Proctalgia Fugax: An Emerging Anorectal Disorder in Children and Adolescents

1. Introduction

Disorders of Gut-Brain interaction (DGBIs) comprise a group of digestive conditions characterized by symptoms related to the interaction between the gastrointestinal tract and the central nervous system, in the absence of a structural or biochemical abnormality that fully explains the clinical picture [1]. The Rome Criteria constitute the main diagnostic framework for these disorders and are updated periodically, approximately every 10 years [1]. In 2026, the fifth edition of the Rome Criteria (Rome V) introduced relevant modifications for the pediatric population, including new diagnoses and the reorganization of DGBIs according to their clinical characteristics [2,3]. Among these changes is the recognition of proctalgia fugax (PF) as a new anorectal disorder in children and adolescents. It is defined as intermittent pain localized to the anorectal region, present for at least 2 months, with asymptomatic periods, unrelated to defecation, generally lasting from a few seconds to several minutes, and not fully explained by another medical condition after appropriate evaluation [3].

PF has traditionally been recognized among DGBIs in adults, with a prevalence of 5.6% (range, 5.4%–5.8%) in internet surveys and 1.5% (range, 1.4%–1.7%) in household surveys [4]. In pediatrics, however, evidence on its occurrence is scarce [5,6], with reported prevalences ranging from 1.8 to 2.8% [7,8]. These findings are particularly relevant given the recent inclusion of PF in the pediatric Rome V Criteria [3].

In this context, the present study aimed to determine the prevalence of PF according to the Rome IV Criteria for adults modified for the pediatric population, in schoolchildren and adolescents aged 10 to 18 years old attending a Public School in Cali, Colombia.

2. Materials and Methods

A cross-sectional, observational, descriptive study was conducted in 199 schoolchildren and adolescents aged 10 to 18 years old, enrolled in grades 6 through 11 at a Public School in Cali, Colombia.

The study was authorized by the school administration and approved by the Ethics Committee of the Hospital Universitario Erasmo Meoz (Code: 51-2024; approved on 7 July 2024). Prior to participation, informed consent was obtained from parents or legal guardians, and assent was obtained from the schoolchildren and adolescents. Participation was voluntary, and the confidentiality of the collected information was guaranteed.

Anthropometric assessment included measurement of weight and height using standardized procedures. Nutritional status was characterized based on Body Mass Index (BMI) and Height-for-Age (HFA) according to the World Health Organization [9].

Previously validated questionnaires were administered to identify DGBIs (Questionnaire for Pediatric Gastrointestinal Symptoms–Rome IV, QPGS-IV) [10], quality of life (Pediatric Quality of Life Inventory, PedsQL) [11,12,13], anxiety and depression (PROMIS-Anxiety and PROMIS-Depression) [14].

For this study, PF was defined according to the Rome IV Criteria for adults modified for pediatrics, whose internal consistency, assessed by Cronbach’s alpha coefficient, was high (α=0.8061) [8], as follows: recurrent, intense, short-lasting rectal pain (seconds to minutes), unrelated to bowel movements, with no anorectal pain between episodes and no structural or inflammatory anorectal cause, during the past 2 months, with symptom onset at least 6 months before diagnosis.

For the statistical analysis, measures of central tendency and dispersion were used, along with the chi-square test or Fisher’s exact test, with p<0.05 considered statistically significant. The prevalence of any DGBI, defecation-related DGBIs, and PF was calculated as the proportion of participants who met the diagnostic criteria out of the total number of schoolchildren and adolescents evaluated, expressed as a percentage.

3. Results

3.1. General Characteristics

A total of 199 schoolchildren and adolescents aged 10 to 18 years old were included (mean age 14.3 ± 2.0 years old; 53.8% male; 39.7% mixed race). More than 66.3% had a normal nutritional status according to BMI or HFA. Separated or divorced parents were reported by 65.8%. School absenteeism was present in 43.2%, mainly due to headache (25.6%), and social absenteeism in 34.2%, mainly due to not going out with friends or not practicing sports (32.4%, respectively) (Table 1). The six schoolchildren and adolescents with PF were aged between 11 and 17 years old (mean age 14.3 ± 2.6 years; four were male adolescents, and three were mixed race and three white, respectively), and more than 66.7% had a normal nutritional status according to BMI or HFA. Half of them reported separated or divorced parents; three had school absenteeism, mainly due to abdominal pain, and three had social absenteeism, mainly due to not engaging in other activities (Table 1).

3.1.1. Prevalence of Disorders of Gut-Brain Interaction

Regarding DGBIs, 56 of the 199 schoolchildren (28.1%) had at least one disorder (Table 2). Defecation disorders were the most frequent, identified in 33 participants (16.6%), all corresponding to functional constipation. Abdominal pain disorders were present in 21 participants (10.6%); within this group, the most frequent diagnoses were functional dyspepsia (9.0%) and functional abdominal pain–not otherwise specified (1.5%). Nausea and vomiting disorders were identified in 2 participants (1.0%): adolescent rumination syndrome (0.5%) and functional vomiting (0.5%) (Table 2).

4. Discussion

In this study of 199 schoolchildren and adolescents aged 10 to 18 years old, the prevalence of any DGBI was 28.1%, defecation-related DGBIs was 16.6% and of PF was 3.0%, with anxiety identified as a significant finding. These results show that PF is an anorectal disorder present in the pediatric population, underscore the importance of assessing psychological distress in these children, and are particularly relevant given its recent incorporation as a diagnostic entity among the DGBIs in the Pediatric Rome V Classification [3].

The prevalence of any DGBI and of any defecation-related DGBIs in the present study is consistent with that reported worldwide according to the Rome IV Criteria, as described in the systematic review by Vernon-Roberts, et al. [15]

Historically, in adults, PF went unnoticed by both physicians and patients [16]. It was identified as a severe paroxysmal rectal pain (rectal crisis) not associated with tabes dorsalis (a late complication of neurovascular syphilis) [17], and it drew little medical attention despite being disabling [18]. Since 1990 and to this day, it has been considered by the Rome Foundation as part of the DGBIs [1]. In pediatrics, it has been described only since May 2026 in the current Rome V Criteria [3].

Literature reporting the prevalence of PF in children is scarce, and in most studies it is described through case reports, as reported by Pounders [5] in a female infant under 7 months of age with an allergic history, by Weizman, et al. [6] in three adolescents aged 12 to 15 years old, and by Sonneveld, et al. [19] in two children with anorectal pain. Our prevalence of 3.0% is higher than that reported by Sohrabi, et al. [7] and similar to that described by González, et al. [8]. Sohrabi, et al. [7] conducted a population-based study to assess the prevalence of digestive symptoms in adolescents aged 14 to 19 years old and their relationship with sex, age, and socioeconomic status, using a multistage random sample of middle and high school students and the QPGS-II to identify the frequency of the different DGBIs and their sociodemographic variables. They found a prevalence of at least one digestive symptom of 32.4% and of PF of 1.8%, with PF being more frequent in girls, a finding that differs from ours, in which PF was more frequent in males, although without significant differences. González, et al. [8] determined the prevalence of some adult DGBIs that may occur in pediatrics, and their possible associations, through an observational, prospective, cross-sectional study in preschoolers, schoolchildren, and adolescents aged 4 to 18 years old, using the QPGS-IV adapted for pediatrics. They reported a prevalence of any DGBI of 5.8%, with PF being the most frequent at 2.8% (95% CI, 1.0–4.0%). The main characteristics of the 20 children with PF were school absenteeism due to abdominal pain, social absenteeism from family and friends, impaired quality of life, and mild to moderate anxiety and depression. These data support the possibility that this entity is not a DGBI exclusive to adults, may be clinically relevant in the pediatric age group, and should be included as a cause of anorectal pain in the current Rome V Criteria [3]. Nurko, et al. [20], in the only publication to date describing the prevalence of DGBI according to the Rome V Criteria in pediatrics, did not consider this diagnosis in children under 18 years of age from Mexico, the United States, Italy, and China.

We found no significant differences in demographic variables, unlike what has been described in previous studies [21], socioemotional variables [22] or clinical variables [23], nor in some socioaffective variables, such as school absenteeism [8], social absenteeism [8], quality of life [24], or depression [25]. However, the main statistically significant finding in our study was that children with PF had higher anxiety than children without DGBIs. These findings are consistent with those described by other authors in children with any DGBI [24,25]. Santucci, et al. [26] evaluated psychological distress in schoolchildren and adolescents aged 8 to 18 years with and without DGBIs according to the Rome III Criteria, using the State-Trait Anxiety Inventory for Children (STAIC), and found higher levels of trait anxiety in children with DGBIs, mainly those associated with abdominal pain, compared with their healthy peers. Chen, et al. [25] assessed the prevalence of anxiety in schoolchildren and adolescents aged 6 to 18 years old diagnosed with DGBIs according to the Rome IV Criteria, using the Screen for Child Anxiety Related Emotional Disorders (SCARED), and examined its association with abdominal pain in a mixed-methods design combining cross-sectional surveys with longitudinal follow-up. They concluded that DGBIs are strongly associated with elevated rates of anxiety, with abdominal pain being a determining symptomatic factor. These data support the interaction between functional digestive symptoms and the emotional component, and underscore the importance of considering it within the comprehensive evaluation of pediatric patients with DGBI.

Among the limitations of the present study, these results should be considered exploratory because of the small number of cases and the limited sample size. Among its strengths, the use of validated questionnaires with adequate internal consistency stands out. Taken together, these results support the need for further research on PF in the pediatric population, particularly through studies with larger samples and longitudinal designs that allow a more precise determination of its frequency, associated factors, clinical course, and impact on quality of life. Moreover, as the adult Rome V Criteria already recognize PF as an anorectal disorder [27], future studies should clarify its continuity from childhood to adulthood.

5. Conclusions

In conclusion, the prevalence of PF in the schoolchildren and adolescents studied was 3.0%, which indicates the presence of this DGBI in the pediatric population, with anxiety being an important psychological factor to consider. These findings support the importance of recognizing PF as an entity that can occur during childhood and adolescence and highlight the need for larger pediatric studies to establish its true prevalence, clinical characteristics, associated factors, and impact on quality of life.