Rome IV Diagnostic Criteria for Proctalgia Fugax
Official Rome IV criteria for the diagnosis of proctalgia fugax.
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Use in patients with sudden, infrequent anorectal pain lasting <30 minutes (often seconds to minutes) and often described as cramping, gnawing, aching, or stabbing with severity ranging from uncomfortable to intolerable.
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Can interrupt normal activities and even awaken patients from sleep.
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Can be triggered by stress or anxiety.
Do NOT use these criteria in patients with:
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Tenderness on posterior traction of rectum when not having symptoms.
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Anorectal or pelvic floor structural pathology explaining symptoms.
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Frequent pain related to defecation
If criteria positive and C-reactive protein elevated, leukocytosis, and/or fever:
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Suggests other etiology for anorectal pain.
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Consider imaging such as CT or MRI of pelvis to assess infection or inflammatory bowel disease.
If criteria positive without systemic symptoms and normal inflammatory markers:
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If symptoms infrequent, tolerable: reassurance/education adequate.
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If symptoms frequent, intolerable:
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Inhaled salbumatol (beta agonist) shortened episodes >20 minutes in randomized controlled trial.
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Other less studied treatments: alpha agonists, clonidine, or nitroglycerin, antispasmodics.
Consider anorectal manometry particularly if pelvic floor dyssynergia is suspected.
If criteria negative and thorough structural evaluation has been performed:
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Consider other related etiologies:
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Levator Ani Syndrome (frequent pain lasting ≥30 minutes, tenderness on posterior traction of rectum).
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Unspecified Functional Anorectal Pain (no tenderness on posterior traction of rectum).
Careful history assessing the time duration of symptoms (shorter duration <30 minutes) and digital rectal exam to assess lack of posterior rectal tenderness are critical to accurate diagnosis and directing management.