Sensation of pain or pressure in rectum

Rectal pain is the symptom of pain in the area of the rectum. A number of different causes have been documented.

Anal pain is usually caused by:

Anal fissure

This typically presents with pain on defecation and blood spotting on toilet paper. These symptoms are due to an ischaemic mucosal ulcer within a high-pressure sphincter. The fissure is usually visible at inspection of the gently distracted anus (Pic. 1). 

Defecation is exquisitely painful, ‘it’s like passing razor blades’, resulting in a cycle of fear of defecation, constipation, mucosal trauma and sphincter spasm (the muscle that controls the anal opening). Digital examination is intolerable and should be avoided. Management requires medication. Persistent symptoms or atypical features, such as rolled edges or a lateral location, require examination under anaesthetic and biopsy (examination of a sample of tissue taken from the body). 

Peri-anal abscess

The symptoms are severe pain with point tenderness. Examination will reveal an obvious abscess or tender induration and swelling. An internal or submucosal abscess is an unusual variant, which is frequently missed because the peri-anal region appears normal. Digital examination is exquisitely painful and mandates anaesthetic. 

The management remains incision and drainage, with antibiotics occasionally used as an adjunct to surgery in a few selected patients. 

Acutely prolapsed thrombosed piles

The primary symptom is severe pain, often requiring hospital admission. Examination reveals a tender, oedematous, haemorrhoidal mass (a part of normal human anatomy and become a pathological disease only when they experience abnormal changes) protruding from the anus (Pic. 2), which is often circumferential and occasionally mistaken for a rectal prolapse. 

Treatment can be conservative or surgical. A randomised control trial comparing surgery to conservative management demonstrated that conservative management is appropriate for many patients.

Peri-anal haematoma

This is caused by the rupture of a subcutaneous blood vessel in the peri-anal region and is sometimes incorrectly called an ‘external pile’. This purple pea-sized swelling is tender but not inflamed. 

It is easily managed by scalpel incision after instillation of local anaesthetic via an insulin syringe. Success is confirmed by the expression of a blood clot and a grateful patient. Scalpel incision should be reserved for acute lesions as delayed presentation results in a more diffuse swelling which is best managed conservatively.

Anorectal cancer

Occasionally a low-lying cancer arising from the anus or rectum can cause severe anal pain due to sepsis or sphincter invasion (Pic. 3). However, it is important to realise that the absence of pain does not exclude cancer. 

Any abnormality palpable in the anal canal must be regarded as cancer until proven otherwise. Internal haemorrhoids are not palpable on digital examination and are diagnosed with a proctoscope (Pic. 4).

Ectopic pregnancy

Ectopic pregnancies implant outside the endometrial cavity. Symptoms and signs of ectopic pregnancy vary but include abdominal or pelvic pain, missed period, vaginal bleeding, and gastrointestinal or urinary symptoms as well as pressure or pain on defecation. Rectal pain is getting worse if the ectopic pregnancy ruptures. Ectopic pregnancy resulting in perforation of the rectum and rectal bleeding is clinically rare.