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    Rome IV Diagnostic Criteria for Functional Anorectal Pain

    Official Rome IV criteria for the diagnosis of levator ani syndrome or unspecified functional anorectal pain.

    INSTRUCTIONS

    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:

    • Levator Ani Syndrome: tenderness on palpation of pelvic floor or vagina.

      • Pain during posterior traction of puborectalis.

      • Pain often asymmetric, more often on left side (but not universally).

      • Posterior massage may elicit characteristic discomfort.

    • Unspecified Functional Anorectal Pain:

      • NO pain during posterior traction of puborectalis.

    Do NOT use in patients with:

    • Anorectal or pelvic floor structural pathology explaining symptoms.

    When to Use
    Pearls/Pitfalls
    Why Use

    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 with tenderness on posterior traction of rectum is central to diagnosis of Levator Ani Syndrome.

    • Obtain C-reactive protein, white blood count and check temperature if infection or inflammatory bowel disease is suspected. 

    • In men, perform prostate exam and consider chronic prostatitis.

    • In women, prudent to perform a pelvic exam to rule out other pelvic pain disorders.

    • Structural evaluation such as sigmoidoscopy or colonoscopy with close anorectal inspection must occur prior to diagnosis as management for structural causes such as anal fissures or peri-anal Crohn’s disease greatly differs.

    • Ancillary imaging studies can include pelvic computed tomography (CT) or magnetic resonance imaging (MRI) and/or anal ultrasound.

    • Other conditions synonymous with Levator Ani Syndrome: levator spasm, puborectalis syndrome, piriformis syndrome, pelvic tension myalgia.

    • Anorectal manometry may reveal an increased tone of the anal sphincter because of contracted pelvic floor muscles. In the vast majority, dyssynergic defecation without constipation may be found. Reversal with biofeedback is a strong predictor of successful treatment outcome.

    • Coccydynia is a different condition with pain in the tailbone on sitting and leaning back and pain with rising or prolonged standing. 

    • Pain can occur during defecation or sexual intercourse. 

    • Digital rectal exam yields tenderness to palpation of the coccyx but adjacent structures are non-tender.

    • Management differs from Levator Ani Syndrome, unspecified functional anorectal pain, and Proctalgia Fugax.

    • Often under-reported symptom requiring adept clinical history taking and focused exam including careful digital rectal exam.

    • While under-reported, can negatively affect quality of life and lead to school and work absenteeism.

    Levator ani syndrome
    Must have the following:

    For 3 months prior with symptom onset ≥6 months ago

    Unspecified functional anorectal pain
    Must have the following:

    Diagnostic Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights
    Dr. Douglas Drossman

    About the Creator

    Douglas Drossman, MD, is professor emeritus of medicine and psychiatry at the University of North Carolina School of Medicine. He is founder, President Emeritus and Chief of Operations of the Rome Foundation. He is also the founder of the Drossman Center for the Education and Practice of Biopsychosocial Care and Drossman Consulting, LLC. Dr. Drossman has written over 500 articles and book chapters, has published two books, a GI procedure manual and a textbook of functional GI disorders (Rome I-IV), and serves on six editorial and advisory boards.

    To view Dr. Douglas Drossman's publications, visit PubMed

    Dr. Lin Chang

    About the Creator

    Lin Chang, MD is responsible for the oversight and coordination of the Rome IV calculators on MDCalc. She is a Professor of Medicine at the Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA and is a member of the Rome Foundation Board of Directors.

    To view Dr. Lin Chang's publications, visit PubMed

    The Rome Foundation

    About the Creator

    The Rome Foundation is an independent not for profit 501(c) 3 organization that provides support for activities designed to create scientific data and educational information to assist in the diagnosis and treatment of Disorders of Gut-Brain Interaction (DGBI), also known as functional gastrointestinal (GI) disorders. Their mission is to improve the lives of people with DGBI. Over the last 3 decades, the Rome organization has sought to legitimize and update our knowledge of the DGBIs. This has been accomplished by bringing together scientists and clinicians from around the world to classify and critically appraise the science of GI function and dysfunction. This knowledge permits clinical scientists to make recommendations for diagnosis and treatment that can be applied in research and clinical practice. Diagnosis is based on the use of symptom-based criteria which are used in clinical trials and daily practice. The list of Rome IV categories and the Chair and Co-Chair of each chapter committee are listed below.

    Committees Chair Co-Chair
    Esophageal Disorders Ronnie Fass, MD John Pandolfino, MD
    Gastroduodenal Disorders Nicholas J. Talley, MD, PhD, FRACP Vincenzo Stanghellini, MD
    Bowel Disorders Fermin Mearin, MD Brian Lacy, MD, PhD
    Gallbladder and Sphincter of Oddi Disorders Grace Elta, MD Peter Cotton, MD
    Centrally Mediated Disorders of Gastrointestinal Pain Peter J. Whorwell, MD Laurie Keefer, PhD
    Anorectal Disorders Adil E. Bharucha, MD, MBBS Satish S. C. Rao, MD, PhD, FRCP
    Childhood Functional Gastrointestinal Disorders: Neonate/Toddler Sam Nurko, MD Marc A. Benninga, MD
    Childhood Functional Gastrointestinal Disorders: Child/Adolescent Carlo Di Lorenzo, MD Jeffrey S. Hyams, MD

    Rome IV Diagnostic Criteria Chapters, Chairs and Co-Chairs

    Rome IV Editorial Board: Douglas A. Drossman, MD, Senior Editor, Lin Chang, MD, William D. Chey, MD, John Kellow, MD, Jan Tack, MD, PhD, and William E. Whitehead, PhD.

    To view The Rome Foundation's publications, visit PubMed

    Content Contributors
    • Justin Brandler, MD
    Reviewed By
    • Max J. Schmulson W., MD
    About the Creator
    Dr. Douglas Drossman
    Dr. Lin Chang
    The Rome Foundation
    Content Contributors
    • Justin Brandler, MD
    Reviewed By
    • Max J. Schmulson W., MD