Rectal Pain

Rectal Pain: Excerpt from In a Page: Signs and Symptoms

Rectal complaints are common and distressing for patients. Although most causes of rectal pain and bleeding are benign and treatable, carcinoma must be considered and ruled out in older patients (>40 years) and those with suggestive findings (e.g., polyps). Many of the rectal pathologies are easily diagnosed; however, nongastrointestinal diagnoses (e.g., genitourinary or gynecologic) may present with rectal complaints and should be considered.

Differential Diagnosis

• Anal fissure
  –Acute fissure presents with pain and bleeding (noticed on toilet paper) immediately following defecation
  –Chronic fissure presents with long-standing itching and mild pain, with or without bleeding

• Perianal abscess (with or without associated fistula formation
• Thrombosed hemorrhoid
• Levator ani syndrome
• Proctalgia fugax (rectal muscle spasm)
• Coccyodynia/coccygodynia
• Fecal impaction
• Neoplasm (rectal, pelvic, or cauda equina)
• Idiopathic
• Inflammatory bowel disease (ulcerative proctitis, Crohn's disease)
• Solitary rectal ulcer syndrome
  –Misnomer: May be multiple, not restricted to rectum, and lesion may be polypoid
  –Neoplasm is a concern
• Pruritus ani
• Trauma
• Anal sex
• Constipation
• Diarrhea
• Less common causes (“zebras”) include familial rectal pain, endometriosis, pelvic inflammatory disease, prostatitis, myopathies, foreign bodies, and compression or inflammation of sacral nerves

Workup and Diagnosis

• A careful history and physical exam are crucial and often diagnostic for many conditions
  –Acute anal fissure presents as an anal tear (typically posterior) with a tender perineum; no further workup is necessary if the classic history and exam are found
  –Chronic anal fissure presents as an open ulcer with drainage and sentinel pile
  –Levator ani symptoms can be elicited by digital rectal examination
  –Proctalgia fugax symptoms cannot be elicited by exam
  –Coccyodynia: Palpation of coccyx reproduces symptoms

• In cases of perianal abscess, must rule out the presence of an anal fistula and inflammatory bowel disease
• Anoscopy may be indicated to rule out inflammatory bowel disease
• If an underlying disease process is suspected, consider stool cultures, viral titers, serologies, and/or biopsy

Treatment

• Acute anal fissure: 90% heal within 3–4 weeks with conservative management (increased fiber and water intake, stool softeners, Sitz bath, topical corticosteroids)
• Chronic anal fissure: Only 40% heal with conservative treatment; sphincterotomy (<5% risk of significant incontinence) is the treatment of choice
• Perianal abscess: Requires incision and drainage followed by packing and Sitz baths until healed
• Levator ani syndrome: Decrease anal canal pressure by digital massage (3–4/week), Sitz baths, muscle relaxants
• Proctalgia fugax: Self-limited, infrequent brief attacks; primary treatment is reassurance; treat any underlying psychological disorders
• Coccyodynia: Warm Sitz baths, analgesics, and corticosteroid injections; coccygectomy may be indicated in rare cases
• Thrombosed hemorrhoid: Incision and drainage or surgical excision

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

 » Next page: RECTAL BLEEDING (Differential Diagnosis in Primary Care)

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