Pain in the rectum

Causes of anorectal pain

There are many different causes of pain in the rectal region. It is important to distinguish between them, as the treatment of nerve pain is very different from the treatment of a fissure or hemorrhoid.

1. Anal fissure (tears in the rectum)

An anal fissure is a small wound or tear in the mucous membrane of the anus itself.

• Symptoms: Characterized by sharp, "glass-like" pain during bowel movements and a subsequent burning sensation that can last for hours.
• Why does it hurt? The pain is often caused by the internal sphincter muscle going into spasm, which prevents the tear from healing.
• Tears in the rectum often require prompt treatment with a special ointment to prevent them from becoming chronic.

2. Hemorrhoids and Perianal Thrombosis

Hemorrhoids are enlarged blood vessels that can be located both internally and externally.

• Symptoms: Typically irritation and fresh bleeding. If a small blood clot forms in an external hemorrhoid (a thrombosis), a sudden, hard, and very tender lump will appear.
• Clinical signs: The pain is constant and worsens with touch or pressure.

3. Levator Ani Syndrome

This is a functional muscle pain where the pelvic floor muscles are overstretched.

• Symptoms: A dull, aching pain or a feeling of heaviness in the pelvic floor. Patients often describe it as "sitting on a ball."
• Clinical signs: The pain is often unrelated to defecation, but may worsen with prolonged sitting.

4. Proctalgia fugax

A harmless but very frightening condition involving sudden convulsions.

• Symptoms: Intense, short-lived attacks of pain (lasting seconds to minutes) that often occur at night and wake the patient.
• Clinical signs: There is no pain or symptoms between attacks.

5. Pudendal Neuralgia

The cause here is nerve pain in the pelvis, specifically irritation of the pudendal nerve.

• Symptoms: Burning, electric shock-like, or tingling pain in the perineum and rectum.
• Clinical sign: The pain is typically relieved when standing up or sitting on a toilet seat (where there is no direct pressure on the nerve).

6. Perianal Abscess and Fistula

An inflammatory condition (abscess) near the opening of the rectum.

• Symptoms: Throbbing, constant pain accompanied by redness, swelling, and possibly fever.
• Clinical signs: Often requires prompt surgical evaluation to drain the inflammation.

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How do we clinically distinguish between the causes?

In order to provide you with the appropriate treatment, we conduct a systematic examination:

1. Visual inspection: Here we look for external signs of anal fissures, hemorrhoids, or signs of inflammation.
2. Digital palpation: The doctor gently feels with a finger. This is crucial for distinguishing between muscle pain (Levator Ani) and structural problems such as lumps or scar tissue.
3. Endoscopy: An examination of the lower part of the intestine using a telescope, which allows us to see the mucous membrane directly.

When should you have a colonoscopy?

Although the pain is often localized at the opening, in some cases a full bowel examination may be necessary. We recommend a colonoscopyif:

• You experience unexplained bleeding (other than fresh blood on the paper).
• There is a change in bowel habits (e.g., alternating bowel movements).
• There is suspicion of chronic intestinal inflammation (Crohn's disease or ulcerative colitis).
• You are at the age where you are screened for polyps and tissue changes.

Condition	Primary symptom	Investigation
Anal fissure	Sharp pain during bowel movements	Inspection / Anoscopy
Hemorrhoids	Bleeding and pressure	Inspection / Proctoscopy
Levator ani	Dull, throbbing pain	Digital palpation
Pudendal Neuralgia	Burning nerve pain	Clinical test / Nerve block
Abscess	Throbbing pain and fever	Clinical assessment

References (PubMed)

• Bharucha, A. E., et al. (2016). Functional Anorectal Disorders. Gastroenterology. (PMID: 26760631)
• Mazzari, A., et al. (2020). Management of Anal Fissure: A review. Journal of Clinical Medicine. (PMID: 32630129)
• Labat, J. J., et al. (2008). Diagnostic criteria for pudendal neuralgia (Nantes criteria). Neurourology and Urodynamics. (PMID: 17823944)