Anal pain

Anal pain, which is pain in or around your bottom (anus) or back passage (rectum), is also known as proctalgia. It is a common complaint that can affect anyone, at any age.

Anal pain is often caused by a minor condition and often goes away on its own. You can usually relieve the pain yourself but if not, your GP will be able to offer treatment.

Anal pain causes include:

• Anal abscess — a painful swelling containing infected liquid (pus) with swelling and redness, which is caused by an infection in or around your anus; treatments include:
• Antibiotics – if the abscess is caught early
• Draining of the abscess – this may need to be carried out at the hospital under general anaesthetic
• Anal fissure — a tear in the skin tissue that lines the opening of your bottom, which usually heals on its own after a few weeks and causes sharp, severe anal pain after a bowel movement or a burning pain that lasts for several hours after a bowel movement, as well as bleeding from your back passage; treatments include: 
• Drinking more fluids, eating a diet high in fibre and taking laxatives — anal fissures can be caused by passing a large or hard stool; these approaches will soften your stools
• Ointment to relax the ring of muscle around your anus
• Over-the-counter painkillers
• Surgery to help your anal fissure heal
• Anal fistula — an infected tunnel that develops between your anus and your rectum that develops from an anal abscess and causes throbbing, constant pain, swelling and itchy skin around your anus, bleeding from your anus and a high temperature (fever); treatment almost always involves anal fistula surgery
• Haemorrhoids (piles) — piles do not always cause symptoms but if they do, symptoms often resolve after a few days and include swellings inside or around your anus, an itchy anus, soreness, redness and bleeding after passing a stool; treatments include: 
• Drinking more fluids, eating a diet high in fibre and taking laxatives — piles can be caused by straining when having a bowel movement due to constipation; these approaches will soften your stools
• Over-the-counter painkillers
• Surgery — if the blood supply to the pile is blocked by a clot, surgery under local anaesthetic can be carried out to remove the clot

Occasionally, other anal pain causes include:

• A urinary tract problem
• Anal sex
• Coccydynia — a painful tail bone
• Digestive system symptoms and conditions — this includes constipation, Crohn’s disease and diarrhoea 
• Infections — this includes: 
• Fungal infections
• Sexually transmitted infections (STIs) — this includes anogenital warts, which you may see or feel as bumps around your anus, and herpes, which causes anal pain with blisters or a blistery rash
• Some rare cancers eg cancer of the anus or rectum — anal pain is usually constant and worse when you have a bowel movement; other symptoms include blood mixed with your stools or on your underwear

Rectal prolapse can also cause anal pain. This occurs when muscles that support your back passage weaken, allowing some of your rectum to bulge out of your anus. Symptoms include difficulty holding your stools in and feeling a lump in your anal area.

If all other causes have been ruled out, you may receive one of two diagnoses: 

• Levator ani syndrome — a constant or long-lasting achy or pressured feeling in and around your anus, which is worse when sitting and affects six in every 100 people, often having a significant impact on their quality of life; physiotherapy to relax your pelvic muscles can help
• Proctalgia fugax — this common condition affects up to one in every five people and involves sudden, severe bouts of anal pain that last for several seconds or minutes at a time; medicines to relax your pelvic muscles can help

It is not fully understood what causes levator ani syndrome or proctalgia fugax. Spasms of the muscles around the anus may be involved but it is not known what triggers these spasms. These conditions are more common in people with anxiety or irritable bowel syndrome (IBS).

Talk to your doctor if you're concerned about symptoms.

Many causes of anal pain can be resolved with simple self-care treatments you can do at home. However, you should see your GP if you have anal pain that:

• Has lasted for several days
• Is accompanied by rectal bleeding, fever, a change in your bowel habits or anal discharge
• Is severe or getting worse

Your GP will ask about your symptoms, any pain after a bowel movement and your general health. To help with diagnosis, your GP may examine your anus and carry out a rectal examination.

They will ask you to lie down on your side, with your knees pulled up to your chest. Your GP will look for lumps, bumps, fissures and skin rashes around your anus. Then, using a gloved finger, they will feel inside your rectum to check for bleeding, lumps and tender areas. They may need to further examine your rectum using a proctoscope — a short, straight, hollow metal tube with a light at the end.  

Your GP may refer you for further investigations or to a consultant, such as a gastroenterologist or colorectal surgeon. Your doctor may recommend further tests including: 

• A sigmoidoscopy — a thin, flexible tube with a camera on the end is passed further inside your gut to look for abnormalities
• An ultrasound scan
• An MRI scan
• Anorectal manometry — to measure the force of your anal muscle contractions

You may not need all of these tests. If the results of your initial anal and rectal examination are normal, you have occasional pain and no bleeding, you may be diagnosed with proctalgia fugax and will not need further tests. Your doctor may advise that you return to see them if your symptoms change.

To help relieve anal pain, try:

• Eating a diet full of fibre, taking regular exercise and drinking lots of water
• Having warm baths, especially if you have anal pain after a bowel movement
• Taking over-the-counter medication, such as ibuprofen or paracetamol and, if you have haemorrhoids, haemorrhoid cream or, for anal fissures, hydrocortisone cream

Depending on the cause, your GP may recommend:

• Antibiotics or surgical draining for an anal abscess
• Laxatives, a special cream or medication for an anal fissure
• Minor surgery to remove painful haemorrhoids
• Surgery for an anal fistula

If you have proctalgia fugax, you may not need any treatment. Currently, there are no proven treatments but your doctor may recommend: 

• A cream that relaxes the blood vessels around your anus eg diltiazem or glyceryl trinitrate cream
• An injection into a nerve in the anal area to make the nerve less sensitive
• Using a salbutamol inhaler — these inhalers are used by people with asthma to open up their airways; it may therefore also relax the muscles around your anus

If you have levator ani, treatments include: 

• Biofeedback therapy — therapy to learn how to relax your pelvic floor muscles
• Botulinum toxin injections
• Electrogalvanic stimulation — using a probe to stimulate the anus with an electric current 
• Nerve stimulation — to make nerves in and around your anus less sensitive
• Using a salbutamol inhaler — these inhalers are used by people with asthma to open up their airways; it may therefore also relax the muscles around your anus

If another underlying condition is responsible for your anal pain, your GP or consultant will recommend treatment depending on your diagnosis.