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Low-dose intravenous lidocaine as treatment for proctalgia fugax
Low-Dose Intravenous Lidocaine as Treatment for Proctalgia Fugax Roni Peleg, M.D., and Pesach Shvartzman, M.D. Background: Proctalgia fugax is characterized by a sudden internal anal sphincter and anorectic ring attack of pain of a short duration. Objective:
Description of the influence of intravenous lidocaine treatment for proctalgia fugax.
Case Report: A 28-year-old patient suffering of proctalgia fugax for 8 months. Conventional treatment efforts did not improve his condition. A single dose of an intravenous lidocaine infusion completely stopped his pain attacks. Conclusions: Based on the experience reported in this case and the potential benefit of this treatment for proctalgia fugax, controlled studies comparing intravenous lidocaine with placebo should be conducted to confirm the observation and to provide a more concrete basis for the use of intravenous lidocaine for this indication. Reg Anesth Pain Med 2002;27:97-99. Key Words:
Proctalgia fugax, Intravenous lidocaine.
P
roctalgia fugax is characterized by sudden internal anal sphincter and anorectal ring attacks of intense pain. The pain is typically unrelated to defecation, usually lasts for less than 20 minutes, appears spontaneously, and often awakens the patient from sleep. In extreme cases the pain can last for many hours, vanish, and then return again.1 Treating proctalgia fugax is difficult, and no single therapeutic approach is completely successful. It is still a frustrating entity for many patients and their physicians. We describe a patient who suffered from prolonged intractable symptoms of proctalgia fugax. The pain was completely relieved after administration of a single intravenous (IV) lidocaine infusion.
Case Report A 28-year-old man complained of anal pain that began 8 months before his first visit. The attacks lasted only a few minutes. It occasionally caused the
From the Department of Family Medicine, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel. Accepted for publication June 19, 2001. Reprint requests: Roni Peleg, M.D., Department of Family Medicine, Ben Gurion University of the Negev, PO Box 653, Beer-Sheva, 84105, Israel. E-mail: [email protected] © 2002 by the American Society of Regional Anesthesia and Pain Medicine. 1098-7339/02/2701-0109$35.00/0 doi:10.1053/rapm.2002.27839
patient to awaken at night. There were no changes in the defecation habits or weight. In the 2 months before his initial visit the attacks came more often, for short intervals every day, especially at night, and at a higher intensity, described on a visual analog scale (VAS) as 7 to 8/10. External observation and digital examination of the rectum was normal. No pathology was seen on rectoscopy, and the barium enema examination was normal. The working diagnosis was proctalgia fugax. During the 2 months following the patient’s initial clinic visit, 8 office visits were recorded for the same problem. The patient was treated with hot baths, antispasmodics such as spasmalgin (a combination of atropine 0.4 mg, papaverin HCl 80 mg, paracetamol 150 mg, codeine phosphate 10 mg) 3 times a day, and inhalations of salbutamol 0.5 mL (2.5 mg) with 2 mL saline initially, followed a few days later by 1 mL (5 mg) with 2 mL saline. No calcium antagonists were tried. Each treatment was prescribed separately and administered in intervals of a few days apart, though no improvement in his condition was noted. After 1 month of these treatment trials, and after 1 week of not receiving any treatment, the patient again complained of an increased intensity of the pain attacks. This time the patient was treated with an IV infusion of lidocaine (1 mg/kg) in saline solution as a single dose over a period of 30 minutes; no pain attacks occurred during the treatment. After this treatment the pain ceased completely.
Regional Anesthesia and Pain Medicine, Vol 27, No 1 (January–February), 2002: pp 97–99
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Follow-up at 3 weeks, 6 months, and 1 year showed no relapse of the pain attacks.
Discussion The term proctalgia fugax was coined by Thaysen in 1935,2 even though the characteristics of the phenomena were described many years before.3,4 Proctalgia fugax is characterized by sudden attacks of intense pain of short duration in the region of the internal anal sphincter and anorectal ring. This disorder is often a diagnostic enigma for physicians, because usually by the time the patient comes to the office for diagnosis and treatment the pain has subsided. Some of the patients suffer only a single attack. Pain attacks that follow may appear irregularly and at different intervals such as days, weeks, months, and even years.1 The lifetime prevalence of proctalgia fugax is 14%, with both men and women between the ages of 30 to 50 equally affected.5 The immediate cause of proctalgia fugax is not known, and the etiology of this syndrome remains unclear. Musculoneuropathic involvement was described as a possible diagnosis for this problem. A manometric and morphological study showed that in the resting state, patients with proctalgia fugax have normal anal function and morphology; however, they may exhibit a motor abnormality of the anal smooth muscle during attacks.6 Many types of therapy have been recommended for proctalgia fugax. These include the following1: immediate taking of food or drink, dilatation of the rectum, hot baths and firm pressure to the perineum, inhaled salbutamol, antispasmodics, local nitroglycerin, nifedipine, and carbamazepine. Diltiazem has been suggested as a prophylactic agent.7 In the present case, the IV infusion of lidocaine brought about complete relief from the pain. Lidocaine is an anti-arrhythmic and a sodium channel blocker. This drug acts as a membrane stabilizer and thus prevents ectopic and spontaneous electric activity in nerves. This treatment is effective for the relief of pain from a neuropathic source and is also effective in postherpetic neuralgia. The effect also occurs in low dosages and in a variety of types and mechanisms of pain. Baranowski et al.8 reported the results of IV lidocaine therapy in 24 patients who suffered from postherpetic neuralgia. The study included IV lidocaine infusions at doses of 1 mg/kg and 5 mg/kg over a 2-hour period, compared with an IV infusion of saline as placebo. The placebo had no effect on the pain compared with a positive effect after a brief IV infusion of lidocaine. The investigator concluded that the higher-dose infusion might produce plasma levels in the toxic range, with no significant clinical increase in response.
Another study9 reported the success of IV therapy for herpes zoster and postherpetic neuralgia with 0.1% or 0.2% procaine in saline, administered over 30 minutes, for up to 5 treatment sessions. No serious side effects were observed. Possible side effects of higher doses of IV lidocaine may include stimulation of the central nervous system that may lead to excitement, confusion, anxiety, and seizures. Preliminary studies showed antinociceptive effects of sodium channel blockers in experimental models leading to sensitization and increased responses of nociceptive afferents.10,11 However, it remained unclear if sodium channel blockers act primarily on the increased activity and excitability of sensitized nociceptors and/or on the responsiveness of nociceptive neurons in the cord. Recently it has been reported by Koppert et al.12 that IV sodium channel blockers modulate the peripheral as well as the central nervous system, which can involve block of terminal branches of nociceptors. Systemic lidocaine is believed to have its suppressive effects on spontaneous ectopic discharges of injured nerve without blocking normal nerve conduction.13 A single administration of the drug may produce complete elimination of the pain through a change in the nerve action potential setting.8 Because proctalgia fugax is a musculoneuropathic disturbance and anticonvulsants have been reported to be effective in the treatment of proctalgia fugax, we presumed that IV lidocaine might be beneficial in this case. A review of the medical literature showed no data on the effects of IV lidocaine on proctalgia fugax. In our case, the administration of lidocaine IV stopped the pain completely. Alternatively, it is possible that association between the use of lidocaine and the relieved pain in this case was incidental, involved a placebo effect, or was due to suggestion of the therapist, although that seems doubtful after 8 months of suffering. Based on the experience reported in this case and the potential benefit of this treatment for proctalgia fugax, controlled studies comparing IV lidocaine with placebo should be conducted to confirm our observation and to provide a more concrete basis for the use of IV lidocaine for this indication. This probably will require multicenter collaboration to recruit sufficient patients.
References 1. Wesselmann U, Burnett AL, Heinberg LJ. The urogenital and rectal pain syndromes. Pain 1997;73:269294. 2. Thaysen TEH. Proctalgia fugax. Lancet 1935;2:243-246.
Low-Dose Intravenous Lidocaine for Proctalgia Fugax 3. Hall M. Severe pain in the rectum and its remedy. Lancet 1841;838:854-855. 4. Myrtle AS. Some common affliction of the anus often neglected by medical men and patients. Br Med J 1883;1:61-62. 5. Thompson WG, Heaton KW. Proctalgia fugax. J R Coll Phys 1980;14:247-248. 6. Eckardt VF, Dodt O, Kanzler G, Bernhard G. Anorectal function and morphology in patients with sporadic proctalgia fugax. Dis Colon Rectum 1996;39:755762. 7. Boquet J, Moore N, Lhuintre JP, Boismare F. Diltiazem for proctalgia fugax. Lancet 1986;1:1493. 8. Baranowski AP, De Courcey J, Bonello E. A trial of intravenous lidocaine for the pain and allodyna of postherpetic neuralgia. J Pain Symptom Manage 1999; 17:429-433.
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9. Shanborn E. Treatment of herpetic pain and postherpetic neuralgia with intravenous procaine. JAMA 1961;176:1041-1043. 10. Abram SE, Yaksh TL. Systemic lidocaine blocks nerve injury-induced hyperalgesia and nociceptor-driven spinal sensitization in the rat. Anesthesiology 1994;80: 383-391. 11. Chaplan SR, Bach FW, Shafer SL, Yaksh TL. Prolonged alleviation of tactile allodynia by intravenous lidocaine in neuropathic rats. Anesthesiology 1995;83: 775-785. 12. Koppert W, Ostermeier N, Sittl R, Weidner C, Schmelz M. Low dose lidocaine reduces secondary hyperalgesia by a central mode of action. Pain 2000; 85:217-224. 13. Mao J, Chen LL. Systemic lidocaine for neuropathic pain relief. Pain 2000;87:7-17.
Description of the influence of intravenous lidocaine treatment for proctalgia fugax.
Case Report: A 28-year-old patient suffering of proctalgia fugax for 8 months. Conventional treatment efforts did not improve his condition. A single dose of an intravenous lidocaine infusion completely stopped his pain attacks. Conclusions: Based on the experience reported in this case and the potential benefit of this treatment for proctalgia fugax, controlled studies comparing intravenous lidocaine with placebo should be conducted to confirm the observation and to provide a more concrete basis for the use of intravenous lidocaine for this indication. Reg Anesth Pain Med 2002;27:97-99. Key Words:
Proctalgia fugax, Intravenous lidocaine.
P
roctalgia fugax is characterized by sudden internal anal sphincter and anorectal ring attacks of intense pain. The pain is typically unrelated to defecation, usually lasts for less than 20 minutes, appears spontaneously, and often awakens the patient from sleep. In extreme cases the pain can last for many hours, vanish, and then return again.1 Treating proctalgia fugax is difficult, and no single therapeutic approach is completely successful. It is still a frustrating entity for many patients and their physicians. We describe a patient who suffered from prolonged intractable symptoms of proctalgia fugax. The pain was completely relieved after administration of a single intravenous (IV) lidocaine infusion.
Case Report A 28-year-old man complained of anal pain that began 8 months before his first visit. The attacks lasted only a few minutes. It occasionally caused the
From the Department of Family Medicine, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel. Accepted for publication June 19, 2001. Reprint requests: Roni Peleg, M.D., Department of Family Medicine, Ben Gurion University of the Negev, PO Box 653, Beer-Sheva, 84105, Israel. E-mail: [email protected] © 2002 by the American Society of Regional Anesthesia and Pain Medicine. 1098-7339/02/2701-0109$35.00/0 doi:10.1053/rapm.2002.27839
patient to awaken at night. There were no changes in the defecation habits or weight. In the 2 months before his initial visit the attacks came more often, for short intervals every day, especially at night, and at a higher intensity, described on a visual analog scale (VAS) as 7 to 8/10. External observation and digital examination of the rectum was normal. No pathology was seen on rectoscopy, and the barium enema examination was normal. The working diagnosis was proctalgia fugax. During the 2 months following the patient’s initial clinic visit, 8 office visits were recorded for the same problem. The patient was treated with hot baths, antispasmodics such as spasmalgin (a combination of atropine 0.4 mg, papaverin HCl 80 mg, paracetamol 150 mg, codeine phosphate 10 mg) 3 times a day, and inhalations of salbutamol 0.5 mL (2.5 mg) with 2 mL saline initially, followed a few days later by 1 mL (5 mg) with 2 mL saline. No calcium antagonists were tried. Each treatment was prescribed separately and administered in intervals of a few days apart, though no improvement in his condition was noted. After 1 month of these treatment trials, and after 1 week of not receiving any treatment, the patient again complained of an increased intensity of the pain attacks. This time the patient was treated with an IV infusion of lidocaine (1 mg/kg) in saline solution as a single dose over a period of 30 minutes; no pain attacks occurred during the treatment. After this treatment the pain ceased completely.
Regional Anesthesia and Pain Medicine, Vol 27, No 1 (January–February), 2002: pp 97–99
97
98
Regional Anesthesia and Pain Medicine Vol. 27 No. 1 January–February 2002
Follow-up at 3 weeks, 6 months, and 1 year showed no relapse of the pain attacks.
Discussion The term proctalgia fugax was coined by Thaysen in 1935,2 even though the characteristics of the phenomena were described many years before.3,4 Proctalgia fugax is characterized by sudden attacks of intense pain of short duration in the region of the internal anal sphincter and anorectal ring. This disorder is often a diagnostic enigma for physicians, because usually by the time the patient comes to the office for diagnosis and treatment the pain has subsided. Some of the patients suffer only a single attack. Pain attacks that follow may appear irregularly and at different intervals such as days, weeks, months, and even years.1 The lifetime prevalence of proctalgia fugax is 14%, with both men and women between the ages of 30 to 50 equally affected.5 The immediate cause of proctalgia fugax is not known, and the etiology of this syndrome remains unclear. Musculoneuropathic involvement was described as a possible diagnosis for this problem. A manometric and morphological study showed that in the resting state, patients with proctalgia fugax have normal anal function and morphology; however, they may exhibit a motor abnormality of the anal smooth muscle during attacks.6 Many types of therapy have been recommended for proctalgia fugax. These include the following1: immediate taking of food or drink, dilatation of the rectum, hot baths and firm pressure to the perineum, inhaled salbutamol, antispasmodics, local nitroglycerin, nifedipine, and carbamazepine. Diltiazem has been suggested as a prophylactic agent.7 In the present case, the IV infusion of lidocaine brought about complete relief from the pain. Lidocaine is an anti-arrhythmic and a sodium channel blocker. This drug acts as a membrane stabilizer and thus prevents ectopic and spontaneous electric activity in nerves. This treatment is effective for the relief of pain from a neuropathic source and is also effective in postherpetic neuralgia. The effect also occurs in low dosages and in a variety of types and mechanisms of pain. Baranowski et al.8 reported the results of IV lidocaine therapy in 24 patients who suffered from postherpetic neuralgia. The study included IV lidocaine infusions at doses of 1 mg/kg and 5 mg/kg over a 2-hour period, compared with an IV infusion of saline as placebo. The placebo had no effect on the pain compared with a positive effect after a brief IV infusion of lidocaine. The investigator concluded that the higher-dose infusion might produce plasma levels in the toxic range, with no significant clinical increase in response.
Another study9 reported the success of IV therapy for herpes zoster and postherpetic neuralgia with 0.1% or 0.2% procaine in saline, administered over 30 minutes, for up to 5 treatment sessions. No serious side effects were observed. Possible side effects of higher doses of IV lidocaine may include stimulation of the central nervous system that may lead to excitement, confusion, anxiety, and seizures. Preliminary studies showed antinociceptive effects of sodium channel blockers in experimental models leading to sensitization and increased responses of nociceptive afferents.10,11 However, it remained unclear if sodium channel blockers act primarily on the increased activity and excitability of sensitized nociceptors and/or on the responsiveness of nociceptive neurons in the cord. Recently it has been reported by Koppert et al.12 that IV sodium channel blockers modulate the peripheral as well as the central nervous system, which can involve block of terminal branches of nociceptors. Systemic lidocaine is believed to have its suppressive effects on spontaneous ectopic discharges of injured nerve without blocking normal nerve conduction.13 A single administration of the drug may produce complete elimination of the pain through a change in the nerve action potential setting.8 Because proctalgia fugax is a musculoneuropathic disturbance and anticonvulsants have been reported to be effective in the treatment of proctalgia fugax, we presumed that IV lidocaine might be beneficial in this case. A review of the medical literature showed no data on the effects of IV lidocaine on proctalgia fugax. In our case, the administration of lidocaine IV stopped the pain completely. Alternatively, it is possible that association between the use of lidocaine and the relieved pain in this case was incidental, involved a placebo effect, or was due to suggestion of the therapist, although that seems doubtful after 8 months of suffering. Based on the experience reported in this case and the potential benefit of this treatment for proctalgia fugax, controlled studies comparing IV lidocaine with placebo should be conducted to confirm our observation and to provide a more concrete basis for the use of IV lidocaine for this indication. This probably will require multicenter collaboration to recruit sufficient patients.
References 1. Wesselmann U, Burnett AL, Heinberg LJ. The urogenital and rectal pain syndromes. Pain 1997;73:269294. 2. Thaysen TEH. Proctalgia fugax. Lancet 1935;2:243-246.
Low-Dose Intravenous Lidocaine for Proctalgia Fugax 3. Hall M. Severe pain in the rectum and its remedy. Lancet 1841;838:854-855. 4. Myrtle AS. Some common affliction of the anus often neglected by medical men and patients. Br Med J 1883;1:61-62. 5. Thompson WG, Heaton KW. Proctalgia fugax. J R Coll Phys 1980;14:247-248. 6. Eckardt VF, Dodt O, Kanzler G, Bernhard G. Anorectal function and morphology in patients with sporadic proctalgia fugax. Dis Colon Rectum 1996;39:755762. 7. Boquet J, Moore N, Lhuintre JP, Boismare F. Diltiazem for proctalgia fugax. Lancet 1986;1:1493. 8. Baranowski AP, De Courcey J, Bonello E. A trial of intravenous lidocaine for the pain and allodyna of postherpetic neuralgia. J Pain Symptom Manage 1999; 17:429-433.
•
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9. Shanborn E. Treatment of herpetic pain and postherpetic neuralgia with intravenous procaine. JAMA 1961;176:1041-1043. 10. Abram SE, Yaksh TL. Systemic lidocaine blocks nerve injury-induced hyperalgesia and nociceptor-driven spinal sensitization in the rat. Anesthesiology 1994;80: 383-391. 11. Chaplan SR, Bach FW, Shafer SL, Yaksh TL. Prolonged alleviation of tactile allodynia by intravenous lidocaine in neuropathic rats. Anesthesiology 1995;83: 775-785. 12. Koppert W, Ostermeier N, Sittl R, Weidner C, Schmelz M. Low dose lidocaine reduces secondary hyperalgesia by a central mode of action. Pain 2000; 85:217-224. 13. Mao J, Chen LL. Systemic lidocaine for neuropathic pain relief. Pain 2000;87:7-17.