Pain in the back passage: causes, diagnosis, treatment

Anorectal pain is a common symptom, but patients rarely rush to see a doctor because of the sensitive nature of the problem. At the same time, pain in the anus can indicate relatively simple conditions (anal fissure, haemorrhoids), urgent situations (pararectal abscess) or systemic diseases. In this article, we will discuss the typical causes, differences in symptoms, modern approaches to diagnosis and treatment, as well as when urgent medical attention is required.

When to see a doctor immediately

Before discussing the range of causes, it is important to know the signs that require immediate medical attention. They are not a diagnosis, but they indicate a high risk of complications and the need for examination by a proctologist.

The following symptoms are ‘red flags’ that should not be ignored.

• Severe, throbbing pain in the anus with fever, swelling, or redness of the tissues.
• Increasing pain in the anus at night, inability to sit or walk.
• Heavy bleeding from the rectum, weakness, dizziness.
• Pain in the anus after defecation with prolonged spasm and severe burning.
• Pus discharge, unpleasant odour, induration or ‘lump’ in the anal area.

These signs may correspond to a pararectal abscess, thrombosis of external haemorrhoidal nodes, severe anal fissure or other pathology requiring urgent care.

Why does the anus hurt: the main causes

Pain in the anus varies in intensity, duration and ‘character’ (sharp, stinging, pulling, throbbing). This helps to narrow down the causes.

• Anal fissure. A sharp tear in the mucous membrane in the area of the anus, most often after an episode of constipation. Typically, there is a sharp, ‘cutting’ pain in the anus during defecation, which lasts for another 15-60 minutes, with possible streaks of blood on the stool or toilet paper.
• Haemorrhoids. Internal haemorrhoids more often cause bleeding and a feeling of incomplete emptying; pain in the anus when sitting is more characteristic of thrombosis of external nodes or pinching.
• Pararectal abscess/fistula. Infection of the rectal glands leads to an abscess: throbbing pain in the anus, fever, local tenderness; after spontaneous rupture or surgical opening, a fistula may form with pus discharge.
• Proctalgia fugax, levator syndrome. Short night-time spasms or prolonged discomfort in the pelvic floor area without visible pathology; the pain is often ‘shooting’ and may occur during stress.
• Proctitis, proctocolitis, infections, STIs. Inflammation of the mucous membrane due to infectious agents (including STIs), non-specific intestinal diseases (IBD, Crohn’s disease) cause pain, itching, mucopurulent or bloody discharge, diarrhoea.
• Trauma, micro-tears after anal sex. Acute stabbing pain in the anus with bloody discharge, sometimes accompanied by infection.
• Dermatological causes. Contact dermatitis, eczema, psoriasis, or candidiasis of the anogenital area cause burning, itching, and pain.
• Coccydynia, pelvic floor muscle syndrome. When pain in the lower abdomen radiates to the anus or worsens when sitting, the source may be outside the intestine — sacrum, coccyx, muscle-fascial trigger points.
• Tumours of the rectum and anal canal. Prolonged discomfort, changes in bowel movements, bleeding, weight loss — symptoms that require immediate colonoscopy.
• Gynecological and urological conditions. In women, endometriosis, cysts, and inflammation of the pelvic organs can cause pain that radiates to the anus; in men, prostatitis or neuralgia can cause pain.

The same symptom can have different causes. Self-medication with painkillers or suppositories ‘for everything’ masks the symptoms and delays proper treatment.

How to distinguish pain in the anus by symptoms

Details of the course of the disease help to orientate yourself before the visit. This is not a self-diagnosis algorithm, but a hint about what questions to discuss with your doctor.

• Pain in the anus at night, short attacks — more often protalgia; if the night pain is prolonged with fever — think about an abscess.
• Acute ‘blade-like’ pain during and after defecation — typical for a fissure; blood — on paper, not mixed with faeces.
• Sudden lump and sharp pain when sitting — possible thrombosis of external haemorrhoids.
• Throbbing, bursting pain + swelling, fever — suspected abscess.
• Chronic pulling pain, ‘recoil’ in the perineum/coccyx area — pelvic floor syndrome, coccydynia, prostatalgia.

Symptoms often overlap. The final conclusion is made after examination and instrumental methods.

Diagnosis: what the doctor does

At ZDRAVO, we take an evidence-based approach and choose the shortest path to the right answer. First, we take a medical history and perform a physical examination, followed by targeted tests.

• Examination and digital rectal examination. These provide initial information about fissures, nodes, sphincter tone, and painful areas.
• Anoscopy/rectomanoscopy. These assess the mucous membrane, internal haemorrhoidal nodes, and sources of bleeding.
• Ultrasound of the perianal area, MRI of the small pelvis. These are used for abscesses/fistulas, to determine the spread of inflammation, and to plan surgery.
• Colonoscopy. Indicated for suspected inflammatory bowel disease, polyps, tumours, bleeding of unknown origin.
• Laboratory tests. Complete blood count, inflammatory markers, stool (coprogram, occult blood), smears/PCR for STIs.
• Related consultations. If necessary, a gynaecologist, urologist, neurologist, physiotherapist.

The results are summarised at an in-person appointment: the patient receives a diagnosis (or differential diagnosis) and a personalised plan with a timeline and follow-up visits.

Pain in the anus: treatment

The approach depends on the diagnosis, severity of pain, and concomitant diseases. We start with conservative measures and proceed to procedures/surgery only when indicated. Below are the key scenarios.

Anal fissure

Goal: to relieve sphincter spasm, heal the tear, normalise stool consistency.

• High-fibre diet (vegetables, whole grains), drinking 1.5–2 litres of water per day, mild laxatives (psyllium, lactulose) to reduce trauma to the mucosa.
• Sitting in warm baths for 10–15 minutes 2–3 times a day to reduce spasm and pain.
• Local remedies as prescribed by a doctor (short courses of anaesthetics; nitrate-based preparations or calcium channel blockers — only under the supervision of a specialist).
• Botulinum toxin injections or lateral internal sphincterotomy — for chronic fissures that do not heal conservatively.

The treatment strategy should be reviewed if the pain in the anus does not subside within 2–4 weeks or if signs of infection appear.

Haemorrhoids

Goal: to eliminate symptoms and prevent recurrence.

• Modification of diet and toilet habits: fibre, water, not sitting on the toilet for long periods, avoiding straining.
• Local remedies in short courses as prescribed (to reduce swelling and itching).
• Office procedures for internal haemorrhoids of stage II–III: rubber band ligation, infrared coagulation, sclerotherapy.
• Surgical treatment (haemorrhoidectomy, Longo method) — for severe, recurrent forms or complications.

If thrombosis of the external node occurs with sharp pain when sitting, early surgical removal of the thrombus is sometimes advisable.

Pararectal abscess and fistula

Goal: to quickly drain the infectious focus and prevent complications.

• The only effective method of treating an abscess is incision and drainage. Antibiotics are used additionally, as indicated (e.g., in cases of widespread inflammation or immunodeficiency).
• Rectal fistulas are treated surgically: fistulotomy, seton, ligatures, or modern sphincter-preserving techniques (LIFT, flaps).

Delay increases the risk of spreading the infection and forming a complex fistula.

Protalgia, levator syndrome, pelvic pain

Goal: to relieve muscle spasm, teach the patient self-help.

• Pelvic floor physiotherapy, biofeedback, relaxation techniques.
• Warm baths, short courses of antispasmodics as prescribed.
• Behavioural therapy: avoidance of triggers (stress, prolonged sitting), workplace ergonomics.

If pain in the anus is frequent and debilitating at night, discuss personal strategies with your doctor (inhaled bronchodilators are sometimes used as a ‘rescue’ measure, but only as prescribed).

Infections, STIs, dermatological conditions

Goal: etiotropic treatment and restoration of the barrier function of the skin/mucosa.

• Targeted antibacterial/antifungal therapy after confirmation of the diagnosis.
• Delicate hygiene: no aggressive detergents or fragrances; protect the skin with barrier creams.
• Examination and treatment of sexual partner if necessary.

Self-prescription of corticosteroid or antibiotic suppositories without a diagnosis is often harmful — do not do this.

Tumours, inflammatory bowel disease

Goal: early diagnosis and multidisciplinary treatment.

• Colonoscopy with biopsy — the standard for determining the source of bleeding, pain, and changes in stool.
• Treatment of IBD/Crohn’s disease — anti-inflammatory therapy, dietary control, gastroenterologist supervision.
• Cancer screening and treatment — according to current protocols, maintaining quality of life as a priority.

Self-help and prevention

Basic steps can help reduce the intensity of symptoms and the risk of recurrence. These tips are a supplement to treatment, not a replacement for it.

• Fibre 25–35 g/day and adequate water intake — soft stools cause less trauma to the mucous membrane.
• Regular exercise and ‘sitting hygiene’: do not sit on the toilet for long periods of time; use a footrest for optimal posture.
• Warm sitz baths for spasms and discomfort.
• Gentle hygiene without aggressive agents; soft paper or alcohol-free wet wipes.
• Control triggers: correct constipation/diarrhoea, avoid excessive pressure when lifting weights.

Do not apply hot compresses to painful lumps, do not use enemas and do not perform ‘self-enemas’ — this is dangerous.

Why does it hurt ‘below, but radiates to the anus’?

Patients often describe pain in the lower abdomen that radiates to the anus. This is a symptom of colon spasms (irritable bowel syndrome), gynaecological conditions (endometriosis, cystic formations), prostatitis, coccydynia, and neuralgia. Differential diagnosis is important here: we evaluate not only the rectum, but also adjacent organs, so as not to ‘treat the wrong thing.’

How a visit to ZDRAVO works

Our team’s goal is to relieve pain and eliminate its cause in the safest way possible. A visit usually includes: a confidential consultation and examination; if necessary, anoscopy and simple procedures on the day of the visit; a treatment plan with clear deadlines; recommendations on nutrition, hygiene, and physical activity. If pain in the anus requires surgery, we discuss the options, risks, and expected results.