Causes and Treatment of Rectal Cramps and Pain

Rectal pain is a common health condition that people try their best to ignore and hope will go away. They will often endure an itch, pain, or a sore for months and even years at a time out of embarrassment, and they avoid treatments that could otherwise make things better.

It's the kind of hesitancy that 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

While the rectum and anus are terms we often use interchangeably, they actually refer to 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 a stool enters 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, by contrast, is the opening of the rectum centered around two sphincters that control the exit of feces during defecation. Broadly speaking, any pain occurring in the rectum or anus is often caused by either 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. However, there may be clues that can point you to the underlying cause.

Anal Fissure

An anal fissure is a superficial tear in the thin, moist mucosal tissues that line the anus. They are common in people with a history of 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 occur in people of any age group.

Anal fissures are characterized by rectal discomfort that worsens when passing stools, causing pain that is sharp and sometimes excruciating. There may be bleeding, although generally not profuse. The pain can persist for hours after a bowel movement.

The diagnosis of anal fissures typically involves a physical and endoscopic examination of the affected tissues. Treatment may be nonsurgical (involving topical anesthetics, topical nitroglycerin, blood pressure medications, or Botox injections) or surgical (to repair the tear).

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 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, diverticular disease, or inflammatory bowel disease (IBD), among other things.

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), blood tests to check for signs of infection, and a computed tomography (CT) or magnetic resonance imaging (MRI) scan if cellulitis is suspected.

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, although 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 treatment for the condition, although walking, warm baths, and rectal massage often seem to help. Electrostimulation therapy and therapeutic ultrasound have been proposed as treatments.

Hemorrhoids

A hemorrhoid is an swollen vein (or collection of veins) in and around the rectum. Hemorrhoids can be internal or external and vary in size 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, anal fissure, infection, 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 (prolapse) through the opening of the anus and cause significant pain and irritation.

The diagnosis is based on a physical exam, DRE, or anoscope if needed. Treatment options range from hemorrhoid creams, ice application, stool softeners, and sitz baths to 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 the inflammation of the large intestine (colon). It can be caused by infections like Clostridium 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.

Because the causes of colitis are so varied, the prescribed treatment may involve everything from changes in diet, antibiotics, and stress reduction to long-term immunosuppressant therapy and 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 are commonly passed during anal sex, including chlamydia, genital herpes, gonorrhea, HIV, human papillomavirus (HPV), and syphilis. Some cause more overt 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 itch, 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. With that said, 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

When there is rectal pain—particularly severe or chronic rectal pain—many people worry about whether it is a sign of cancer. In the vast majority of cases, it is not, but that doesn't mean you should ignore any symptom that is severe or persistent.

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.

The color of the blood is a key sign as to where the bleeding is occurring. This is because the longer that blood remains in the intestines, the more the hemoglobin in blood will begin to oxidize and darken. Maroon or tarry stools suggest the tumor is higher up in the colon, while bright red blood suggests the bleeding is nearer the rectum and anus.

When to See a Doctor

Rectal pain may be a sign of something serious or something relatively benign. By and large, any symptom that persists or worsens warrants an investigation by a doctor. Rather than ignoring the symptom or living with it, take the time to see a doctor.

With that said, 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 may seem silly and embarrassing, but it can often 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.