ABSTRACT Introduction: proctalgia fugax (PF) is a benign, self-limiting disease characterized by episodes of intense anorectal pain at fre- quent intervals in the absence of organic proctological disease. Even though PF was described more than a century ago, its etiolo- gy remains unclear. Currently there is no information available. Few papers quoting many ways of management have been pub- lished. The aim of this study was to investigate patients complain- ing of this condition and to treat them with sequential therapy. Patients and methods: we devised a descriptive, prospec- tive study of patients complaining of acute perianal pain –duration less than 30 minutes– without organic disease or previous peri- anal surgery since 1996 to 2002 in our Department. We treated these patients using a three-step treatment (1: information, hip bath, benzodiazepines; 2: sublingual nifedipine 10 mg, or topic 0.1% nitroglycerin on demand; 3: internal anal sphincterotomy if hypertrophy of the internal anal sphincter was demonstrated by anal ultrasonography and no improvement was confirmed with the previous steps of treatment). We defined remarkable improve- ment as a decrease in the number of episodes by half or in pain intensity by 50%. Results: Fifteen patients with an average follow-up of 4 years. Anal endosonography confirmed a grossly thickened internal anal sphincter (IAS) in 5 cases. After the first step of treatment 7 pa- tients improved and 1 patient was cured; after the second step of treatment 3 patients improved and 1 was cured; the third step was applied to 3 patients with a thickened IAS; 1 patient im- proved and 1 patient was cured. Conclusion: a total resolution of PF is not always possible, but we may improve symptoms and their frequency. Almost 50% of patients in our series improved with the first step of treatment; 30% of our patients had IAS hypertrophy. Anal endosonography can help in the diagnosis of organic diseases or IAS hypertrophy, for which we can perform an internal anal sphyncter myectomy. Key words: Anal pain. Proctalgia fugax. Sphincter hypertrophy. Sphincterotomy. Gracia Solanas JA, Ramírez Rodríguez JM, Elía Guedea M, Aguilella Diago V, Martínez Díez M. Sequential treatment for proctalgia fugax. Mid-term follow-up. Rev Esp Enferm Dig 2005; 97: 491-496. INTRODUCTION Anorectal and perineal pain has been described in as- sociation with different pathologies that are usually easy to recognize, including hemorrhoids, fistula, fissures, pe- rianal sepsis and carcinomas. But perianal pain can also be present in some cases where an organic cause cannot be found, and its pathophysiology remains uncertain. Proctalgia fugax had been traditionally included amongst other functional disorders that produce anorectal and per- ineal pain without recognizable organic disease, includ- ing coccygodynia, levator ani syndrome, vulvodynia, and perineal neuralgia. Although proctalgia fugax was de- scribed more than a century ago, its etiology is still un- clear. Proctalgia fugax is a benign, self-limited disease characterized by episodes of deep recurrent anorectal pain. Even though nearly 14% of the population may suf- fer from proctalgia fugax, most patients do not seek med- ical advice (1). The diagnosis is based upon its particular clinical pattern and the lack of organic disorders explain- ing anorectal pain. Many therapies have been used in the management of such cases, often in an empirical way. There are in fact few papers on proctalgia fugax in the literature, most of them focusing on the study of a partic- ular treatment usually in a short series of patients. Sequential treatment for proctalgia fugax. Mid-term follow-up J. A. Gracia Solanas, J. M. Ramírez Rodríguez, M. Elía Guedea, V. Aguilella Diago and M. Martínez Díez Unit of Coloproctology. Department of Surgery “B”. Hospital Clínico Universitario. Zaragoza, Spain 1130-0108/2005/97/7/491-496 REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS Copyright © 2005 ARÁN EDICIONES, S. L. REV ESP ENFERM DIG (Madrid) Vol. 97. N.° 7, pp. 491-496, 2005 Recibido: 29-11-04. Aceptado: 15-02-05. Correspondencia: José Antonio Gracia Solanas. C/ Miguel Servet, 43, 6º 1ª, esc. izda. 50013 Zaragoza. e-mail: josegraciasolanas@hotmail.com