Rome IV Diagnostic Criteria for Functional Anorectal Pain
Official Rome IV criteria for the diagnosis of levator ani syndrome or unspecified functional anorectal pain.
Use in patients with chronic, recurrent anorectal pain lasting >30 minutes that is often worse with sitting than standing or lying down, often described as a vague, dull ache, or pressure high in rectum.
Digital rectal exam:
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Levator Ani Syndrome: tenderness on palpation of pelvic floor or vagina.
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Pain during posterior traction of puborectalis.
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Pain often asymmetric, more often on left side (but not universally).
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Posterior massage may elicit characteristic discomfort.
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Unspecified Functional Anorectal Pain:
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NO pain during posterior traction of puborectalis.
Do NOT use in patients with:
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Anorectal or pelvic floor structural pathology explaining symptoms.
If criteria positive and C-reactive protein elevated, leukocytosis, and/or fever:
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Suggests other etiology for anorectal pain (e.g. Ulcerative Proctitis, rectal abscess, anal fistula).
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Consider imaging such as CT or MRI of pelvis to evaluate infection or inflammatory bowel disease.
If criteria positive without systemic symptoms and normal inflammatory markers:
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Focus on treatments for reducing tension in striated pelvic floor muscles:
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At home treatment: digital massage of levator ani muscles, sitz baths.
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Therapies: electrogalvanic stimulation, biofeedback training, pelvic floor therapy.
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Medications: muscle relaxants (methocarbamol, diazepam, cyclobenzaprine).
Consider anorectal manometry particularly if pelvic floor dyssynergia is suspected.
If pain is less than 30 minutes in duration, consider proctalgia fugax.
If criteria negative and thorough structural evaluation has been performed, consider other etiologies.
Careful history assessing the time duration of symptoms (longer duration >30 minutes) and digital rectal exam to assess posterior rectal tenderness are critical to accurate diagnosis and directing management.