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Anal Pain

-Connie Pennington, MD


People frequently assume that the major source of anal pain is hemorrhoids. Actually, anal pain can result from a variety of causes. The most common reason for anal pain is an anal fissure, which is a tear in the anla canal. These tears are created by trauma, such as hard stool forcing through the anus, generally associated with constipation. Fissures produce an acute, sharp pain somethimes associated with bright red blood noted when wiping. There may be associated muscle spasm, resulting in prolonged pain over hours. Anal pain can also be caused by an abscess, which is most commonly due to a bacterial infection and may cause fever, night sweats, and prolonged constant pain. Anal pain can be caused by a tumor which may produce progressively worsening pain over time. Anal pain can also be caused by sexually transmitted diseases (STD's) such as gonorrhea, chlamydia, or herpes. STDs can be asymptomatic in some people while not in others. Gonorrhea and chlamydia both present either in an asymptomatic state or with concomitant symptoms and purulent discharge. Because of the diversity of causes, persistent anal pain should be evaluated by a health care professional.

Anal pain can be due to external or prolapsed internal hemorrhoids. External hemorrhoids can present as swelling around the anal canal, or thrombosis, meaning a large blood clot under the skin that fills out the skin tag. This presents with acute anal pain that is persistent. It may occur during a bowel movement or lifting something heavy. An internal hemorrhoid generally does not cause much pain unless it swells to the point of being able to prolapse outside of the anal canal. Internal hemorrhoids are covered with mucosa and should gently pushed back into the anal canal. Sometimes anal pain is caused by a combination of internal and external hemorrhoids, and may be irreducible. In this case sitting in warm/hot water is the best method to reduce swelling and ease discomfort.

When anal pain is present in the absence of any identifiable cause there are other conditions to consider. Persistent anal pain should be met with physical examination by a health care provider and appropriate diagnostic X-Ray's if needed. 

Pain can be caused by inflammation of the tailbone, called coccydynia. This may be due to trauma to the tailbone and is best treated with anti-inflammatory medications. When physical examination and x-rays are normal, muscle spasm syndromes must be considered. The pelvic floor contains large muscles that can cause serious discomfort when they are inflamed. This is called Levator Syndrome, with a variant called Proctalgia Fugax. Levator Syndrome is characterized by episodic pain felt internally near the rectum. The pain is often described as being worse on the left side. Digital rectal examination with pressure on the pelvic levator muscles, particularly on the left, often reproduces the pain and confirms the diagnosis. Up to 55% of patients who experience this pain also have constipation, so increasing fiber and water consumption is helpful. A variant muscle pain syndrome is Proctalgia Fugax, which is a short-lasting, intense muscle spasm that often awakens a person from sleep. This is like a "charley horse" of the rectal muscles and is common with irritable bowel syndrome. Muscle spasm syndromes are best treated with anti-inflammatory medications, like ibuprofen and relaxing the muscles by sitting in hot water baths. Pelvic floor muscle spasm, like neck and back spasm, can be related to stress and this should be considered. Anxiety and depression also play a role and may be the body's way of expressing painful emotions. Please do not hesitate to discuss anything you think may be contributing to your pain.

Sometimes inflammation of the prostate, ovaries, uterus, or bladder can present as rectal pain. Be sure to alert your health care provider of any and all symptoms related to the pain you are experiencing. Anal pain can be embarrassing and many people do not seek medical attention due to fear of a painful examination. Early detection is key. Trained medical professionals can examine the visual aspects of the anus and diagnose most common problems. An examination under anesthesia can be done for patients experiencing severe pain. If you are experiencing anal pain, do not ignore what your body is telling you. Seek medical care by a trained health care professional. Appropriate diagnosis and treatment equals peace of mind.

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