Causes and Treatment of Rectal Cramps and Pain

Rectal pain is a common health condition that many people try to ignore in hopes that it will go away. However, delaying medical care for rectal pain puts you in harm's way. Though a pain or itch often ends up being nothing more than hemorrhoid, there are other times when the causes are more serious.

Anatomy of the Rectum and Anus

The rectum and anus are distinct parts of the lower gastrointestinal tract with unique physiological functions. 

• The rectum is an 8-inch long chamber that connects the colon to the anus. When stool fills the rectum, nerves embedded deep in rectal tissues send a message to the brain that triggers a muscular response that pushes the stool through the anus and out of the body.
• The anus is the opening of the rectum centered around two sphincters that control the exit of feces during defecation.

Most of the time, pain occurring in the rectum or anus is often caused by trauma or inflammation.

Causes of Rectal Pain

Rectal pain may be a sign of something serious or something relatively minor; there is often no way to know until you see your doctor.

Anal Fissure

An anal fissure is a superficial tear in the thin, moist mucosal tissues that line the anus. They can develop due to chronic constipation, anal trauma, or surgery. Anal fissures can be acute (lasting for less than six weeks) or chronic (lasting for more than six weeks) and can affect people of any age group.

Anal fissures are characterized by rectal discomfort that worsens when passing stools, causing sharp pain that is sometimes excruciating. You can also have rectal bleeding, although it's generally not profuse. The pain can persist for hours after a bowel movement.

The diagnosis of anal fissures typically involves a symptom history and a visual inspection of the anus by a trained healthcare provider. Rarely, an examination under general anesthesia is needed to diagnose the cause and extent of the fissure.

Treatment may be nonsurgical, involving topical anesthetics, topical nitroglycerin, blood pressure medications, or Botox injections. Sometimes surgical treatment includes a procedure that involves cutting the internal anal sphincter to reduce muscle tension in the anal area and allow blood to flow more freely, thus allowing the fissure to heal.

Rectal Abscess

A rectal abscess, also referred to as an anorectal or perianal abscess, is a pocket of pus caused by a localized infection. Abscesses can occur when the glands of the anus and rectum become clogged, triggering inflammation and an accumulation of pus.

Rectal abscesses can be caused by rectal trauma, a sexually transmitted infection, inflammatory bowel disease (IBD), poor hygiene, or poorly controlled medical conditions like diabetes.

People who have a rectal abscess will generally complain of persistent pain, which may be dull, sharp, aching, or throbbing. The onset of pain will often be abrupt and may be accompanied by diarrhea, constipation, fever, chills, and a pus-like discharge. The pain may or may not worsen with defecation, depending on the location of the abscess.

The diagnosis typically involves a digital rectal exam (DRE) and sometimes blood tests to check for signs of infection. Occasionally computed tomography (CT), magnetic resonance imaging (MRI) scan, or transrectal ultrasound (TRUS) scan will be done if there is concern about a deep abscess that might not be apparent on physical examination.

Treatment may involve the drainage of the abscess (by needle or with surgery) along with antibiotics to resolve the infection.

Levator Ani Syndrome

Levator ani syndrome is a condition in which the levator ani muscle, which comprises a major part of the pelvic floor, will spontaneously begin to spasm. It is unclear why this happens, and the spasms often occur after long periods of sitting, after bowel movements, during or after anal sex, following surgery or childbirth, or in stressful situations.

The pain associated with levator ani syndrome is described as a dull, persistent ache accompanied by constant rectal pressure. The pain is often situated 2 inches above the rectum and frequently to the left side. The spasms start abruptly and can last for up to 30 minutes or more, causing constant or intermittent pain or discomfort.

The diagnosis of levator ani syndrome is based on a review of the clinical symptoms. There is no specific cure for the condition. Walking, warm baths, and rectal massage may help. Electrostimulation therapy and therapeutic ultrasound have been proposed as treatments.

Hemorrhoids

A hemorrhoid is a swollen vein, or collection of veins, in and around the rectum. Hemorrhoids can be internal or external, and they vary in size, ranging from a few millimeters to several centimeters. In some cases, a blood clot can form within an external hemorrhoid, resulting in a thrombosed hemorrhoid.

Causes of hemorrhoids include bowel straining, pregnancy, anal sex, violent coughing, and cirrhosis, among others.

The symptoms can vary by the hemorrhoid type:

• External hemorrhoids may cause rectal itching, tenderness, anal swelling, mild bleeding, and pain or discomfort, particularly during bowel movements. The pain from a thrombosed hemorrhoid can sometimes be excruciating.
• Internal hemorrhoids are often painless but can cause notable bleeding during bowel movements. In some cases, an internal hemorrhoid can protrude through the opening of the anus and cause significant pain and irritation.

The diagnosis is based on a physical exam, DRE, or anoscopy if needed. Treatment options can include hemorrhoid creams, ice application, stool softeners, sitz baths, rubber band ligation, sclerotherapy, cauterization, and surgery.

Proctalgia Fugax

Proctalgia fugax is a more serious variation of levator ani syndrome characterized by episodes of severe cramping and pain due to spontaneous spasms of the levator ani muscle. What differentiates proctalgia fugax from levator ani syndrome is the onset, severity, and duration of symptoms.

With proctalgia fugax, the pain often occurs at night, causing spasms painful enough to awaken a person from sleep. In some cases, the spasms are misinterpreted as the need to defecate. While the cramping of the rectum and anus can be abrupt and severe, it tends to be short-lasting, resolving within minutes.

As with levator ani syndrome, the diagnosis is based purely on symptoms. There are no recommended treatments for proctalgia fugax, but calcium channel blockers, topical nitroglycerin, Botox injections, and local anesthetic blocks have been proposed.

Colitis

Colitis is inflammation of the colon (large intestine). It can be caused by infections like Clostridioides difficile, inflammatory bowel diseases like Crohn’s disease or ulcerative colitis, immune-mediated disorders like microscopic colitis, or conditions that impede blood flow to the colon (like bowel obstruction or atherosclerosis).

Depending on the underlying cause, the symptoms of colitis can range in severity from mild to debilitating. Common symptoms include abdominal cramping, pain, diarrhea, bloody stools, and bloating. Severe cases can manifest with fever, fatigue, chills, joint pain, nausea, vomiting, and dehydration.

An endoscopic exam is central to the diagnosis, involving either colonoscopy, sigmoidoscopy, or capsule endoscopy. A stool sample will also be taken. Imaging studies, such as CT, MRI, or an abdominal ultrasound, may also be ordered.

The causes of colitis are varied, and the prescribed treatment can vary based on the cause. Treatments can include changes in diet, antibiotics, stress reduction, long-term immunosuppressant therapy, or surgery.

Anorectal Fistula

An anorectal fistula is a small tunnel that develops between the end of the bowel and the skin near the anus or rectum. A fistula is usually the aftermath of an anorectal abscess in which the drainage of pus can leave behind an abnormal channel. Sexually transmitted infections, inflammatory bowel diseases, and radiation therapy are among the common causes.

Depending on the location of the fistula, symptoms may include itching, discomfort, anal swelling, pain with defecation, and a mucus- or pus-like discharge. The symptoms are similar to those of an anorectal abscess and difficult to differentiate without a medical evaluation.

Although the diagnosis of a fistula is similar to that of an anorectal abscess, fistulas are typically treated with fistulotomy, a surgical procedure used to open and drain the channel. While most fistulas are treated this way, smaller ones may heal with a course of antibiotics.

Tenesmus

Tenesmus is not a condition but a symptom in which you feel the need to defecate even though the bowels are empty. Tenesmus is characterized by persistent discomfort and a feeling of fullness. While it generally doesn't cause outright pain, it can if it leads to extreme or chronic straining to pass stool.

Among the conditions that cause tenesmus are:

• Anorectal abscess
• Colorectal cancer or tumors
• Colorectal radiation
• Crohn's disease
• Gastric motility disorders
• Infectious colitis
• Ulcerative colitis

The treatment of the underlying cause will usually resolve the symptoms of tenesmus.

Perianal Hematoma

A perianal hematoma is a pocket of blood that develops from a ruptured blood vessel near the anus. They are typically caused by activities that put extreme pressure on the blood vessels around the anus, such as weightlifting, pregnancy, bowel straining, severe coughing fits, certain medical procedures, and anal sex.

Symptoms tend to develop abruptly and cause pain and pressure ranging from mild to severe. The initial pain can be sharp but generally subsides over a period of days, during which there can be itching, throbbing, pain with defecation, and the formation of a visible lump. You can expect some bleeding at first, but this too will quickly subside once a blood clot forms.

Most perianal hematomas heal on their own without treatment. Larger ones may require drainage in the doctor's office, followed by oral painkillers and a topical ointment to help break up the clot.

Sexually Transmitted Infections

There are many sexually transmitted infections (STIs) that a person can get from anal sex, including chlamydia, genital herpes, gonorrhea, HIV, human papillomavirus (HPV), and syphilis. Some cause noticeable symptoms, and others may cause little to no symptoms at all.

Common symptoms of anal STIs include:

• Chlamydia: Rectal pain, rectal discharge, mucus on stools, rectal bleeding, painful bowel movements
• Genital herpes: Multiple ulcerative sores causing extreme pain, especially during bowel movements
• Gonorrhea: Rectal pain, discharge, itching, bleeding, painful bowel movements
• HIV: Usually none during the acute infection, although anorectal diseases are common in people with advanced HIV infection
• HPV: Anal warts that can cause itching, bleeding, mucus discharge, a feeling of a lump or mass inside the rectum
• Syphilis: Rectal itching, bleeding, tenesmus, rectal discharge, blood or mucus in stools

Rectal Injury or Trauma

Rectal trauma can occur for many reasons, including medical procedures, anal sex (including anal toys), sports, or injuries sustained during motorcycle or cycling accidents.

Depending on the cause, rectal trauma can lead to an anal fissure, rectal tears or hematoma, damage to perineal muscles and nerves, or damage to the anal sphincter muscles. As with all traumatic injuries, the pain can be severe and may be accompanied by rectal bleeding, bruising, abdominal pain, lightheadedness, pallor, and other signs of trauma.

The treatment is based on an evaluation by the emergency room doctors, which may involve a DRE, CT scan, and proctoscopy.

Rectovaginal Endometriosis

Rectovaginal endometriosis (RVE) is a severe form of endometriosis affecting around 4% of people with the disease. With RVE, the overgrowth of tissue infiltrates the vagina, rectum, and the connective tissues that support them (called the rectovaginal septum).

With RVE, the pelvic pain is typically chronic, often causing severe cramping and shooting pains. The pain may be accompanied by rectal bleeding, pain, constipation, abnormal periods, and pain during sex. The extent of RVE infiltration does not necessarily correspond to the severity of rectovaginal pain.

The diagnosis of RVE may involve a transvaginal ultrasound, laparoscopy, MRI, CT, or colonoscopy. Hormone therapy can improve symptoms in the majority of people with RVE, but for those with severe symptoms and deep infiltration, surgery may be needed to remove the tissue overgrowth.

Rectal Pain and Cancer

Different types of cancers can cause rectal pain, including anal cancer and rectal cancer. By and large, colon cancer is associated more with abdominal pain than rectal pain or discomfort. In addition to rectal pain, there may be anal itching, rectal discharge, tenesmus, a palpable mass, bleeding, and bloody stools.

When to See a Doctor

Rectal pain may be a sign of something serious or something relatively benign. By and large, it warrants an appointment to see your doctor.

There are times when immediate action is needed, particularly if the rectal pain is associated with a severe infection or is causing severe bleeding.

Call 911 or seek emergency care if:

• Rectal bleeding is profuse and can't be stopped
• Rectal bleeding is accompanied by lightheadedness, blue lips, shallow breathing, profuse sweating, or confusion
• Rectal pain is accompanied by high fever, chills, rapid heartbeat, or the inability to urinate
• Rectal pain is accompanied by severe diarrhea lasting for more than two days

A Word From Verywell

The important thing to remember is that rectal pain can be a sign of something serious (including anal cancer, which disproportionately affects gay and bisexual men with HIV).

If you have anal or rectal pain, don't let nervousness prevent you from getting it looked at. In the end, your rectal health is every bit as important as your heart, lungs, brain, and bones.