Rectal Pain

Picture of Patient with Hemorrhoids

• Four common causes of the symptom of rectal pain, pressure, or discomfort are
  • hemorrhoids,
  • anal fissures,
  • fleeting anal spasms (Proctalgia fugax), and
  • other more constant muscle spasms (Levator ani syndrome)
• Many other infrequent causes of rectal pain are cancers, some prostate problems and/ or foreign bodies.
• Rectal pain usually varies according to its underlying cause; for example, hemorrhoids usually cause mild or moderate discomfort, while anal fissures can cause a tearing or knife-like sharp pain.
• If you experience rectal pain without bleeding, contact your health-care professional, however, go to an Emergency Department if you are
  • bleeding from the rectum,
  • have increasing severity of pain and/or the pain is spreading, or
  • have a foreign object stuck in the rectum (for example, a vibrator).
• For most people, the diagnosis of the cause of rectal bleeding is made a doctor by taking the patient's history and performing a physical exam that includes a rectal exam. Occasionally, X-rays and other studies may be ordered to determine infrequent underlying causes.
• Once the cause of rectal pain is diagnosed there are home remedies to reduce rectal pain for three of the four most common rectal pain causes.
  1. Sit in a tub of warm water for about 20 minutes.
  2. Eat a high fiber diet.
  3. OTC creams and anti-inflammatory medications may help.
• Fleeting anal spasms lasts for very short periods of time so that no treatment is available to stop an attack; however, for other sources of rectal pain the following may help:
  • muscle relaxers,
  • asthma medication,
  • anti-hypertensive (high blood pressure) medications, and
  • botulinum toxin (Botox) may help.
• The prognosis for rectal pain depends upon the cause.

Hemorrhoids are a common cause of rectal pain.

Many conditions can cause rectal pain. Most of these are not serious.

4 Common causes of rectal pain include:

• Hemorrhoids: Hemorrhoids (painful swelling of a vein or veins at the anus) are a common problem affecting up to 25% of American adults. They are usually caused by straining during bowel movements. Heavy lifting and childbirth are also common causes. They can cause discomfort when sitting down (pressure on the hemorrhoids).
• Anal fissure: An anal fissure is a small tear in the skin at the opening of the rectum. It is caused when a large, hard stool is passed, with excessive stretching of the anus. This problem can also occur in people whose anal sphincter tone (the muscle that controls the anal opening) is too tight and cannot relax to pass the stool. This can cause pain both before and after a bowel movement.
• Fleeting anal spasms (Proctalgia fugax): Proctalgia fugax is a condition associated with fleeting rectal pain and occurs in 8% of Americans. This disorder occurs more commonly in women and in people younger than 45 years of age. Although the exact cause of the pain is not known, many doctors believe spasm of the anal sphincter muscle is the responsible factor.
• Levator ani syndrome: Levator ani syndrome affects 6% of the US population and occurs in women slightly more often than in men. The term levator ani refers to a group of muscles that surround and support the anus. Spasm of these muscles is believed to cause rectal pain.

The above are the primary causes of rectal discomfort but there are other causes. The intent of this article is to emphasize the above causes but the article will mention a few fairly common problems that may produce rectal pain; however, this list is not all-inclusive. Less frequent or secondary causes of rectal pain (discomfort, pressure) may include:

• cancer (colorectal cancer);
• infection, including anorectal abscesses (proctitis, rectal inflammation) prostate problems (prostatitis) may produce pressure, pain, or throbbing sensations in the rectum;
• inflammatory bowel diseases, such as ulcerative colitis and Crohn's disease;
• foreign bodies in the rectum or rectal prolapse; and
• tailbone pain (coccydynia or pain around the coccyx).

• Most hemorrhoids only cause a mild discomfort, but the pain can become severe if the hemorrhoids become thrombosed. This occurs when the blood in the hemorrhoid clots. There is an excruciating throbbing or stabbing pain that begins suddenly and can last for several days.
• An anal fissure causes a tearing or knifelike pain when it first occurs and turns into a dull ache that can last for hours. The tearing of the skin may also cause a small amount of bleeding. Each bowel movement irritates the injured skin producing sharp pain. The pain can be so intense that most people try to delay or not have a bowel movement, which only causes formation of harder stools and more pain when stool is passed.
• The pain of proctalgia fugax is sudden and intense, usually lasting less than a minute. But in rare cases, the spasm can continue for an hour. The pain is described as a sharp, stabbing, or cramp-like occurring at the anal opening. The pain can awaken the person from a sound sleep. The attacks occur in clusters, appearing daily for a while then disappearing for weeks or months.
• The pain of levator ani syndrome is a constant or frequently occurring dull pain that is felt higher up inside the rectal passage. The sensation is made worse by sitting and improves with walking or standing. The pain usually lasts approximately 20 minutes and tends to reoccur at regular intervals.
• Colorectal pain may be a sign of colorectal cancer
• Rectal pain, pressure or throbbing pain may occur with other primary problems like prostate problems, infections or other diseases.

Contact your doctor if home therapies are not helpful.

• You should call immediately if you think you may have a thrombosed hemorrhoid because early treatment is the key to pain relief.
• Also call your doctor if you are having any bleeding. Sometimes rectal bleeding can be a sign of a more serious problem such as colon cancer.

It is unlikely that rectal pain would require a visit to a hospital's emergency department. You may want to contact your doctor first before going to the hospital. A more urgent evaluation in the emergency department might be required if the following conditions develop:

• Rectal pain becomes more severe, especially if associated with fevers and infectious discharge from the rectum.
• Pain is no longer confined to the rectum but spreads to the abdomen.
• You notice an increasing amount of rectal bleeding or a large amount of bleeding in one episode.
• You think you have a foreign body in your rectum or suspect rectal prolapse as the cause of pain.

Although many patients with uncomplicated rectal pain can be treated by their primary physician, the following specialists may need to become members of a team to treat some patients who have more severe symptoms or complicating underlying causes of rectal pain. The specialists may include the following:

• Gastroenterologists
• Urologists
• Oncologists
• Infectious disease specialists
• Rectal surgeons

Your doctor may use several techniques to diagnose your rectal pain's cause.

• The doctor can make the diagnosis of a thrombosed hemorrhoid by doing a visual exam of the patient's rectum.
• The diagnosis of anal fissure is usually made by a visual exam.
• The diagnosis of proctalgia fugax is made by history. The doctor may do a rectal exam on the patient to rule out other causes of the pain.
• A digital rectal exam is needed to make the diagnosis of levator ani syndrome. During the exam, the doctor can feel the levator ani muscles. The muscles may feel tight, and touching them can reproduce the pain.

A warm sitz bath can help relieve rectal pain.

• Hemorrhoids: The following treatments can help lessen the discomfort of a painful hemorrhoid.
  • Sit in a tub of very warm water (not hot enough to scald) for 20 minutes several times a day.
  • Apply over-the-counter hemorrhoid creams, especially those containing hydrocortisone. If the person has diabetes, check with your health care practitioner as some hemorrhoid creams interact with some diabetes medications.
  • Take stool softeners and extra fiber to lessen pain with bowel movements.
• Anal fissures: These home treatments will promote healing of anal fissures.
  • Sit in a tub of hot water for 20 minutes, three times a day, to reduce pain and help healing.
  • Eat a high-fiber diet and use stool softeners to make bowel movements less painful.
  • Apply hydrocortisone cream to decrease pain.
• Proctalgia fugax: Because the pain lasts briefly, there is no treatment that will stop an attack of proctalgia fugax.
• Levator ani syndrome: The patient can help stop an attack of levator ani syndrome with the following techniques.
  • Sit in a tub of hot water.
  • Massage the levator ani muscles to relieve the muscle spasm.
  • Take over-the-counter, anti-inflammatory medications such as ibuprofen or naproxen.

For specific home and medical treatments for underlying causes such as prostate problems or colon cancers, the reader should consider reviewing those problems as this article is mainly about rectal sources of rectal pain.

• Because proctalgia fugax attacks last for such a brief period, no treatment acts fast enough to stop an attack. Albuterol (Salbutamol), an inhaler used in asthma, may help in cases with more frequent or prolonged attacks. Other treatment options include clonidine (Catapres) tablets, and nitroglycerine ointment applied locally.
• To help control the pain of levator ani syndrome, your doctor may prescribe an anti-inflammatory medication or a muscle relaxer.
• The best time to treat a thrombosed hemorrhoid is in the first 48 hours. If the patient goes to their doctor during this time period, a simple office procedure can bring instant relief. After the hemorrhoid is injected with an anesthetic, a small incision is made and the blood clot is removed. If the patient is seen after the first 48 hours, treatment for the hemorrhoid is the same as the home treatment recommendations.
• To help heal an anal fissure, your doctor may give the patient prescription creams such as diltiazem (Cardizem, Tiazac, Cartia XT, Dilacor XR, Diltia XT) or glycerine nitrate that will relax the anal muscle. Injection of botulinum toxin into the anal sphincter can also improve healing in patients with chronic anal fissure. If the fissure fails to heal, a procedure called sphincterotomy may be needed. A small nick is made in the anal sphincter to decrease the muscle tone. This procedure can be performed in the doctor's office or at an outpatient surgery center.
• For underlying problems that may also cause rectal problems (colorectal cancers, some prostate diseases), pain management often involves treatments of the underlying problems.

The best way to prevent rectal pain is to eat a high-fiber diet and drink plenty of water. This will produce soft stools that are easy to pass and result in fewer traumas to the anal passage.

• Thrombosed hemorrhoids are treated with a simple procedure.
• Ninety percent of anal fissures heal in three weeks.
• Two-thirds of people suffering from levator ani syndrome will get some relief with treatment.
• Proctalgia fugax remains the most difficult condition to treat, but new therapies are being tested.
• Other rectal pain sources like colorectal cancers or prostatic disease have a prognosis of good to poor, depending on the effectiveness of treatments of these potential causes.