Anal Pain

The Condition

Description

Anal pain, also called proctalgia, is pain in and around the region of the anus or rectum. It can be a source of distress but usually has a benign cause that is easily treated.

Causes

Anal pain is commonly caused by anal fissures, haemorrhoids and fistulas. Large or hard stools can cause injury to the anus. Pain may be due to an abscess or infection of the anus, rectum, prostate gland or other parts of the urinary tract. People with inflammatory bowel disease may complain of anal pain. Pain may be referred from the tail bone or lower back. It may rarely be due to a tumour, cancer or certain conditions such as proctalgia fugax and levatorani syndrome.

Impact

Pain can be mild or severe enough to affect your daily routine. It may be associated with a change in bowel habits. Some causes of pain require urgent medical attention.

Anatomy

Towards the end of the digestive tract is the rectum which leads to the anal canal. The anal canal is narrower than the rectum, about 2.5 to 4 cm long and leads to the anal opening. Unlike the rectum, which is lined by mucous membrane, the anal canal transitions to a skin-like lining. There are circular folds of mucous membrane called anal valves. Sinuses present between the valves communicate with glands and lymph ducts. Abscesses can sometimes form in these sinuses. The lining in the lower portion of the canal is keratinized and consists of hair and glands. Muscles around the anal canal, called sphincter muscles, expand and contract to help with the passage of stool. Longitudinal muscles prevent the anus from prolapsing as the stool passes out. Skin folds in the anal opening allow the skin to stretch without tearing. Blood vessels surround the anal canal and may get enlarged and rupture, a condition called haemorrhoids. Nerves in the anal canal sense pressure and pain, causing the sphincter muscles to respond by relaxing and allowing the passage of stool.

Symptoms

An anal fissure usually occurs when you pass a large or hard stool. It can produce sharp pain or burning pain that can last a few hours. Bleeding may also be present. Anal fissures usually take a few weeks to heal. Haemorrhoids usually cause discomfort, but you can experience pain if there is blockage of the blood vessel. Proctalgia fugax produces sharp, cramp-like pain that usually lasts about a minute. Levatorani syndrome produces a pressure-like pain that is felt higher in the anal canal. Pain usually lasts about 20 minutes and tends to occur at intervals. It is worse with sitting and may partially be relieved by walking or standing. Certain conditions necessitate an immediate evaluation by a doctor. These include severe pain, pain associated with bleeding, symptoms affecting other parts of the body, prolapse of the rectum or anal canal or a foreign object within the rectum or anal canal.

Diagnosis

Your doctor will make a diagnosis by reviewing your symptoms and history and performing a physical examination. A digital rectal examination may be performed for which your doctor gently inserts a lubricated finger into the anal canal to palpate the region for abnormalities. Examination may be performed under anaesthesia if necessary. The pressure of the anal sphincter muscles may also be evaluated.

Untreated

Certain causes of anal pain such as fissures or haemorrhoids may resolve on their own, but your doctor can suggest measures to ease your symptoms and prevent a recurrence. Pain can be severe if a haemorrhoid gets blocked with a clot. Bleeding should be investigated as it can have a serious cause such as cancer. Chronic bleeding can lead to anaemia. A foreign body should be emergently removed as it may damage the anal canal and surrounding tissues.

Treatments

To treat an anal fissure, your doctor may prescribe a cream as well as a stool softener. A procedure called sphincterectomy may be performed for fissures that do not heal. This involves making a small nick in the anal sphincter to decrease muscle tone. Anal fissures may be avoided by eating a high-fibre diet and drinking plenty of water. This produces softer stools that are easy to pass and do not traumatize the anal tissues.

Discomfort associated with haemorrhoids can be addressed by sitting in a hot bath for 20 minutes at a time at frequent intervals throughout the day. Stool softeners and a high-fibre diet are recommended. Certain over-the-counter haemorrhoid treatments are available. A blocked haemorrhoid should be treated within 48 hours. The vessel is injected with an anaesthetic and an incision made to remove the clot.

Infections are usually treated by antibiotics. Anal pain from the tail bone can be treated by anti-inflammatory medication, hot or cold packs, avoiding prolonged sitting and using special cushions while seated. Severe pain may be treated by physical therapy, corticosteroid injections or surgery.

Anal fistulas usually require surgical treatment such as a fistulotomy. During this procedure, the length of the fistula is cut and opened to heal. An alternate procedure using a seton may be carried out if the fistula runs through the sphincter muscles.

Levatorani syndrome is treated by anti-inflammatory medication or a muscle relaxant. You can also control your symptoms by massaging the levatorani muscle or sitting in a hot bath to ease muscle spasm.

Proctalgia Fugax is difficult to treat mainly because the pain lasts for a very short duration. New treatments are being investigated.  

Costs

Our staff will discuss cost details, insurance and other funding options with you in detail.

Research

Research articles related to anal pain:

Grigoriou M, Ioannidis A, Kofina K, Efthimiadis C. Use of botulinum A toxin for proctalgia fugax-a case report of successful treatment.J Surg Case Rep. 2017 Nov 29;2017(11):rjx236. doi: 10.1093/jscr/rjx236. eCollection 2017 Nov.

Fransiska D, Jeo WS, Moenadjat Y, Friska D. Methylene Blue Effectiveness as Local Analgesic after Anorectal Surgery: A Literature Review.Advances in Medicine. 2017;2017:3968278. doi: 10.1155/2017/3968278. Epub 2017 Aug 15.

Tournu G, Abramowitz L, Couffignal C, et al. Prevalence of anal symptoms in general practice: a prospective study. BMC Family Practice. 2017;18:78. doi:10.1186/s12875-017-0649-6.