Rectal pain, or more correctly, anal pain; has a number of causes. I say anal pain because the lower rectum and the internal anal canal are not sensitive to pain in the usual sense. These portions of the intestinal track are lined by cells found within the intestinal track and supplied by ‘gut’ nerve fibers which are not sensitive to sharp pain. This allows us to treat internal hemorrhoids, which line the internal anal canal, very differently than external hemorrhoids and other conditions which can cause anal (anorectal ) pain. In fact, this is what allows us to remove polyps or do biopsies during colonoscopy without causing any post procedure pain. Keep this in mind as we discuss the causes of anorectal pain. With conditions affecting the rectum or internal anal canal, patients may have a sensation of pressure or an uncomfortable urge to go to the bathroom; but not the type of pain that we experience from an injury to the skin or ‘external’ anal canal. The external anal canal is lined with a modified type of skin cell and nerve fibers which make it very sensitive to pain! Most of us have experienced this at one time or another during our lives. The program director of my Colorectal Surgery residency had a saying “you don’t have to be a genius to be a colorectal surgeon”. The reason; there are only three common causes of anorectal pain, and all three are visible without inserting a finger or a scope!

THROMBOSED HEMORRHOIDS

ANAL FISSURES

PERIRECTAL ABCESS

There are other causes of less severe discomfort such as pruritus ( burning and itching ), skin tags, anal warts, and even muscular pain within the pelvic floor. Notice that thrombosed hemorrhoids are one of only a number of conditions, and not even the most common! As I have pointed out in previous articles, hemorrhoids are normal structures. They consist of columns of vascular tissue within the anal canal. That portion within the INTERNAL anal canal is relatively insensitive to pain, can cause painless bleeding and protrusion, and can be treated by a variety of methods including the most common; hemorrhoid ligation. The hemorrhoidal tissue lying within the external canal, which is the area just around anal opening and within the lower 1-2 cm of the anal opening, is very sensitive to pain. As most of us are aware, even those of us in the medical profession; most health care workers and patients refer to any anorectal pain as being a ‘hemorrhoid’. I have seen countless patients referred to me over the years being told that they had a ‘hemorrhoid’, regardless of their symptoms. Though it is technically true that they have a hemorrhoid, most patients have another cause of their discomfort. In my practice I found the most common cause of pain to be an anal fissure. More about that later. I started all my medical school lectures with the phrase, “all that hurts in the anorectal area is not a hemorrhoid!’ In fact, the only time a hemorrhoid causes pain is when one or more of the 3 hemorrhoids becomes thrombosed. Thrombosed hemorrhoids occur when the the blood vessels within the hemorrhoid become clotted ( thrombosed). This causes swelling, inflammation and pain. The swelling is visible on simple inspection and visualization of the area. The level of pain is dependent upon the amount of clot and whether a single or all three hemorrhoids are involved. Despite the severity of the thrombosis, all cases will resolve on there own, with the pain subsiding in from 3-10 days with the use of warm soaks, topical ointment, and pain medicines. Surgery is never mandatory but can be done in patients with recurrent episodes in order to prevent recurrences. Surgery is painful but effective with a recurrence rate under 5%. The decision to have surgery is strictly up to the patient after consultation with their physician. Anal fissures consist of a crack or tear in the lining of the external anal canal.They are most commonly caused by a hard bowel movement resulting in the tear. Sphincter muscle spasm complicates the condition by causing pain and further difficulty in passing stool. In fact, the muscle spasm is the primary cause of pain. Treatment consists of increasing fiber in the diet, often with the use of a psyllium product, warm soaks, and the application of a topical ointment, or injection of botox, designed to break the muscle spasm. Medical therapy is effective in over 80% of patients. Surgical treatment consists of a partial sphincterotomy ( division of the lowermost fibers of the sphincter ) in order to break the spasm: it is effective in 95% of patients. Anorectal abcess occurs when one of the small mucous glands within the anal canal becomes infected. As with abcesses in other parts of the body they present with swelling, pain, redness and sometimes drainage. The treatment for these is incision and drainage, preferably by a surgeon familiar with the anatomy of the anal canal. There is no place for antibiotics except in patients with severe infections or other complicating conditions… and only after incision and drainage. Several important points to make, especially with the wave of devices advertised to treat hemorrhoids ‘painlessly’ or ‘in the office’.

1) These treatments are strictly for internal hemorrhoids; and only those with symptoms of painless bleeding or protrusion. They should only be done by a physician with specific training in the anatomy, diseases and treatment of anorectal problems 2) If you have a painful condition; seek expert consultation. Thrombosed hemorrhoids, fissures, abcess, skin tags, warts and other skin or muscular pain cannot be treated with a device or technique designed to treat internal hemorrhoids. Seek expert consultation with a Colorectal Surgeon. 3) Patients treated by Colorectal Surgeons have better outcomes!

Thank you, the physicians and Staff of Tri-State Colorectal.