Disorders of defecation and proctalgia syndromes are anorectal functional disorders. Here we discuss the diagnosis and treatment recommendation from the American College of Gastroenterology (ACG) for both conditions.

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Anorectal biofeedback therapy is the cornerstone for managing defecation disorders. For proctalgia syndromes, biofeedback possesses no significant risks and can be a good option looking at the lack of effective alternative therapies.

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Defecatory disorders

Defecation disorders are defined as difficulty in evacuating stool from the rectum in patients with chronic or recurring symptoms of constipation. Diagnosis depends on assessing symptoms of constipation as well as using anorectal tests to check for impaired rectal evacuation.

Anorectal tests are important as relying on symptoms alone cannot distinguish between defecation disorders and other conditions causing constipation. The diagnostic tests include:

• Anorectal manometry (ARM) - Assess rectal sensation and anorectal pressures
• Balloon expulsion test (BET) - Assess the patient’s ability to evacuate a simulated stool
• Electromyogram (EMG) - Assess the external anal sphincter and pelvic floor muscle activity
• Barium or MRI defecography - Study of rectal evacuation

Of all the tests, ARM and BET are more convenient, readily available, and avoid exposure to radiation. When using defecography, the test results should be correlated with the clinical features because there is a high probability for false positives and false negatives. The diagnosis of defecation disorders should be confirmed by at least 2 abnormal tests as per the Rome IV criteria.

Differential diagnosis is important when evaluating defecation disorders. Defecation disorders may be associated with IBS and conditions associated with rectal bleeding such as haemorrhoids. Abdominal imaging and/or a colonoscopy should be conducted when clinically possible. Anxiety, depression, or generalised somatoform disorders may be common in patients with severe conditions.

In patients with defecation disorders and excessive perineal descent, with or without pelvic organs prolapse, it can be challenging to determine the contributions of structural and functional disturbances to DD. There is a possibility of slow transit constipation which may occur in isolation or coexist with defecation disorders.

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Treatment recommendations for defecation disorders

Conservative treatment

Anorectal biofeedback therapy is the cornerstone for managing defecation disorders. Instrumented anorectal biofeedback therapy should be used to manage symptoms in defecation disorders. Alternative options include:

1. Avoiding medications that cause or exacerbate constipation.
2. Use of soluble fibre (e.g., psyllium and sterculia) or laxatives for patients with hard stools.
3. Insoluble fibre for patients with loose stools.
4. While regular toileting, the use of a footstool to enhance defecation is suggested.

Apart from these, consuming meals of 500 Kcal or more to induce the gastrocolonic response is suggested. Patients should be advised to heed the call to defecate and avoid straining and spending excessive time during defecation. It is also suggested to treat anorectal conditions (e.g., anal fissure or symptomatic haemorrhoids) simultaneously.

Surgery and minimally invasive procedures

If the above measures fail to provide adequate relief of symptoms, MRI or barium defecography should be conducted to detect structural disorders. Structural abnormalities of the pelvic floor are mostly found in asymptomatic subjects and rarely require surgery.

1. Surgery is suggested in patients who present with overt full-thickness rectal prolapse, with or without defecatory symptoms and/or progressive faecal incontinence.
2. Rectocele surgery should be considered in patients with bothersome gynaecological symptoms such as bulging in the perineum or protrusion through the vaginal introitus.
3. Symptomatic, sigmoidoceles and enteroceles may be treated with surgery. Radiological testing using MRI, defecating proctogram, and/or transperineal ultrasound should be carried out before the surgery.

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Proctalgia syndromes

Proctalgia syndromes may be defined as a history of recurrent episodes of anorectal pain in the absence of other known causes of pain on the basis of history and diagnostic testing. Based on the duration of painful episodes, proctalgia can be classified as chronic or acute syndromes.

Chronic proctalgia syndrome is characterised by a history of recurring episodes of anorectal pain lasting at least 20 minutes (often hours or even days) and the exclusion of other causes of anorectal pain by history and diagnostic testing.

The symptoms of chronic proctalgia can often be confused with other pelvic conditions such as chronic prostatitis in men and chronic pelvic pain syndrome in women. It is important to test and exclude these conditions before deciding on therapy. ARM and balloon expulsion testing is recommended in patients with levator syndrome (but not idiopathic chronic proctalgia syndrome) to select patients who may benefit from biofeedback therapy.

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Treatment recommendations for proctalgia syndromes

1. Biofeedback to teach pelvic floor muscle reconditioning for levator syndrome with abnormal ARM.
2. Biofeedback possesses no significant risks and can be a good option looking at the lack of effective alternative therapies.
3. Electrical (galvanic) stimulation may be attempted to manage levator syndrome with an abnormal ARM if biofeedback is not available. 
4. The use of botulinum toxin or digital rectal massage to treat either levator syndrome or chronic idiopathic proctalgia syndrome is not recommended.

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Proctalgia fugax

Proctalgia fugax is characterised by intense sensations of rectal or anal pain lasting only a few seconds to less than 20 minutes. A characteristic history and a normal digital rectal examination (DRE) are two key parameters which help diagnose the condition.

The presence of anorectal conditions such as prolapsed haemorrhoids, chronic anal fissures, or other conditions does not invalidate the diagnosis. Due to the brevity of episodes, currently, there is no evidence to support treatment interventions or to prevent attacks in proctalgia fugax. The recommended approach is an explanation of the disorder and reassurance.

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Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.