Rectal pain is discomfort arising in the anorectal area, often described by patients as pain in the rectum, anus, or perianal region. Because the mucocutaneous border of the anal canal and perianal skin contains somatic nerve fibers, lesions in this area are particularly painful. Pain may be aggravated by defecation, constipation, diarrhea, or prolonged irritation from mucus, blood, or fecal matter.

Pathophysiology

• Pain arises from inflammation, trauma, infection, or obstruction in the anorectal area.

• The internal sphincter separates the anal canal from the rectum, but patients often perceive pain as generalized rectal discomfort.

• Secondary irritation from pruritus, scratching, or drainage exacerbates the pain.

History and Physical Examination

History:

• Ask the patient to describe the pain: sharp or dull, burning or knifelike.

• Determine frequency, duration, and severity, especially in relation to defecation.

• Ask about associated symptoms: bleeding, mucus or pus drainage, constipation, diarrhea, pruritus.

• Record bowel habits and diet, and note any avoidance of defecation due to pain.

Physical Examination:

• Inspect for bleeding, drainage, protrusions, skin tags, or thrombosed hemorrhoids.

• Assess for inflammation or lesions.

• A digital rectal examination may be necessary to identify internal pathology.

• Additional diagnostic evaluation may include anoscopy, proctosigmoidoscopy, or stool sampling.

Medical causes

Special considerations

• Pain Management: Apply analgesic ointments or suppositories.

• Constipation Prevention: Administer stool softeners.

• Hemorrhoid Care: Cold compresses can reduce swelling and pain.

• Positioning: Trendelenburg or buttocks elevation may relieve discomfort.

• Diagnostics: Prepare patient for anoscopy, proctosigmoidoscopy, and stool analysis.

• Emotional Support: Maintain privacy and reassure patients who may feel embarrassed.

Patient counseling

• Advise on pain relief strategies and preventive measures.

• Emphasize adequate fluid intake, high-fiber diet, and stool softeners.

• Discuss proper hygiene and avoidance of prolonged straining during defecation.

Pediatric considerations

• Acute anal fissure is common in children and may lead to constipation due to fear of pain.

• Assess for bleeding, drainage, infection, or congenital anorectal anomalies in infants.

• Consider sexual abuse in all children presenting with rectal pain.

Geriatric considerations

• Elderly patients may underreport rectal pain and have higher risk of neoplastic anorectal disorders.

• Thorough evaluation is essential to rule out malignancy or chronic pathology.

References

1. Berkowitz CD. Berkowitz’s Pediatrics: A Primary Care Approach. 4th ed. USA: American Academy of Pediatrics; 2012.

2. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.

3. McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights, MO: Mosby Elsevier; 2010.

4. Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.