Functional Anorectal Disorders
2006; Elsevier BV; Volume: 130; Issue: 5 Linguagem: Inglês
10.1053/j.gastro.2005.11.064
ISSN1528-0012
AutoresAdil E. Bharucha, Arnold Wald, Paul Enck, Satish S.C. Rao,
Tópico(s)Anorectal Disease Treatments and Outcomes
ResumoThis report defines criteria for diagnosing functional anorectal disorders (ie, fecal incontinence, anorectal pain, and disorders of defecation). Functional fecal incontinence is defined as the uncontrolled passage of fecal material recurring for ≥3 months in an individual with a developmental age of ≥4 years that is associated with: (1) abnormal functioning of normally innervated and structurally intact muscles, and/or (2) no or minor abnormalities of sphincter structure and/or innervation insufficient to explain fecal incontinence, and/or (3) normal or disordered bowel habits (ie, fecal retention or diarrhea), and/or (4) psychological causes. However, conditions wherein structural and/or neurogenic abnormalities explain the symptom, or are part of a generalized process (eg, diabetic neuropathy) are not included within functional fecal incontinence. Functional fecal incontinence is a common, but underrecognized symptom, which is equally prevalent in men and women, and can often cause considerable distress. The clinical features are useful for guiding diagnostic testing and therapy. Functional anorectal pain syndromes include proctalgia fugax (fleeting pain) and chronic proctalgia; chronic proctalgia may be subdivided into levator ani syndrome and unspecified anorectal pain, which are defined by arbitrary clinical criteria. Functional defecation disorders are characterized by 2 or more symptoms of constipation, with ≥2 of the following features during defecation: impaired evacuation, inappropriate contraction of the pelvic floor muscles, and inadequate propulsive forces. Functional disorders of defecation may be amenable to pelvic floor retraining by biofeedback therapy (such as dyssynergic defecation). This report defines criteria for diagnosing functional anorectal disorders (ie, fecal incontinence, anorectal pain, and disorders of defecation). Functional fecal incontinence is defined as the uncontrolled passage of fecal material recurring for ≥3 months in an individual with a developmental age of ≥4 years that is associated with: (1) abnormal functioning of normally innervated and structurally intact muscles, and/or (2) no or minor abnormalities of sphincter structure and/or innervation insufficient to explain fecal incontinence, and/or (3) normal or disordered bowel habits (ie, fecal retention or diarrhea), and/or (4) psychological causes. However, conditions wherein structural and/or neurogenic abnormalities explain the symptom, or are part of a generalized process (eg, diabetic neuropathy) are not included within functional fecal incontinence. Functional fecal incontinence is a common, but underrecognized symptom, which is equally prevalent in men and women, and can often cause considerable distress. The clinical features are useful for guiding diagnostic testing and therapy. Functional anorectal pain syndromes include proctalgia fugax (fleeting pain) and chronic proctalgia; chronic proctalgia may be subdivided into levator ani syndrome and unspecified anorectal pain, which are defined by arbitrary clinical criteria. Functional defecation disorders are characterized by 2 or more symptoms of constipation, with ≥2 of the following features during defecation: impaired evacuation, inappropriate contraction of the pelvic floor muscles, and inadequate propulsive forces. Functional disorders of defecation may be amenable to pelvic floor retraining by biofeedback therapy (such as dyssynergic defecation). Consistent with the other disorders encompassed in this supplement, the anorectal disorders are defined by specific symptoms, and in one instance (functional disorders of defecation), also by abnormal diagnostic tests. Our concepts of the pathophysiology of anorectal disorders continue to evolve with an increasing array of sophisticated tools that can characterize anorectal structure and function.1Bharucha A.E. Fecal incontinence.Gastroenterology. 2003; 124: 1672-1685Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar These assessments may reveal disturbances of anorectal structure and/or function in patients who were hitherto considered to have an “idiopathic” or “functional” disorder. Likewise, the distinction between “organic” and “functional” anorectal disorders may be difficult to make in individual patients because (1) the causal relationship between structural abnormalities and anorectal function or bowel symptoms may be unclear because such abnormalities (eg, small anal sphincter defects, rectoceles) are often observed in asymptomatic subjects. (2) Organic lesions are influenced by behavioral adaptations. For example, repeated straining to defecate may contribute to rectal prolapse or pudendal nerve injury. (3) Patients may have several structural or functional disturbances, each of which may contribute to but cannot solely explain symptoms. For example, diarrhea may lead to fecal incontinence in patients with previously asymptomatic sphincter weakness. The functional anorectal disorders are defined primarily on the basis of symptoms (Table 1).2Whitehead W.E. Wald A. Diamant N.E. Enck P. Pemberton J.H. Rao S.S.C. Functional disorders of the anus and rectum.Gut. 1999; 45: II55-II59Crossref PubMed Scopus (242) Google Scholar Because patients may not accurately recall bowel symptoms,3Ashraf W. Park F. Lof J. Quigley E.M. An examination of the reliability of reported stool frequency in the diagnosis of idiopathic constipation.Am J Gastroenterol. 1996; 91: 26-32PubMed Google Scholar reliability of symptom reports can be improved by prospectively obtained symptom diaries.Table 1Functional Gastrointestinal DisordersF. Functional anorectal disorders F1. Functional fecal incontinence F2. Functional anorectal pain F2a. Chronic proctalgia F2a1. Levator ani syndrome F2a2. Unspecified functional anorectal pain F2b. Proctalgia fugax F3. Functional defecation disorders F3a. Dyssynergic defecation F3b. Inadequate defecatory propulsion Open table in a new tab This report and the associated recommendations are based on a review of the world literature by investigators with longstanding interest in anorectal disorders. The diagnostic criteria include a minimum duration of symptoms so as to avoid the inclusion of self-limited conditions. Fecal incontinence (FI) is defined as uncontrolled passage of fecal material recurring for ≥3 months. Leakage of flatus alone should not be characterized as FI, partly because it is difficult to define when passage of flatus is abnormal. FI should not be considered a medical problem earlier than age 4 years. FI can also be associated with organic disorders (eg, dementia, multiple sclerosis, Crohn’s disease). FI is a common problem with a prevalence ranging from 2.2%–15% in the community, and up to 46% in nursing homes.4Nelson R.L. Epidemiology of fecal incontinence.Gastroenterology. 2004; 126: S3-S7Abstract Full Text Full Text PDF PubMed Scopus (226) Google Scholar Differences in prevalence rates among studies may be explained by variation in survey methods, definitions of FI, and age distribution of populations surveyed. In a recent community survey of adults aged 40 years and older in the UK, 1.4% reported major FI and 0.7% had major FI with bowel symptoms that had an impact on quality of life.5Perry S. Shaw C. McGrother C. Matthews R.J. Assassa R.P. Dallosso H. Williams K. Brittain K.R. Azam U. Clarke M. Jagger C. Mayne C. Castleden C.M. Prevalence of faecal incontinence in adults aged 40 years or more living in the community.Gut. 2002; 50: 480-484Crossref PubMed Scopus (410) Google Scholar Despite this impact, patients may not disclose the symptom to their physician unless they are asked about it, partly out of embarrassment. Age, gender, physical limitations, and general health are risk factors for FI in the community. Other identified risk factors include diarrhea and rectal urgency.6Kalantar J.S. Howell S. Talley N.J. Prevalence of faecal incontinence and associated risk factors; an underdiagnosed problem in the Australian community?.Med J Aust. 2002; 176: 54-57PubMed Google Scholar Among the elderly, cognitive and mobility impairment, diarrhea, and fecal retention are significant risk factors for functional FI.7Read N.W. Abouzekry L. Why do patients with faecal impaction have faecal incontinence?.Gut. 1986; 27: 283-287Crossref PubMed Scopus (104) Google Scholar, 8Drossman D.A. Sandler R.S. Broom C.M. McKee D.C. Urgency and fecal soiling in people with bowel dysfunction.Dig Dis Sci. 1986; 31: 1221-1225Crossref PubMed Scopus (65) Google Scholar The extent to which other risk factors (eg, obstetric or iatrogenic anal sphincter trauma) contribute to FI in the community is unclear. F1. Diagnostic Criteria ⁎Criteria fulfilled for the last 3 months for Functional Fecal Incontinence 1Recurrent uncontrolled passage of fecal material in an individual with a developmental age of at least 4 years and 1 or more of the following: aAbnormal functioning of normally innervated and structurally intact musclesbMinor abnormalities of sphincter structure and/or innervation; and/orcNormal or disordered bowel habits (fecal retention or diarrhea); and/ordPsychological causes AND2Exclusion of all of the following: aAbnormal innervation caused by lesion(s) within the brain (eg, dementia), spinal cord or sacral nerve roots or mixed lesions (eg, multiple sclerosis), or as part of a generalized peripheral or autonomic neuropathy (eg, owing to diabetes)bAnal sphincter abnormalities associated with a multisystem disease (eg, scleroderma)cStructural or neurogenic abnormalities believed to be the major or primary cause of FI 1Recurrent uncontrolled passage of fecal material in an individual with a developmental age of at least 4 years and 1 or more of the following: aAbnormal functioning of normally innervated and structurally intact musclesbMinor abnormalities of sphincter structure and/or innervation; and/orcNormal or disordered bowel habits (fecal retention or diarrhea); and/ordPsychological causes AND2Exclusion of all of the following: aAbnormal innervation caused by lesion(s) within the brain (eg, dementia), spinal cord or sacral nerve roots or mixed lesions (eg, multiple sclerosis), or as part of a generalized peripheral or autonomic neuropathy (eg, owing to diabetes)bAnal sphincter abnormalities associated with a multisystem disease (eg, scleroderma)cStructural or neurogenic abnormalities believed to be the major or primary cause of FI The spectrum of “functional” FI is broader compared to the Rome II criteria because 1The relationship of structural disturbances (eg, anal sphincter defects visualized by imaging) to FI is often unclear because even asymptomatic women may have small anal sphincter defects. Therefore, structural abnormalities are not necessarily inconsistent with the diagnosis of functional FI.2Limitations of testing hinder a precise assessment of certain dysfunctions (eg, pudendal neuropathy). Anal sphincter electromyography (EMG), the only accurate technique for assessing indirectly for a pudendal neuropathy, is not widely available. The revised criteria recognize that many patients with anal sphincter weakness may exhibit evidence of denervation/reinnervation changes. Such patients are included within the category of functional FI, provided they do not have a generalized disease process (eg, diabetes with peripheral neuropathy) that can cause a pudendal neuropathy3The demonstration of mild anal sphincter denervation/reinnervation changes does not prove causality of FI, especially in the presence of coexistent small sphincter defects. Organic causes of FI (eg, diabetes with peripheral neuropathy, scleroderma, neurologic disorders) are generally identified by detailed clinical evaluation. A comprehensive clinical assessment is useful to elucidate the etiology and pathophysiology of FI, evaluate severity of incontinence, establish rapport with the patient, and guide testing and treatment. The history should characterize the type and frequency of FI, bowel patterns, awareness of the desire to defecate prior to FI, and identify risk factors for anorectal injury. Staining, soiling, and seepage reflect the nature and severity of FI.5Perry S. Shaw C. McGrother C. Matthews R.J. Assassa R.P. Dallosso H. Williams K. Brittain K.R. Azam U. Clarke M. Jagger C. Mayne C. Castleden C.M. Prevalence of faecal incontinence in adults aged 40 years or more living in the community.Gut. 2002; 50: 480-484Crossref PubMed Scopus (410) Google Scholar Soiling indicates more leakage than staining of underwear; soiling can be specified further, namely, of underwear, outer clothing, or furnishings/bedding. Seepage refers to leakage of small amounts of stool. Symptoms also provide clues to the pathophysiology of FI. Incontinence for solid stool suggests more severe sphincter weakness than does liquid stool alone. Urge incontinence (ie, an exaggerated sensation of the desire to defecate before leakage) is associated with reduced squeeze pressures and squeeze duration,9Engel A.F. Kamm M.A. Bartram C.I. Nicholls R.J. Relationship of symptoms in faecal incontinence to specific sphincter abnormalities.Int J Colorectal Dis. 1995; 10: 152-155Crossref PubMed Scopus (198) Google Scholar, 10Chiarioni G. Scattolini C. Bonfante F. Vantini I. Liquid stool incontinence with severe urgency anorectal function and effective biofeedback treatment.Gut. 1993; 34: 1576-1580Crossref PubMed Scopus (80) Google Scholar reduced rectal capacity, and increased perception of rectal balloon distention.11Bharucha A.E. Fletcher J.G. Harper C.M. Hough D. Daube J.R. Stevens C. Seide B. Riederer S.J. Zinsmeister A.R. Relationship between symptoms and disordered continence mechanisms in women with idiopathic fecal incontinence.Gut. 2005; 54: 546-555Crossref PubMed Scopus (211) Google Scholar In contrast, passive incontinence (ie, incontinence without awareness of the desire to defecate) is associated with lower resting pressures.9Engel A.F. Kamm M.A. Bartram C.I. Nicholls R.J. Relationship of symptoms in faecal incontinence to specific sphincter abnormalities.Int J Colorectal Dis. 1995; 10: 152-155Crossref PubMed Scopus (198) Google Scholar The severity of FI and its impact on quality of life can be summarized by specialized scales.12Rockwood T.H. Church J.M. Fleshman J.W. Kane R.L. Mavrantonis C. Thorson A.G. Wexner S.D. Bliss D. Lowry A.C. Fecal Incontinence Quality of Life Scale quality of life instrument for patients with fecal incontinence.Dis Colon Rectum. 2000; 43: 9-16Crossref PubMed Google Scholar The rectum should be examined before enemas or laxatives are given. In patients with FI, the rectal examination may disclose stool impaction in patients with fecal retention, gaping of the external anal sphincter in patients with neurologic or traumatic sphincter involvement, weak contraction of the external sphincter and puborectalis to voluntary command, and/or dyssynergia during simulated evacuation (discussed in the section on category F3 disorders).13Hill J. Corson R.J. Brandon H. Redford J. Faragher E.B. Kiff E.S. History and examination in the assessment of patients with idiopathic fecal incontinence.Dis Colon Rectum. 1994; 37: 473-477Crossref PubMed Scopus (82) Google Scholar Diagnostic testing is tailored to the patient’s age, probable etiologic factors, symptom severity, impact on quality of life, and response to conservative medical management. Endoscopic assessment of the rectosigmoid mucosa, with biopsies if necessary, should be considered in patients who have diarrhea or a recent change in bowel habit; a colonoscopy may be desirable in certain circumstances (eg, if the differential diagnosis includes colon cancer or age appropriate colon cancer screening). Manometry assesses continence and defecatory mechanisms by determining the (1) resting anal pressure; (2) amplitude and duration of the squeeze response; (3) recto-anal inhibitory reflex; (4) threshold volume of rectal distention required to elicit the first sensation of distention, a sustained feeling of urgency to defecate, and the pain threshold or maximum tolerable volume; and (5) recto-anal pressure changes during attempted defecation (see below). The methods for conducting and analyzing anorectal manometry are detailed elsewhere.14Rao S.S. Azpiroz F. Diamant N. Enck P. Tougas G. Wald A. Minimum standards of anorectal manometry.Neurogastroenterol Motil. 2002; 14: 553-559Crossref PubMed Scopus (247) Google Scholar Anal endosonography identifies anal sphincter thinning and defects,15Bartram C.I. Sultan A.H. Anal endosonography in faecal incontinence.Gut. 1995; 37: 4-6Crossref PubMed Scopus (87) Google Scholar which are often clinically unrecognized16Sultan A.H. Kamm M.A. Hudson C.N. Thomas J.M. Bartram C.I. Anal-sphincter disruption during vaginal delivery.N Engl J Med. 1993; 329: 1905-1911Crossref PubMed Scopus (1407) Google Scholar and may be amenable to surgical repair. Endosonography reliably identifies anatomic defects or thinning of the internal sphincter.17Vaizey C.J. Kamm M.A. Bartram C.I. Primary degeneration of the internal anal sphincter as a cause of passive faecal incontinence.Lancet. 1997; 349: 612-615Abstract Full Text Full Text PDF PubMed Scopus (185) Google Scholar Interpretation of external sphincter images is much more subjective, operator dependent, and confounded by normal anatomic variations of the external sphincter.18Enck P. Heyer T. Gantke B. Schmidt W.U. Schafer R. Frieling T. Haussinger D. How reproducible are measures of the anal sphincter muscle diameter by endoanal ultrasound?.Am J Gastroenterol. 1997; 92: 293-296PubMed Google Scholar Defecography records anorectal anatomy and pelvic floor motion at rest, and during coughing, squeezing, and straining to expel barium from the rectum. Methods for testing and interpretation are incompletely standardized,19Diamant N.E. Kamm M.A. Wald A. Whitehead W.E. AGA technical review on anorectal testing techniques.Gastroenterology. 1999; 116: 735-760Abstract Full Text Full Text PDF PubMed Scopus (360) Google Scholar and some findings (eg, pelvic floor prolapse and rectoceles) are relatively common in asymptomatic older women. Defecography is useful only for selected patients with FI, namely, to identify or confirm rectal prolapse, excessive perineal descent, a significant rectocele, an enterocele, or internal rectal intussusception, particularly prior to surgery. Pelvic magnetic resonance imaging (MRI) is the only imaging modality that can visualize both anal sphincter anatomy and global pelvic floor motion in real time without radiation exposure.11Bharucha A.E. Fletcher J.G. Harper C.M. Hough D. Daube J.R. Stevens C. Seide B. Riederer S.J. Zinsmeister A.R. Relationship between symptoms and disordered continence mechanisms in women with idiopathic fecal incontinence.Gut. 2005; 54: 546-555Crossref PubMed Scopus (211) Google Scholar Endosonography is the first choice for anal sphincter imaging in FI, because it is widely available, reasonably accurate for identifying internal and external sphincter abnormalities, and less costly than MRI. Endoanal MRI may be useful for identifying external sphincter atrophy,11Bharucha A.E. Fletcher J.G. Harper C.M. Hough D. Daube J.R. Stevens C. Seide B. Riederer S.J. Zinsmeister A.R. Relationship between symptoms and disordered continence mechanisms in women with idiopathic fecal incontinence.Gut. 2005; 54: 546-555Crossref PubMed Scopus (211) Google Scholar particularly prior to surgical repair of external sphincter defects. Pudendal nerve terminal motor latencies are of questionable utility for identifying a pudendal neuropathy; an American Gastroenterological Association technical review recommended that pudendal nerve terminal motor latencies should not be used for evaluating patients with FI.19Diamant N.E. Kamm M.A. Wald A. Whitehead W.E. AGA technical review on anorectal testing techniques.Gastroenterology. 1999; 116: 735-760Abstract Full Text Full Text PDF PubMed Scopus (360) Google Scholar Needle EMG can identify myogenic, neurogenic, or mixed (neurogenic and myogenic) injury affecting the external anal sphincter, and is recommended when there is a clinical suspicion of a proximal neurogenic lesion, that is, involving the sacral roots, conus, or cauda. Surface EMG is used as a biofeedback signal for pelvic floor retraining of the external anal sphincter in FI.20Heymen S. Jones K.R. Ringel Y. Scarlett Y. Whitehead W.E. Biofeedback treatment of fecal incontinence a critical review.Dis Colon Rectum. 2001; 44: 728-736Crossref PubMed Scopus (139) Google Scholar Fecal continence is maintained by anatomic factors (the pelvic barrier, rectal curvatures, and transverse rectal folds), recto-anal sensation, rectal compliance and fecal consistency, and delivery to the rectum. Decreased anal resting pressure may be associated with structural or functional disturbances (defects and/or thinning) of the internal sphincter. External anal sphincter weakness may result from sphincter damage, neuropathy, myopathy, or reduced corticospinal input. In addition to the anal sphincters, puborectalis function may also be impaired in FI.21Fernandez-Fraga X. Azpiroz F. Malagelada J.R. Significance of pelvic floor muscles in anal incontinence.Gastroenterology. 2002; 123: 1441-1450Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar The importance of rectal compliance and/or sensation for maintaining continence is emphasized by the finding that sphincter pressures alone do not always distinguish continent from incontinent subjects. Reduced rectal sensation allows stool to leak through the anal canal before the external sphincter contracts.22Buser W.D. Miner Jr, P.B. Delayed rectal sensation with fecal incontinence. Successful treatment using anorectal manometry.Gastroenterology. 1986; 91: 1186-1191Abstract Full Text PDF PubMed Scopus (137) Google Scholar, 23Sun W.M. Donnelly T.C. Read N.W. Utility of a combined test of anorectal manometry, electromyography, and sensation in determining the mechanism of ‘idiopathic’ faecal incontinence.Gut. 1992; 33: 807-813Crossref PubMed Scopus (146) Google Scholar Decreased rectal sensitivity and increased rectal compliance may also contribute to fecal retention by decreasing the frequency and intensity of the urge (and hence the motivation) to defecate. Increased rectal perception in some patients with FI may be a marker of coexistent irritable bowel syndrome, or may be associated with reduced rectal compliance23Sun W.M. Donnelly T.C. Read N.W. Utility of a combined test of anorectal manometry, electromyography, and sensation in determining the mechanism of ‘idiopathic’ faecal incontinence.Gut. 1992; 33: 807-813Crossref PubMed Scopus (146) Google Scholar, 24Whitehead W.E. Palsson O.S. Is rectal pain sensitivity a biological marker for irritable bowel syndrome psychological influences on pain perception.Gastroenterology. 1998; 115: 1263-1271Abstract Full Text Full Text PDF PubMed Scopus (263) Google Scholar or reduced rectal capacity.11Bharucha A.E. Fletcher J.G. Harper C.M. Hough D. Daube J.R. Stevens C. Seide B. Riederer S.J. Zinsmeister A.R. Relationship between symptoms and disordered continence mechanisms in women with idiopathic fecal incontinence.Gut. 2005; 54: 546-555Crossref PubMed Scopus (211) Google Scholar Therefore, FI is a heterogeneous disorder in which patients often exhibit >1 deficit. Management of functional FI should be tailored to clinical manifestations. Restoring normal bowel habits by antidiarrheal agents (eg, loperamide) for diarrhea, and laxatives and/or suppositories for constipation, is often the cornerstone to effectively managing incontinence. Although uncontrolled studies report improved continence in ∼70% of patients with FI after biofeedback therapy,20Heymen S. Jones K.R. Ringel Y. Scarlett Y. Whitehead W.E. Biofeedback treatment of fecal incontinence a critical review.Dis Colon Rectum. 2001; 44: 728-736Crossref PubMed Scopus (139) Google Scholar a controlled study reported similar symptom improvement (∼50%) in incontinent patients randomized to standard medical/nursing care, that is, advice only, advice plus verbal instruction on sphincter exercises, hospital-based computer-assisted sphincter pressure biofeedback, or hospital biofeedback plus use of a home EMG biofeedback device.25Norton C. Chelvanayagam S. Wilson-Barnett J. Redfern S. Kamm M.A. Randomized controlled trial of biofeedback for fecal incontinence.Gastroenterology. 2003; 125: 1320-1329Abstract Full Text Full Text PDF PubMed Scopus (303) Google Scholar Sacral nerve stimulation is an emerging option for FI; multicenter trials are in progress in the United States and will provide a clear view of the value of this technique.26Matzel K.E. Kamm M.A. Stosser M. Baeten C.G.M. Christiansen J. Madoff R. Sacral spinal nerve stimulation for faecal incontinence multicenter study.Lancet. 2004; 363: 1270-1276Abstract Full Text Full Text PDF PubMed Scopus (273) Google Scholar The 2 functional anorectal pain disorders (chronic proctalgia and proctalgia fugax) are distinguished on the basis of duration, frequency, and characteristic quality of pain. It is necessary to exclude other causes of anorectal pain such as ischemia, fissures, and inflammation. The prevalence of anorectal pain in a sample of US householders was 6.6% and was more common in women.27Drossman D.A. Li Z. Andruzzi E. Temple R. Talley N.J. Thompson W.G. Whitehead W.E. Janssens J. Funch-Jensen P. Corazziari E. Richter J.E. Koch G.G. U.S. householder survey of functional gastrointestinal disorders prevalence, sociodemography and health impact.Dig Dis Sci. 1993; 38: 1569-1580Crossref PubMed Scopus (1913) Google Scholar Chronic proctalgia is also called levator ani syndrome, levator spasm, puborectalis syndrome, pyriformis syndrome, or pelvic tension myalgia. This is described as a vague, dull ache or pressure sensation high in the rectum, often worse with sitting than with standing or lying down. Chronic proctalgia may be further characterized into levator ani syndrome or unspecified anorectal pain based on digital rectal examination. F2a. Diagnostic Criteria ⁎*Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis. for Chronic ProctalgiaMust include all of the following: 1Chronic or recurrent rectal pain or aching2Episodes last at least 20 minutes3Exclusion of other causes of rectal pain such as ischemia, inflammatory bowel disease, cryptitis, intramuscular abscess and fissure, hemorrhoids, prostatitis, and coccygodynia F2a1. Levator Ani SyndromeDiagnostic CriterionSymptom criteria for chronic proctalgia and tenderness during posterior traction on the puborectalis.F2a2. Unspecified Functional Anorectal PainDiagnostic CriterionSymptom criteria for chronic proctalgia but no tenderness during posterior traction on the puborectalis. Must include all of the following: 1Chronic or recurrent rectal pain or aching2Episodes last at least 20 minutes3Exclusion of other causes of rectal pain such as ischemia, inflammatory bowel disease, cryptitis, intramuscular abscess and fissure, hemorrhoids, prostatitis, and coccygodynia F2a1. Levator Ani Syndrome Diagnostic Criterion Symptom criteria for chronic proctalgia and tenderness during posterior traction on the puborectalis. F2a2. Unspecified Functional Anorectal Pain Diagnostic Criterion Symptom criteria for chronic proctalgia but no tenderness during posterior traction on the puborectalis. In the previous classification, patients who had the above symptoms were characterized as “highly likely” or “possible” levator ani syndrome based on presence or absence of tenderness during posterior traction on the puborectalis, respectively. This distinction is emphasized by modifying the nomenclature in the current version. It is recognized that symptoms present for <3 months that are otherwise consistent with the diagnosis may warrant clinical diagnosis and treatment, but for research studies, symptoms should be present for ≥3 months. The diagnosis is based on the presence of characteristic symptoms and physical examination. During puborectalis palpation, tenderness may be predominantly left sided, and massage of this muscle generally elicits the characteristic discomfort. Evaluation often is necessary to exclude alternative diseases. Levator ani syndrome is hypothesized to result from overly contracted pelvic floor muscles. The etiology is unknown. The pathophysiology of unspecified functional anorectal pain is also poorly understood. Some reports suggest that these disorders are associated with psychological distress, tension, and anxiety.28Heymen S. Wexner S.D. Gulledge A.D. MMPI assessment of patients with functional bowel disorders.Dis Colon Rectum. 1993; 36: 593-596Crossref PubMed Scopus (60) Google Scholar Uncontrolled studies have evaluated a variety of treatments including electrogalvanic stimulation, biofeedback training, muscle relaxants, digital massage of the levator ani muscles, and sitz baths. A recent double-blind, placebo-controlled study showed no efficacy of intrasphincteric injection of botulinum toxin A in levator ani syndrome.29Rao S.C. McLeod M. Beaty J. Stessman M. Effects of Botox on levator ani syndrome a double blind, placebo controlled cross-over study.Am J Gastroenterol. 2004; 99: S114-S115Google Scholar Surgery should be avoided. Proctalgia fugax is sudden, severe pain in the anal area lasting several seconds or minutes, and then disappearing completely. Attacks are infrequent, occurring <5 times per year in 51% of patients.30Thompson W.G. Proctalgia fugax in patients with the irritable bowel, peptic ulcer, or inflammatory bowel disease.Gastroenterology. 1984; 79: 450-452Google Scholar Community prevalence estimates range from 8%–18%, and are similar in men and women.27Drossman D.A. Li Z. Andruzzi E. Temple R. Talley N.J. Thompson W.G. Whitehea
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