Do Not Confuse Anal Fissure (Pain in the Butt) with Anal Cancer

A clinical picture showing a case of anal fissure. (Dr. Noorali Bharwani)
A clinical picture showing a case of anal fissure. (Dr. Noorali Bharwani)

There are various kinds of anal and rectal problems. Some are painful and some are not. Some are serious and others are a mere nuisance – if that is the right word. But all of them are a real pain in the butt – so to speak.

Anal fissure can be really painful. On the other hand, cancer of the rectum may be painless. The only way to find the real diagnosis is to see a doctor to get a good rectal examination consisting of inspection, finger examination and some sort of a scope test depending on your age and history. The important thing is to make sure we are not dealing with cancer or Crohn’s disease.

I have written about this subject before. You can check it out on my website. Today, I want to focus on the management of anal fissure. I want to emphasize that management of painful anal fissure requires a more aggressive approach than managing a “hemorrhoid itch.”

Five steps to manage acute or chronic anal fissure:

1. Make your stool well formed and bulky with a diet high in fiber. Take psyllium (Metamucil) two to four capsules per day with lots of water. This relaxes the anal muscles, helping the healing process.

2. Sit in a hot bath for 20 minutes twice a day for several days until the pain goes away. This really helps the healing process by relaxing the anal sphincter.

3. Minimize the intake of constipating painkillers.

4. Use two per cent diltiazam or nifedipine ointment inside and outside of anal canal twice a day. You need a prescription for this. This medication is associated with healing of chronic anal fissures in 65 to 95 per cent of patients.

5. What can be done if the fissure does not heal after three to six weeks? Rule out other illness of the colon and rectum. Your colon and rectal specialist will advise you on that. Surgical options for treating anal fissure include Botulinum toxin (Botox) injection into the anal sphincter and surgical division of a portion of the internal anal sphincter (partial lateral internal sphincterotomy).  Both of these are performed typically as outpatient procedures with good results and minimal of complications.

During my surgical training, I was taught if a doctor does not put a finger in the patient’s rectum then he may end up putting his foot in it. If you have rectal and anal symptoms then get that area examined well. You do not want anybody’s foot in it!

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Five Things You Should Know About Proctalgia Fugax (Pain in the Butt)

After a sleepless night. (iStockphoto)
After a sleepless night. (iStockphoto)

Proctalgia fugax was first described in Ancient Rome over 2000 years ago and still carries the Latin name which translates to “fleeting rectal pain.” I wrote about this some years ago. If you go to my website (nbharwani.com) and search proctalgia fugax, you will find that this is the most discussed article – more than 100 people have shared their experience with this condition.

Because of my interest in this, my attention was drawn to an article in the Canadian Medical Association Journal (CMAJ March 19 2013) titled “Five things you should know about proctalgia fugax.”

First thing you should know is proctalgia fugax has many triggers. There are episodes of sharp fleeting pain that recur over weeks, are localized to the anus or lower rectum, and last from seconds to several minutes with no pain between episodes. The authors of the article say that there are numerous precipitants including sexual activity, stress, constipation, defecation and menstruation, although the condition can occur without a trigger.

Second thing you should know is proctalgia fugax is common. In the general population, the prevalence of the condition may be as high as eight to 18 per cent. Seventy five per cent are women. It usually affects patients between 30 and 60 years of age.

Third thing you should know is that anal sphincter spasm may cause the pain in proctalgia fugax. The authors say that although the cause of proctalgia fugax is unclear, spasm of the anal sphincter is commonly implicated. It may occur after sclerotherapy for hemorrhoids and vaginal hysterectomy. Stress, anxiety and irritable bowel syndrome may be associated with proctalgia fugax.

Fourth thing you should know is proctalgia fugax is a diagnosis of exclusion. That means there is no test to tell if the person is suffering from this condition. We have to exclude common painful conditions of anus and rectum before we can say a person is suffering from proctalgia fugax. These conditions are: hemorrhoids, cryptitis, ischemia, abscess, fissure, rectocele and cancer.

Finally, the fifth thing you should know about this condition is that the treatments are geared towards relaxing the anal sphincter spasm. These treatments are: oral diltiazem, topical glyceryl nitrate (gives you headache), nerve blocks and salbutamol act by relaxing the anal sphincter spasm. But these treatments are not very effective.

Persistent symptoms require thorough investigations of anal and rectal areas and if no pathology is found then reassurance to patient is very important. There is no known effective treatment for this condition. There are anecdotal reports of benefit from trying any of the following treatments:
-Reassurance and warm baths
-Topical glyceryl trinitrate 0.1 per cent or diltiazem two per cent whenever required
-Salbutamol inhalation 200µg regular three times a day or whenever required
-Warm water enema at the time of symptoms
-Clonidine 150µg twice a day
-Local anesthetic block or botulinum toxin injection
-Help to relieve anxiety and stress

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Proctalgia Fugax Is A Pain In The Butt

A man with pain shooting up his back. (Zoonar/Thinkstock)
A man with pain shooting up his back. (Zoonar/Thinkstock)

You have pain in the butt which comes and goes. You see a doctor. You want to know if you have hemorrhoids or cancer. Well, what else could it be?

There are at least six common causes for rectal and anal pain: pruritus (itch), external thrombosed hemorrhoid (a blood clot), prolapsed internal thrombosed hemorrhoids, fissure (tear), abscess, and fistula (tunnel). Ok, you can add one more condition to the list – proctalgia fugax.

Your next question is, “Doc, what is proctalgia fugax?”

This condition was first described in Ancient Rome over 2000 years ago and still carries the Latin name which translates to “fleeting rectal pain.” It occurs in about 14 percent of healthy people. Seventy five percent of these are women.

Sufferers of this condition often describe waking up from a sound sleep with a sharp pain, often described as stabbing pain “like a knife sticking deep in the rectum.” The pain is usually brief – lasting less than 20 minutes – and disappears as mysteriously as it comes.
Proctalgia fugax falls under the category of “unexplained rectal and anal pain”. Other conditions under this group are levator ani syndrome and coccygodinia.

Let us try and understand some anatomy first.

Colon ends in the pelvis to become sigmoid, rectum and anus. Sigmoid and rectum act as storage area for fecal matter. At a socially convenient place, the anal sphincters (valves) relax to allow us to defecate.

Anal canal is surrounded by two circular muscles known as internal and external sphincters. Rectum is surrounded by and held in place by pelvic floor consisting of a group of muscles called levator ani. Coccyx is the tail end of the spine, not too far from the anal canal.

Proctalgia fugax can begin during sleep, defecation, urination, or intercourse. The character of the pain has been compared to a charlie horse. It may only occur once a year or several times a week. Pain may be severe enough to cause sweating and palpitation. There may be a desire to have a bowel movement, yet pass no stool.

It is thought that a sudden spasm of the levator muscle complex or the sigmoid colon can result in proctalgia fugax. It is believed that people who frequent the toilet are at greatest risk. Professionals, managers, and perfectionists are more likely to be afflicted. Stress and anxiety plays a role in precipitating the pain.

The diagnosis is based almost entirely on the patient’s history. Clinical examination is usually negative. Patients should undergo flexible sigmoidoscopy to screen for other causes of ano-rectal diseases. Careful pelvic and prostate examinations should be undertaken. Ultrasound or CT scan of the pelvis may be necessary.

Patients with levator ani syndrome experience pain for hours to days. The pain is most often constant or rhythmic and may be likened to sitting on a ball or feeling like a ball (or corncob) was inside the rectum. Pain may be caused by defecation, sexual intercourse, sitting for long periods, and stress or anxiety. The pain is probably due to spasm of the pelvic floor muscles.

Coccygodynia is a cramp or ache in the tailbone and typically results from injury to the coccyx or arthritis. Movement of the coccyx can reproduce the pain. Pain from proctalgia fugax, levator syndrome, and coccygodynia may be hard to differentiate.

Treatment is often unrewarding. Some of the measures worth trying are: reassurance, hot baths, bowel regimens, massage therapy, perineal strengthening exercises, pain killers, anti-inflammatory, muscle relaxants, topical nitrates, tranquillizers, calcium channel blockers, acupuncture, and psychiatric evaluation.

Unfortunately, proctalgia fugax is one of the many medical conditions for which there is no good explanation or treatment.

This article was mentioned in my video blog (Had Your Butt Checked Out Lately?) on September 25, 2011.

Topics on my website: Proctalgia fugax and Hemorrhoids.

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Rectal Pain (Proctalgia Fugax)

A doctor putting on his glove. (iStockphoto/Thinkstock)
A doctor putting on his glove. (iStockphoto/Thinkstock)

A patient asks: I have pain in my rectal area and I have been told that I have proctalgia fugax. What is this condition and how can I get some relief?

There are at least six common causes for rectal and anal pain: pruritus (itch), external thrombosed hemorrhoid (a blood clot), prolapsed internal thrombosed hemorrhoids, fissure (tear), abscess, and fistula (tunnel).

Proctalgia fugax is not part of the list as it is not that common. But unfortunately it is not that rare either. It occurs in about 14 percent of healthy people. Seventy five percent of these are women.

Proctalgia fugax falls under the category of “unexplained rectal and anal pain”. Other conditions under this group are levator ani syndrome and coccygodinia.

Let us try and understand some anatomy first.

Colon ends in the pelvis to become sigmoid, rectum and anus. Sigmoid and rectum act as storage area for fecal matter. At a socially convenient place, the anal sphincters (valves) relax to allow us to defecate.

Anal canal is surrounded by two circular muscles known as internal and external sphincters. Rectum is surrounded by and held in place by pelvic floor consisting of a group of muscles called levator ani. Coccyx is the tail end of the spine, not too far from the anal canal.

Proctalgia means pain in the rectum. Fugax means flying, fleeting, momentary like a fugitive – trying to elude justice!

Proctalgia fugax is an intensely painful spasm in the rectal area that begins abruptly and lasts for several minutes. It can begin during sleep, defecation, urination, or intercourse. The character of the pain has been compared to a charley horse.

Sharp cramp or stabbing pain may awaken the patient from sleep. It lasts less than 30 minutes and may radiate to the coccyx or perineum. It may only occur once a year or several times a week. Pain may be severe enough to cause sweating and palpitation. There may be a desire to have a bowel movement, yet pass no stool.

It is thought that a sudden spasm of the levator muscle complex or the sigmoid colon can result in proctalgia fugax.

It is believed that people who frequent the toilet are at greatest risk. Professionals, managers, and perfectionists are more likely to be afflicted. Stress and anxiety plays a role in precipitating the pain.

The diagnosis is based almost entirely on the patient’s symptoms. Clinical examination is usually negative. Patients should undergo flexible sigmoidoscopy to screen for other causes of ano-rectal diseases. Careful pelvic and prostate examinations should be undertaken. Ultrasound or CT scan of the pelvis may be necessary.

Patients with levator ani syndrome experience pain for hours to days. The pain is most often constant or rhythmic and may be likened to sitting on a ball or feeling like a ball (or corncob) was inside the rectum. Pain may be caused by defecation, sexual intercourse, sitting for long periods, and stress or anxiety. The pain is probably due to spasm of the pelvic floor muscles.

Coccygodynia is a cramp or ache in the tailbone and typically results from injury to the coccyx or arthritis. Movement of the coccyx can reproduce the pain.

Pain from proctalgia fugax, levator syndrome, and coccygodynia may be hard to differentiate.

Treatment is often unrewarding. Some of the measures worth trying are: reassurance, hot baths, bowel regimens, message therapy, perineal strengthening exercises, pain killers, anti-inflammatory, muscle relaxants, topical nitrates, tranquillizers, calcium channel blockers, acupuncture, and psychiatric evaluation.

Unfortunately, proctalgia fugax is one of the many medical conditions for which there is no good explanation or treatment.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!