What Causes Anal & Rectal Pain — and How Pelvic Floor PT Can Help
When you feel pain in your anus or rectum, it’s common to react in one of two ways: Assume it’s no big deal and never mention it to a doctor — or worry that it's anal cancer and consider driving yourself to the ER. If you fall into the latter group, let us reassure you that, unless you have risk factors for anal cancer, pain alone is very unlikely to be due to cancer. That said, brushing it off isn’t a good idea, either.
Anytime you have persistent or recurring rectal pain, it’s important to let your healthcare provider know so they can assess your symptoms.
Read on to learn about what causes rectal pain and the treatment options that can help you feel better.
What Anal or Rectal Pain Can Feel Like
Rectal pain refers to pain or discomfort felt in and around the rectum or anus — and it can range from uncomfortable to unbearable. The good news is that most causes of this common condition are easily treatable, and working with a pelvic floor physical therapist is often key to getting relief.
Depending on what’s causing your symptoms, anal or rectal pain can feel a bit different for everyone. Pain can be nagging and nonstop, or it may feel like a sharp or aching pain that only occurs during certain activities.
For example, you may experience:
- Painful poops
- Rectal pain or discomfort during sex
- Rectal pain before, during, or after sitting
- Rectal pain at night
Depending on what is causing your symptoms, you may also notice:
- Minor anal bleeding
- Anal itching
- Anal discharge
- Bowel dysfunction (constipation, diarrhea, or both)
Is Painful Pooping & Other Rectal Pain Common?
Research has found that nearly 1 in 4 women will be impacted by this frustrating symptom at some point in their lives. In reality, that number is likely much higher — one study involving 1,061 people found that only 15% said they had anal pain when verbally asked about their symptoms, yet a physical exam revealed that pain was present in 76%. If you’re experiencing rectal or anal pain, know that you’re certainly not alone and talking to your doctor is worth the effort.
Medical Conditions that Cause Rectal Pain
There are a handful of medical conditions (i.e. identifiable tissue injury or disease) that cause rectal pain. The most common include:
Anal fissures: These are small tears in the fragile anal tissue that can bleed and cause recurrent anal pain during and after bowel movements. People with anal fissures often have pelvic floor muscle tension that makes it hard to relax these muscles during bowel movements.
Hemorrhoids: When placed under a lot of pressure, the veins in the anus and lower rectum can bulge and distend, forming what are known as hemorrhoids. Pregnancy, pushing during childbirth, and straining during bowel movements can increase your risk of developing hemorrhoids.
Hemorrhoids can occur externally where they can be seen, or internally where they are less obvious. Hemorrhoids can also bleed, or even form blood clots in the distended veins which can lead to sudden and increased rectal pain.
Anal abscess: When clogged or infected, the glands near the anus can form an abscess that leads to rectal pain.
Skin conditions: Various skin conditions can cause rectal pain if they impact the tissues of the rectum or anus, including rash/dermatitis, anal warts, herpes lesions or postherpetic neuralgia, lichens sclerosis or lichens planus.
Inflammatory bowel diseases: Crohn’s Disease and Ulcerative Colitis are known to contribute to symptoms of rectal pain.
Infection: Sexually transmitted infections (STIs), bacterial infections, or fungal infections can cause rectal pain.
Endometriosis: If you have endometriosis — an inflammatory gynecological condition in which tissue similar to the lining of the uterus grows outside of the uterus — it can also impact your rectum, causing pain and bowel dysfunction.
Functional Disorders That Cause Anal & Rectal Pain
Anal and rectal pain can also be caused by a functional disorder, which refers to pain that isn’t related to an underlying medical condition. In all functional anorectal pain disorders, the pelvic floor plays a significant role.
Pelvic floor muscle dysfunction: Your pelvic floor muscles wrap around and provide support to your rectum and anus. These muscles are a very common cause of conditions that lead to rectal pain. When they become tight, overactive, uncoordinated, and/or develop trigger points, the pain can feel like it’s coming from your rectum or anus (this is known as referred pain).
Coccydynia: Also known as tailbone pain, coccydynia can be another cause of rectal pain. Coccydynia can occur as a result of pain or dysfunction in the coccyx bone itself, or any of the surrounding structures including the ligaments, pelvic floor muscles, and hip muscles. Pain is usually the result of injury, sitting on a hard surface for too long, or an injury to the lumbar or sacral spine.
Rectal prolapse: When the rectum bulges down out of place, sometimes dropping outside of the anus, it’s known as a rectal prolapse. The prolapse itself is not typically painful, however, it can lead to difficult and obstructed bowel movements which can lead to rectal pain. It’s also possible to have pain as a result of rectal prolapse corrective surgery (rectopexy).
Pudendal Neuralgia: The pudendal nerve, which is one of the main nerves that provide sensation to the perineal area and pelvic floor (it even has a rectal branch that provides sensation to the anal area), can get entrapped or injured causing prolonged and chronic pain in the area of the perineum including the anus.
How is Rectal Pain Diagnosed?
While a topic as personal as rectal pain can be difficult to bring up with your healthcare provider, it’s important to get a proper diagnosis. For all causes of rectal pain, the first step is to determine if pain is a result of an underlying medical condition. Your doctor may conduct any or all of the following assessments to find out.
- A thorough medical history to get a better understanding of your symptoms and any aspects of your health history that could shed light on your pain.
- A visual inspection to identify things like external hemorrhoids or fissures, inflamed or injured tissues, or a skin condition.
- A physical rectal examination during which your physician inserts their finger into your rectum so they can feel for any abnormalities in the tissue.
- Lab work to rule out STIs or other kinds of infections.
- Various imaging techniques to check for suspected conditions. For example, an endoscopy which uses a thin, flexible camera can be used to inspect the lining of the rectum for abnormalities. More advanced imaging such as an MRI or CT scans can be used to rule out more pathological conditions such as cancer.
If these steps don’t reveal a cause of pain, your provider should check for functional anorectal disorders, ideally using the Rome Criteria for Functional Anorectal Pain as a guide (if they don't, it's okay to ask — they can always refer you to a pelvic floor PT if they're not familiar with these procedures).
Further analysis may include:
- Dynamic imaging such as defecography can be used to assess what the structures in your pelvic area are doing when you’re having a bowel movement. This can be helpful in diagnosing dyssynergic defecation, and internal rectal prolapse also known as intussusception.
- Balloon explosion testing: Despite the alarming name, this is a simplified, less invasive tool that can be used to both examine, and treat defecatory dysfunction when dyssynergia is present. During a balloon explosion test, a water-filled catheter balloon is inserted into the rectum, and then the patient is asked to expel the balloon. If it takes longer than 1 minute for the person to expel the balloon, then a defecation disorder can be diagnosed.
- Pelvic floor muscle examination: When the pelvic floor is involved — as it often is — a pelvic floor muscle examination will help to identify where your symptoms are coming from, and help guide treatment. When your symptoms include rectal pain, the examination will often include assessment of the muscles through the rectum (although this is not required), as well as examination of the coccyx and pudendal nerve.
How Rectal Pain is Treated
Most causes of rectal pain are easily treatable. After getting a diagnosis, the most common medical treatment options include:
- Medications: Medications can be used to help resolve infections, clear up skin conditions, or assist in managing pain. Topical medications such as Nitroglycerin and Nifedipine can be used to encourage healing in instances anal fissures. Botox injections have even been found helpful in certain instances for muscle-related rectal pain.
- OTC Options: When difficult bowel movements, fissures/ hemorrhoids, or other skin irritations are to blame, it’s common to first use dietary adjustments and over-the-counter supplementation to optimize your stool consistency. Soft, formed still are easier to pass and more gentle on torn anal tissue or veins, and can help with healing of tissues and resolution of pain (check out numbers 3 and 4 on the Bristol Stool chart in this helpful pooping guide). Sitz baths also encourage blood flow and healing in the area, and ice can be used to reduce swelling and ease pain.
- Surgery: Surgery may be an option for treating certain causes of rectal pain, for example when treating anal abscesses, muscle damage, and more recalcitrant hemorrhoids and anal fissures. Surgery is also extremely helpful for those who have endometriosis, as removing any lesions found on the rectum will often relieve associated rectal pain and dysfunction.
Pelvic Floor Physical Therapy for Anal & Rectal Pain
If you’re dealing with anal and rectal pain, pelvic floor physical therapy is likely to help. A 2022 randomized control trial found pelvic floor PT to be an effective treatment option in helping those with rectal pain, especially due to pelvic floor muscle dysfunction and anal fissures. Another randomized control trial found that both biofeedback and rectal balloon training — two treatments routinely used in pelvic physical therapy to treat pelvic floor muscle dyssynergia — were effective in reducing bowel function issues. Finally, a major literature review supports the use of pelvic floor physical therapy as a first-line treatment for all types of pelvic floor muscle dysfunctions, including overactive pelvic floor disorders and myofascial pain.
Pelvic floor physical therapy treatment for rectal pain often involves:
- Vaginal or anal dilators to help the pelvic floor muscles to move and stretch without pain
- Manual therapy to help reduce muscle activity, improve tissue flexibility, normalize joint mobility, improve blood flow, and reduce neural tension
- Exercises to help retrain pain-free movement and stability throughout the pelvic joints
- Biofeedback therapies including rectal balloon training, in order to help restore normal pelvic floor muscle proprioception and coordinated movement
- Lifestyle and behavioral modifications to improve bowel, bladder and sexual function
Compassionate Care for Rectal Pain at Origin
For any new and persistent or recurrent rectal pain, it’s best to check in with your primary healthcare provider to check for underlying medical conditions and find out if a referral to pelvic floor PT is right for you.
At Origin, our team of pelvic floor physical therapists treat issues like rectal pain every day, which means you can feel comfortable talking to your PT about any and all symptoms you might be experiencing. If you have anal or rectal pain, don’t hesitate to book a visit in-person or online.