Rectal pain
A common symptom of anorectal disorders, rectal pain is discomfort that arises in the anorectal area. Although the anal canal is separated from the rest of the rectum by the internal sphincter, the patient may refer to all local pain as rectal pain.
Because the mucocutaneous border of the anal canal and the perianal skin contains somatic nerve fibers, lesions in this area are especially painful. This pain may result from or be aggravated by diarrhea, constipation, or passage of hardened stools. It may also be aggravated by intense pruritus and continued scratching associated with drainage of mucus, blood, or fecal matter that irritates the skin and nerve endings.
History
Ask the patient to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.
Be sure to ask appropriate questions about the development of any associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.
Physical assessment
Inspect the rectal area for bleeding; abnormal drainage such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Also, check for inflammation and other lesions. A rectal examination may be necessary.
Medical causes
Abscess
A perirectal abscess can occur in various locations in the rectum and anus, causing pain in the perianal area. Typically, a superficial abscess produces constant, throbbing, local pain that’s exacerbated by sitting or walking. The local pain associated with a deeper abscess may begin insidiously high in the rectum or even in the lower abdomen and is accompanied by an indurated anal mass. The patient may also develop such associated signs and symptoms as fever, malaise, anal swelling and inflammation, purulent drainage, and local tenderness.
A prostatic abscess occasionally produces rectal pain. Common associated findings include urine retention and frequency, dysuria, and fever. A rectal examination may reveal prostatic tenderness and gas.
Anal fissure
An anal fissure is a longitudinal crack in the anal lining that causes sharp rectal pain on defecation. The patient typically experiences a burning sensation and gnawing pain that can continue up to 4 hours after defecation. Fear of provoking this pain may lead to acute constipation. The patient may also develop anal pruritus and extreme tenderness and may report finding spots of blood on the toilet tissue after defecation.
Anorectal fistula
Pain develops when a tract formed between the anal canal and skin temporarily seals. It persists until drainage resumes. Other chief complaints of an anorectal fistula include pruritus and drainage of pus, blood, mucus and, occasionally, stool.
Cryptitis
Cryptitis results when particles of stool that are lodged in the anal folds decay and cause infection, which may produce dull anal pain or discomfort and anal pruritus. Intense pain may occur when the anal sphincter contracts.
Hemorrhoids
Thrombosed or prolapsed hemorrhoids cause rectal pain that may worsen during defecation and abate after it. The patient’s fear of provoking the pain may lead to constipation. Usually, rectal pain is accompanied by severe itching. Internal hemorrhoids may also produce mild, intermittent bleeding that characteristically occurs as spotting on the toilet tissue or on the stool surface. External hemorrhoids are visible outside the anal sphincter.
Proctalgia fugax
With proctalgia fugax, muscle spasms of the rectum and pelvic floor produce sudden, severe episodes of rectal pain that last up to several minutes and then disappear. The patient may report being awakened by the pain, which is sometimes associated with stress or anxiety and relieved by food and drink.
Other causes
Anal intercourse
Shearing forces may cause inflammation or tearing of the mucous membranes and discomfort.
Special considerations
Apply analgesic ointment or administer suppositories. Administer a stool softener, if needed. If the rectal pain results from prolapsed hemorrhoids, apply cold compresses to help shrink protruding hemorrhoids, prevent thrombosis, and reduce pain. If the patient’s condition permits, place him in Trendelenburg’s position with his buttocks elevated to further relieve pain.
You may have to prepare the patient for an anoscopic examination and proctosigmoidoscopy to determine the cause of rectal pain. He may also need to provide a stool sample. Because the patient may feel embarrassed by treatments and diagnostic tests involving the rectum, provide emotional support and as much privacy as possible.
Pediatric pointers
Observe any child with rectal pain for associated bleeding, drainage, and signs of infection (fever and irritability). Acute anal fissure is a common cause of rectal pain and bleeding in children, whose fear of provoking the pain may lead to constipation. Infants who seem to have pain on defecation should be evaluated for congenital anomalies of the rectum. Consider the possibility of sexual abuse in all children who complain of rectal pain.
Geriatric pointers
Because elderly people typically underreport their symptoms and have an increased risk of neoplastic disorders, they should always be thoroughly evaluated.
Patient counseling
Teach the patient how to apply hot, moist compresses. Also teach him how to give himself a sitz bath; this will ease his discomfort by helping to relieve the sphincter spasm associated with most anorectal disorders. Stress the importance of following a proper diet and drinking plenty of fluids to maintain soft stools and thus avoid aggravating pain during defecation.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Watery stool
» Next page: Diarrhea (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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