Anal pain

Essentials

  • Carefully taken patient history and clinical examination are usually sufficient for the diagnosis.
  • Further investigations mainly aim at the exclusion of precancerous and cancerous conditions and inflammatory bowel diseases.

Epidemiology

  • Anal pain is a common symptom. It is usually caused by a benign condition, most commonly anal fissure.
  • A tumour is a rare cause of anal pain.
  • Patients often try self-medication with topical over-the-counter ointments. Patients often delay seeking medical care for anal problems.

Causes of anal pain

  • Common causes and sources of anal pain are listed in table T1.

Table 1. Common types and sources of anal pain
Symptoms and signs Probable source
Pain associated with bleeding or weight loss Rule out cancer, colitis
Pain of recent onset, constant or increasing, with or without fever Abscess
Sudden onset of pain Thrombosed haemorrhoid
Chronic short or intermittent pain associated with defaecation Fissure
Tenesmus or cramping associated with bleeding or diarrhoea Proctitis, colitis
Deep, aching intermittent pain, not associated with defaecation Levator spasm
Pain and feeling of pressure deep in the lesser pelvis after defecation Rectal intussusception
Chronic itching, no associated symptoms Pruritus ani
Itching, diarrhoea Proctitis
Itching, mucosal prolapse Haemorrhoids
Bleeding Haemorrhoids, cancer, colitis
Palpable mass Prolapsed haemorrhoids, sentinel pile associated with fissure, tumour, condylomata, abscess, foreign body
  • Rare causes include:
    • Crohn's disease
    • anal cancer
    • rectal cancer
    • other anorectal malignancies
    • rectal prolapse
    • anal mucosal prolapse
    • anal fistula
    • leukaemia
    • suppurative hidradenitis.
  • The cause of anal pain can usually be treated in primary care.

History and clinical examination

  • It is important to ask about other symptoms that can give a clue to the diagnosis. The patient usually complains of haemorrhoids irrespective of the actual cause of the symptoms. Other common proctological symptoms include bleeding, itch, discharge, incontinence, and mucosal prolapse.
  • The proctological examination consists of local examination and palpation of the abdomen and inguinal lymph nodes. The anus can most easily be examined when the patient is lying on his left side with the hips and knees flexed. Good focal and general light is necessary.
  • Proceed slowly with the examination so that the patient can overcome his/her anxiety and relax; the doctor thus obtains more information. Explain to the patient the course of the examination, as he/she cannot see what happens behind his/her back.

Inspection

  • During the inspection, ask the patient to strain down, as if defecating.
  • Palpate the perineum for the presence of a hidden abscess in patients who complain of pain.
  • If the inspection is difficult because of large buttocks elevate the right buttock to make the anus visible.
  • The following conditions can be diagnosed at inspection:
    • incarcerated haemorrhoids
    • perianal haematoma
    • pruritus ani
    • anal fistula
    • anal fissure
    • prolapsed haemorrhoids
    • rectal prolapse
    • anal malignancies
    • anal condylomata.

Digital rectal examination (DRE)

  • DRE can usually be performed, with the exception of very painful conditions such as incarcerated haemorrhoids, anal fissure or perianal abscess.
  • Structures that can be examined by DRE:
    • rectal mucosa
    • anal canal
    • internal and external sphincter
    • levator muscle (the so-called anorectal ring)
    • anovaginal septum
    • sacrum and pre-sacral space
    • sites of pain
    • palpable masses – cervix, prostate
    • finally, the material visible on the glove should be examined, particularly for the presence of blood.
  • The following conditions can be diagnosed at DRE:
    • anal abscess
    • anal stenosis
      • Anal stenosis may result from Crohn's disease or anal (postoperative) scars.
    • anal fissure
    • rectal tumours
    • tumours of the anal canal.
  • In syndroma pelvis spastica (also known as anismus, non-relaxing puborectalis levator syndrome) the levator muscle may be tender on palpation, and moving the puborectalis in the posterior midline between the anus and the coccyx will be painful.

Proctoscopy

  • Proctoscopy (anoscopy) is a simple investigation and a part of adequate proctological practice. No emptying of the rectum is necessary. The most common finding on proctoscopy is haemorrhoids, but conditions of the anal canal and distal rectum can also be distinguished.
  • Conditions that can be diagnosed by proctoscopy:
    • haemorrhoids
    • anal fissure
    • anal stenosis
    • polyps of the anal canal
    • hypertrophic anal papillae.

Further investigations

  • The above-mentioned investigations do not require any preparation. Fibreoptic sigmoidoscopy and colonoscopy, as well as colonography, instead can only be performed after emptying the bowel.
  • All examinations can be performed in primary care but both the procedures and interpretation of the findings require experience.
  • Colonoscopy is recommended as a further investigation to exclude malignancy and inflammatory diseases, if the cause of the pain is not obvious.

Treatment

  • Proctological diseases usually require some sort of intervention in order to be cured. Medical treatment is rarely sufficient, with the exception of anal fissure (Anal fissure) that can be treated with an ointment containing glyceryl trinitrate [Evidence Level: B] or a calcium channel blocker.
  • Topical antihaemorrhoidal ointments are widely used. They alleviate symptoms but do not cure the disease. There is no research evidence on the efficacy of topical preparations in the treatment of proctological diseases.
  • Do not prescribe ointments for haemorrhoids before careful proctological assessment and exclusion of malignant disease.
  • Muscle relaxants and analgesic drugs may be tried in the treatment of idiopathic proctalgia. Also benzodiazepines come into question.
  • Biofeedback therapy provided by a physiotherapist can be used in the treatment of pain caused by excessive nervous tension.
  • Injecting a mixture of a local anaesthetic and a glucocorticoid into an insertional-tendinitis type painful spot at the margin of the pubic bone may be tried, if the spot is clearly palpable through the anus. The injection is performed through perineal skin and guided by rectal touch.
  • Consultation at a specialized pain management clinic may sometimes be useful.

Guidelines for specific diseases

Follow-up

  • Verify the outcome of treatment and encourage the patient to contact medical services again if the symptoms recur.
  • Repeat the examinations when necessary.

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