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Chapter 39. Anorectal Pain

Matthew C. Baker; David S. Fefferman, MD; Ciarán P. Kelly, MD

A 60-year-old gentleman presents to you with a 3-day history of constant perianal pain and bright red blood seen in the toilet bowl. This morning, he noticed a small swollen mass at his anus when washing in the shower. He experienced a similar episode of pain and bleeding several months ago, which he attributed to hemorrhoids, but his symptoms today are far more severe.

  • What else in this patient's history might help to establish the diagnosis?
  • What characteristics of the pain and bleeding are important to know?
  • If the patient is correct about having hemorrhoids, are they likely internal or external?
  • Does this history cause concern for anal cancer?
  • Can you make the diagnosis based on this history alone?

Symptoms of anorectal disease are common. However, due to the reluctance of both patients and clinicians to discuss these symptoms in detail, problems may be attributed hastily to internal hemorrhoids and not investigated adequately. In many cases, a thorough history will point to a specific diagnosis, or at least help target the physical examination and indicate the appropriate special tests. No matter how clear the history seems to be, a perianal inspection and digital anorectal examination are mandatory unless the anal canal is too tender or too stenotic to allow this examination. Anoscopy is an important adjunct to the physical examination in patients with anorectal symptoms. After a detailed history, physical examination, and anoscopy, further or more invasive diagnostic testing may be unnecessary.

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Anal fissureA cut or tear of the anal mucosa.
CoccydyniaReferred pain from injured, inflamed, or hypersensitive coccyx.
Defecatory dysfunction or anismusDysfunction, weakness, or faulty coordination of the muscles that affect defecation.
Fecal impactionObstruction of the anal outlet with stool.
FistulaAbnormal tunnel of infection or inflammation into the perianal skin, usually originating from an anal gland.
Foreign bodyAn item placed within the rectum for therapeutic or recreational purposes can cause rectal irritation, obstruction (if retained), or trauma including tearing of the anal mucosa and a painful anal fissure.
HemorrhoidDilation of the superior or inferior hemorrhoidal venous plexus (cushions) resulting in internal or external hemorrhoids, respectively.
Levator ani syndromeIdiopathic dull ache possibly resulting from dysmotility of the muscles supporting the rectum and anus.
Perianal abscessCollection of infection within or adjacent to the perianal space.
Proctalgia fugaxIdiopathic recurrent sharp pain in the anus or rectum lasting several seconds and that is usually unrelated to bowel movements.
ProctitisInflammation, infection, or ischemia of the rectum.
ProstatitisInfection or inflammation of the prostate gland.
Pruritus aniThis is not an etiology of anorectal pain but rather a symptom of itching in the skin of the anal canal or perianal region. It has a variety of causes including many of those listed above in addition to local irritation of the perianal skin from fecal soilage, infection (bacterial, fungal, viral, parasitic), inflammation, and dermatologic abnormalities. ...

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