Posted 6/13/2014 5:37 AM (GMT -6)
I've suffered from this for years. I've changed my life in every way to try to be rid of it, and for the last couple of years things haven't been as bad. I'll get to the changes I made later on. Last night I got it again and, as is normal for me the day after an episode, today I went crazy with google trying to isolate a potential cause. I tentatively put forth the following in the hopes it might help others out there who suffer from this.
This will be a long read, sorry. I'm not a medical doctor, so please verify what I say with your own research - I could be wrong. I'll try to keep it in a logical sequence, but some of the information is interdependant, and might prove difficult to deliver in series. I'll give the relevant background info, then put forward my hypothesis.
I've got a LOT of notes and references for the following information, and if anyone wants more I can post links and whatnot. I was tempted to produce a detailed report, but it would be an oppressive read and far too long for a forum post. I'll keep this as short as seems reasonable, so go easy on me if I oversimplify and say things a little less than accurately.
Cramps (the proposed cause of proctalgia fugax pain)
Can be caused by a few things, but given the oft-cited correlation of people's episodes of proctalgia fugax with dehydration, I stuck with the obvious cause in my searching: electrolyte imbalance.
Are salts. The body needs them to convey electrical impulses through both neurons and cells (such as muscles).
Electrolyte levels are regulated mainly by: altering blood ratios of water to electrolyte; altering the permeability of cell membranes; regulating fluid intake through thirst and salt cravings etc.
Most electrolytic regulatory processes are controlled by hormones, though some are regulated by pressure sensitive areas in aortic regions and such. Many of these hormones are excreted by elements of the HPA axis (the hypothalamus-pituitary-adrenal axis).
The water to electrolyte ratio is maintained partially by an anti-diuretic hormone (ADH, or vassopressin) excreted by the hypothalamus. This hormone controls the amount of water passed in urine by influencing the insertion of sodium-channels that allow water to pass through kidney cell membranes. WIthout ADH (anti-diuretic hormone) little water permeates the cell and is instead passed through urine.
Anything that stimulates ADH excretion also stimulates thirst. Sensors in the hypothalamus (a region of the brain) are receptive to blood plasma levels and regulate the excretion of ADH. Other sensors, in the aorta and carrotoid areteries, sense bloodflow and regulate ADH levels that way.
That's how the body maintains its overall fluid levels. It can also regulate the water to electrolyte balance by altering electrolye levels.This is rarely a process independant of overall fluid level alterations, since they are interrelated.
The adrenal cortex (a part of the adrenal gland located above the kidney) directy senses plasma concentration. WHen concentrations are above normal, aldosterone (an adrenal hormone) release is inhibited. This reduces sodium (an electrolyte) absorption. At the same time ADH secretion will increase to save water, supplementing the effects of the aldosterone inhibition.
Hormones excreted by the adrenal glands play a diverse role in the maintenance the body. Adrenal excretion levels shift according to many variables, such as time of day, food intake, stress levels, levels of other hormones, posture, and supplies of chemicals from which cortisol may be manufactured.
Notice how many of these correspond to the most often cited correlates with episodes of proctalgia fugax? Most, but not all, episodes occur in the middle of the night, corresponding to the times when the excretion of adrenal hormones is the lowest. People often cite changes in diet as a means of avoiding episodes. Stress is often cited as a correlate to the onset of an episode. Posture may also play a role, for reasons I will relate later.
You may be wondering what adrenal hormones have to do with our condition. I'm finally coming to that. One of the main hormones of the adrenals is cortisol. Levels of this hormone are elevated mostly by: stress, which includes the stress of hunger (ie, missing a meal), pain, not eating enough protien, assuming a slouched posture (as one might if they sit at a computer all day or in front of a tv), staying awake after 10pm.
Long term elevated levels of cortisol cause the adrenals to exhaust their supply, and the body starts to cannibalize 'parent hormones' like DHEA (dehdroepiandrosterone) and pregnenolone in order to make more. This leaves the body short of parent hormones with which to manufacture other neccesary hormones, like aldosterone and ADH. Getting the picture? If not, I'll help: the body's supply of the hormones needed to regulate electrolyte levels is impaired, and lack of electrolytes can lead to cramps like those in proctalgia fugax.
Moreover,increased plasma levels of cortisol lead to increases in catecholamines (adrenal hormones - norepinephrine and adrenaline), which are dehydrating, and in turn lead to more cortisol release in a feedback loop (though not one that can't be easily broken).
Interestingly, I've noticed that a few people have said that there is a correlation between an episode and recent sexual activity. This has been my experience also. In males (I never looked into females, sorry) an orgasm causes dopamine to be metabolised into catecholamines (adrenaline and norepinephrine), leading to changes in electrolyte balance ie. dehydration.
If your hormone levels are normal this won't have a marked effect, but if you've depleted your hormone levels the means of regulation will be impaired, and symptoms like cramps may occur.
Getting to the point (at last)
Most of the things that correlate with the onset of an episode have some effect on proper hydration. Things I've heard people say affect their symptoms:
Water intake - its obvious how this relates to dehydration
Salt intake - low levels of electrolytes can occur even when drinking enough fluids, and especially when drinking too much
Alcohol - scientists don't know why, but drinking alcohol causes you to urinate more fluids than you actually put in with the alcohol, leading to dehydration
Exercise - sweating and losing salts, causing, you guessed it, dehydration
Stress - leads to reduced hormone levels for the regulation of electrolyte ratios and dehydration
Orgasm (in men) - leads to large depletion of dopamine, which is converted into adrenal hormones that increase the excretion of cortisol and lead to depletion of electrolyte balancing hormones. This would not normally affect a person with normal hormonal balances, only those whose hormones are already out
Nutrition - without proper nutrition our hormonal balance becomes awry and electrolyte regulatory hormones may not be present in sufficient proportions to keep the balance
Dehydration leads to cramps, and that's what proctalgia fugax is all about.
For myself, I definitely notice a correlation between episodes and fluid intake, as well as orgasm frequency, exercise, stress and nutrition. If I stick to my routine, eating well and drinking plenty, especially when I exercise, avoiding stress and getting to bed early, I don't get symptoms at all. It's only when I lapse that I suffer. If I feel the onset of symptoms and hydrate hard and fast the pain doesn't get anywhere near as bad or last as long.
Also, it is key to get your hormone levels in balance. There are heaps of things that help with this, but the main ones are the things our mothers told us we should do from the start: eat properly, get to bed early (by ten pm - levels of adrenal hormones are, in part, restored by sleep/wake cycles), always eat breakfast and don't skip meals (adrenal hormone levels are increased during times of food abstinacy, such as when we sleep), keep good posture (bad posture encourages the excretion of adrenal hormones because they are the 'flight or fight' hormones, and a slouched posture is thought to be one of readiness for these reactions), and don't stress.
I've banged on long enough already, but if anyone is interested I could say a fair bit more on this.
I'll close by addressing a hole in this theory: why is the cramping localized to the muscles of the levator ani? If general dehydration is the problem, why don't the cramps occur in random locations or diffusely? I don't know. Perhaps dehydration affects nerves in a specific order, and the ones (there are more than one) innervating the levator ani muscles are among the first affected? I tried to find information pertaining to that, but there doesn't seem to be any.