] shortened the duration of severe pain, particularly in patients having prolonged attacks' but cautions that his trial group was small and more research is needed.
I was 28 when I first sought help. At this time attacks were months apart and invariably followed orgasm. The diagnosis from my GP was a prostate problem which probably required surgery and I decided to suffer. It was correctly diagnosed 6 years later when attacks were more frequent. By this time I had developed quite severe haemorrhoids as my only remedy had been a minimal defacation after much straining.
My new GP could offer little advice except that pressure applied to the anal area could give some relief.
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Some 5 years later a fellow hotel guest disappeared before dawn and arrived back late for breakfast. It transpired that he had been stricken with Proctalgia Fugax and had driven to a doctor acquaintance to be administered a 'cold water enema'. From that day my pain problem was solved. A bulb enema is more important than a toothbrush in my toilet bag. On being awakened with anal cramp I adjourn to the bathroom and toilet and can be asleep again within 15 minutes. Little or no faeces is passed so I can only assume the passage of water activates the cramped muscles. Relief is instantaneous and is accompanied by a small flow of urine. My haemorrhoid problem is now manageable and I have peace of mind at night. I recently met a man who had suffered similarly for 15 years and he has now successfully adopted the same practice.
One swallow does not make a summer and three success stories do not herald a medical breakthrough.
R W Penney [Practitioner, 1970] rejects the enema solution along with many others but gives no supporting research data or alternative treatments. GPs are in the best position to research this line of treatment.
If Proctalgia Fugax is as common and unreported as research suggests, it should not be difficult for any practitioner to build a small database of patients. Douthwaite built up his trial group of 21 male and 27 female sufferers by asking leading questions of all patients, irrespective of their other health problems.
None had previously mentioned the problem to him. Regrettably, he could offer little more than
reassurance to his group.
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Reassurance that the condition is benign and will cease at death or age seventy, whichever comes first, should surely be accompanied by a treatment which can or may alleviate the extremely painful symptoms. A cold water enema [100mls] or Salbutamol are treatments any GP can offer with some hope of success.
Assistance from the staff of the medical libraries at Christchurch and Palmerston North Hospitals is gratefully acknowledged.
Published New Zealand GP Weekly 19 February, 1997.
ADDENDUM
Since this was written I have trialled salbutamol [Ventinol] with mixed success. In mild attacks the pain gradually eased before disappearing 10-15 minutes later. With severe attacks the pain eased but returned. A second dose 10 minutes later was successful on some occasions but on others I resorted to my proven remedy, the cold water enema. In practice now if I awake to mild pain, I use the inhaler. If it is severe I use the enema and am back to sleep in 15 minutes.
Obviously the inhaler is the simpler approach as to many the idea of an enema is repugnant but patients should be told that it is a viable option and in my case at least the most reliable.
B W Judkins Phone 07-362-0015
R39 State Highway 30
Lake Rotoma email –
brianjudkinsesq@slingshot.co.nz
RD 4
Rotorua
New Zealand
13 October 1998
