Materiały źródłowe

• #1 Anal Pain: What It Is, Causes & Treatment

  https://my.clevelandclinic.org/health/symptoms/anal-pain

  Anal pain is a common condition with many possible causes. Most aren’t serious, but some may require treatment. It’s important to acknowledge anal pain and notice if it gets worse or doesn’t get better. […] Some of the most common causes of anal pain include: Hemorrhoids, swollen blood vessels inside your anus or rectum. Infections, including sexually transmitted infections (STIs) and fungal infections. Perianal abscess caused by an infected anal gland. Anal fissures, small tears in your anal lining. Trauma, from straining to pass hard poops or from anal penetration. Pudendal neuralgia, a condition that affects your pudendal nerve. It’s responsible for sensation in your anal and genital areas. […] Some of the less common causes of anal pain include: Anal fistula, a tunnel that develops when an anal abscess erodes through your skin. Inflammatory bowel disease (IBD) in your rectum, like ulcerative colitis or Crohn’s disease. Rectal ulcers, due to IBD or solitary rectal ulcer syndrome. Levator ani syndrome or proctalgia fugax, conditions that cause anal muscle spasms. Cancer in your anus or in your rectum. Anal pruritus, a skin condition that can cause intense itching.

• #2 Anal pain

  https://www.mayoclinic.org/symptoms/anal-pain/basics/causes/sym-20050918

  Causes of anal pain include: […] Pudendal neuralgia, a nerve condition that causes extreme pain in the anal and pelvic area. […] Proctitis (inflammation of the lining of the rectum). […] Ulcerative colitis a disease that causes ulcers and swelling called inflammation in the lining of the large intestine. […] Anal fissure (a small tear in the lining of the anal canal). […] Anal fistula (an abnormal channel between the anus or rectum usually to the skin near the anus). […] Hemorrhoids (swollen and inflamed veins in your anus or rectum). […] Crohn’s disease which causes tissues in the digestive tract to become inflamed. […] Proctalgia fugax (fleeting pain due to rectal muscle spasm). […] Anal or rectal stricture (narrowing that may occur from scarring, severe inflammation or cancer). […] Trauma.

• #3 Anorectal and perineal pain: new pathophysiological hypothesis – PubMed

  https://pubmed.ncbi.nlm.nih.gov/15309642/

  Anorectal and perineal pain has been described in association with a variety of organic conditions but can also occur under circumstances in which organic disorders are absent and pathophysiology is uncertain. […] The three most common functional disorders causing anorectal and perineal pain are levator ani syndrome, coccygodynia and proctalgia fugax; Alcock’s canal syndrome is also responsible for pain in these areas. […] We review current concepts about these disorders and the approach to diagnosis and management, and offer a provocative interpretation of the role of psychological factors.

• #4 Chronic anal pain: A review of causes, diagnosis, and treatment | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/89/6/336

  Chronic anal pain is difficult to diagnose and treat, especially with no obvious anorectal cause apparent on clinical examination. This review identifies 3 main diagnostic categories for chronic anal pain: local causes, functional anorectal pain, and neuropathic pain syndromes. Conditions covered within these categories include proctalgia fugax, levator ani syndrome, pudendal neuralgia, and coccygodynia. The signs, symptoms, relevant diagnostic tests, and main treatments for each condition are reviewed. […] Functional anorectal pain syndromes can be subdivided into 3 diagnoses with management individualized for each, albeit with a limited evidence base. […] Neuropathic pain syndromes are rare but can be positively diagnosed to allow specific management. […] Levator ani syndrome also called pelvic myalgia, pelvic floor myofascial pain, and pelvic floor muscle spasm is chronic anal pain resulting from tension or spasms in the levator muscles leading to compression of nerve endings and pain via peripheral sensitization.

• #5 Chronic anal pain: A review of causes, diagnosis, and treatment | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/89/6/336

  Coccygodynia is pain arising in or around the coccyx depending on its position. The pain is considered to arise from instability of the coccyx with or without pelvic floor spasm. […] Pudendal neuralgia occurs when the pudendal nerve is compressed by the obturator fascia as it forms the Alcock canal. […] Phantom rectum syndrome is a possible diagnosis when an organic source for pain such as perineal hernia or pelvic sepsis is excluded after proctectomy. […] Paroxysmal extreme pain disorder is a genetic disorder caused by a mutation in the SCN9A gene. The patient usually has a family history and onset in the neonatal period or during infancy.

• #6 Proctalgia fugax – Wikipedia

  https://en.wikipedia.org/wiki/Proctalgia_fugax

  Proctalgia fugax, a variant of levator ani syndrome, is a severe, episodic pain in the regions of the rectum and anus. It can be caused by cramping of the levator ani muscle, particularly in the pubococcygeal part. […] Because of the high incidence of internal anal sphincter thickening with the disorder, it is thought to be a disorder of that muscle or that it is a neuralgia of pudendal nerves. […] In one study of 68 people with proctalgia fugax, 55 had tenderness along the course of the pudendal nerve. Pudendal nerve block relieved symptoms completely in 65% of the participants and reduced symptoms in 25%. This suggests that a major cause of proctalgia fugax may be pudendal neuralgia.

• #7 Anal Fissure: Practice Essentials, Anatomy, Pathophysiology and Etiology

  https://emedicine.medscape.com/article/196297-overview

  An anal fissure is a painful linear tear or crack in the distal anal canal, which, in the short term, usually involves only the epithelium and, in the long term, involves the full thickness of the anal mucosa. […] The exact etiology of anal fissures is unknown, but the initiating factor is thought to be trauma from the passage of a particularly hard or painful bowel movement. Low-fiber diets (eg, those lacking in raw fruits and vegetables) are associated with the development of anal fissures. […] Initial minor tears in the anal mucosa due to a hard bowel movement probably occur often. In most people, these heal rapidly without long-term sequelae. In patients with underlying abnormalities of the internal sphincter, however, these injuries progress to acute and chronic anal fissures. […] The most commonly observed abnormalities are hypertonicity and hypertrophy of the internal anal sphincter, leading to elevated anal canal and sphincter resting pressures.

• #8 Anal Fissure: Practice Essentials, Anatomy, Pathophysiology and Etiology

  https://emedicine.medscape.com/article/196297-overview

  The posterior anal commissure is the most poorly perfused part of the anal canal. In patients with hypertrophied internal anal sphincters, this delicate blood supply is further compromised, thus rendering the posterior midline of the anal canal relatively ischemic. […] Pain accompanies each bowel movement as this raw area is stretched and the injured mucosa is abraded by the stool. The internal sphincter also begins to spasm when a bowel movement is passed. This spasm has two effects: First, it is painful in itself, and second, it further reduces the blood flow to the posterior midline and the anal fissure, contributing to the poor healing rate.

• #9

  https://fascrs.org/patients/diseases-and-conditions/a-z/anal-fissure-expanded-information

  Anal fissures are usually caused by trauma to the inner lining of the anus. […] The injury to the tissue creates severe anal pain, resulting in anal sphincter spasm and a subsequent increase in anal sphincter muscle pressure. […] The increase in anal sphincter muscle pressure results in a decrease in blood flow to the site of the injury, thus impairing healing of the wound. […] Ensuing bowel movements result in more pain, more anal spasm, diminished blood flow to the area, and the cycle is propagated. […] Treatment strategies are aimed at interrupting this cycle to promote healing of the fissure. […] The goal of these surgical options is to promote relaxation of the anal sphincter, thereby decreasing anal pain and spasm, allowing the fissure to heal.

• #10 Chronic anal pain: A review of causes, diagnosis, and treatment | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/89/6/336

  Chronic anal pain is difficult to diagnose and treat, especially with no obvious anorectal cause apparent on clinical examination. This review identifies 3 main diagnostic categories for chronic anal pain: local causes, functional anorectal pain, and neuropathic pain syndromes. Conditions covered within these categories include proctalgia fugax, levator ani syndrome, pudendal neuralgia, and coccygodynia. The signs, symptoms, relevant diagnostic tests, and main treatments for each condition are reviewed. […] Functional anorectal pain syndromes can be subdivided into 3 diagnoses with management individualized for each, albeit with a limited evidence base. […] Neuropathic pain syndromes are rare but can be positively diagnosed to allow specific management. […] Levator ani syndrome also called pelvic myalgia, pelvic floor myofascial pain, and pelvic floor muscle spasm is chronic anal pain resulting from tension or spasms in the levator muscles leading to compression of nerve endings and pain via peripheral sensitization.

• #11 Common causes of anal or rectal pain, and how to treat them | Digestive | Men’s Health | Prevention | Women’s Health | UT Southwestern Medical Center

  https://utswmed.org/medblog/anal-rectal-pain-causes/

  Hemorrhoids are veins in the rectum that are usually internal but can stick out through the rectum. When there is too much pressure on the veins, usually caused by straining during bowel movements or sitting for long periods of time, the hemorrhoids can become enlarged or swollen. […] Anal fissures are one of the most common causes of anal pain we see in our clinic they are commonly self-misdiagnosed as hemorrhoids. These are cuts in the anal tissue that can occur after large, hard stools or profuse diarrhea episodes and can reopen without proper treatment. […] Pain can be caused by spasms of the pelvic floor muscles, anal sphincter, or rectum. These spasms should be evaluated by a pelvic floor expert. […] People with PFDs are at increased risk of fissures and hemorrhoids due to constipation issues that can arise from spasms and cramping.

• #12 Proctalgia Fugax: What It Is, Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/proctalgia-fugax

  Proctalgia fugax is severe anal pain that comes on suddenly, lasts briefly and often disappears as unexpectedly as it began. The anal pain isnt a one-time thing. Instead, it recurs (comes back) in episodes that may happen over several weeks or months. Proctalgia fugax doesnt involve tissue damage, but the pain can be so intense that it prevents you from going to work or school. […] The pain associated with proctalgia fugax involves the nerves and muscles associated with these organs. […] Some studies show that proctalgia fugax may arise from muscle spasms in your anal sphincter muscles or other pelvic floor muscles can cause anal pain. […] Damage to your pudendal nerve, also called pudendal neuralgia, may lead to proctalgia fugax. Your pudendal nerve carries electrical signals that allow you to experience sensations in your pelvic muscles, including muscles in your anus.

• #13 Proctalgia fugax and anal pain: Causes, diagnosis, and home remedies

  https://www.medicalnewstoday.com/articles/317254

  Proctalgia fugax refers to the sudden onset of severe pain in the rectal area, which can last from seconds to minutes. The pain is sporadic, can be without warning, and occurs due to muscle spasms in the anal canal. […] The exact cause of proctalgia fugax is unclear, but the pain is due to muscles in the anal canal and pelvic floor tightening suddenly. […] This muscle tightening is called spasming. Spasms often occur in the smooth muscles of the anal canal and the anal sphincter. […] Muscle tension and twitching are natural responses to stressful situations. […] These responses may cause a persons anal muscles to tense or cramp during periods of anxiety or emotional stress, leading to proctalgia symptoms. […] To diagnose proctalgia fugax, a doctor will primarily assess the severity and duration of a persons symptoms. Proctalgia fugax causes sharp, stabbing pain for 30 minutes or less.

• #14 Anal Fissure Causes, Hemorrhoid, Pain, Treatment & How to Heal

  https://www.medicinenet.com/anal_fissure/article.htm

  Anal fissures occur in the specialized tissue that lines the anus and anal canal, called anoderm. […] Studies of the anal canal in patients with anal fissures consistently show that the muscles surrounding the anal canal are contracting too strongly (they are in spasm), thereby generating a pressure in the canal that is abnormally high. […] When an anal fissure is present, the internal anal sphincter is in spasm. […] It is thought that the high resting pressure and the „overshoot” contraction of the internal anal sphincter following a bowel movement pull the edges of the fissure apart and prevent the fissure from healing. […] The supply of blood to the anus and anal canal also may play a role in the poor healing of anal fissures. […] Anatomic and microscopic studies of the anal canal on cadavers found that in 85% of individuals, the posterior part of the anal canal (where most fissures occur) has less blood flowing to it than the other parts of the anal canal.

• #15 Anal Fissure Causes, Hemorrhoid, Pain, Treatment & How to Heal

  https://www.medicinenet.com/anal_fissure/article.htm

  This relatively poor flow of blood may be a factor in preventing fissures from healing. […] Nitroglycerin has been shown to cause relaxation of the internal anal sphincter and to decrease the anal resting pressure. […] This relieves spasms of the muscle and also may increase the flow of blood, both of which promote the healing of fissures. […] The primary side effect of botulinum toxin is the weakness of the sphincters with varying degrees of incontinence (leakage of stool) that usually is transient. […] In some series of patients but not all, the frequency of healing of fissures with botulinum toxin is high. […] Following surgery, 93% to 97% of fissures heal. […] Recurrence rates after this type of surgery are low, 0% to 3%.

• #16 Hemorrhoids: Background, Anatomy, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/775407-overview

  Hemorrhoids are swollen blood vessels in the lower rectum. They are among the most common causes of anal pathology, and subsequently are blamed for virtually any anorectal complaint by patients and medical professionals alike. […] Because of their rich vascular supply, highly sensitive location, and tendency to engorge and prolapse, hemorrhoidal venous cushions are common causes of anal pathology. […] Symptoms can range from mildly bothersome, such as pruritus, to quite concerning, such as rectal bleeding. […] Hemorrhoids generally cause symptoms when they become enlarged, inflamed, thrombosed, or prolapsed. […] Abnormal swelling of the anal cushions causes dilatation and engorgement of the arteriovenous plexuses. This leads to stretching of the suspensory muscles and eventual prolapse of rectal tissue through the anal canal.

• #17 Hemorrhoids: Background, Anatomy, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/775407-overview

  The engorged anal mucosa is easily traumatized, leading to rectal bleeding that is typically bright red due to high blood oxygen content within the arteriovenous anastomoses. […] Internal hemorrhoids cannot cause cutaneous pain, because they are above the dentate line and are not innervated by cutaneous nerves. However, they can bleed, prolapse, and, as a result of the deposition of an irritant onto the sensitive perianal skin, cause perianal itching and irritation. […] Internal hemorrhoids can produce perianal pain by prolapsing and causing spasm of the sphincter complex around the hemorrhoids. […] This spasm results in discomfort while the prolapsed hemorrhoids are exposed. […] Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. […] The pain is related to the sphincter complex spasm.

• #18 Anal pain

  https://www.mayoclinic.org/symptoms/anal-pain/basics/causes/sym-20050918

  Causes of anal pain include: […] Pudendal neuralgia, a nerve condition that causes extreme pain in the anal and pelvic area. […] Proctitis (inflammation of the lining of the rectum). […] Ulcerative colitis a disease that causes ulcers and swelling called inflammation in the lining of the large intestine. […] Anal fissure (a small tear in the lining of the anal canal). […] Anal fistula (an abnormal channel between the anus or rectum usually to the skin near the anus). […] Hemorrhoids (swollen and inflamed veins in your anus or rectum). […] Crohn’s disease which causes tissues in the digestive tract to become inflamed. […] Proctalgia fugax (fleeting pain due to rectal muscle spasm). […] Anal or rectal stricture (narrowing that may occur from scarring, severe inflammation or cancer). […] Trauma.

• #19 Common causes of anal or rectal pain, and how to treat them | Digestive | Men’s Health | Prevention | Women’s Health | UT Southwestern Medical Center

  https://utswmed.org/medblog/anal-rectal-pain-causes/

  This condition can present as rectal pain or rectal bleeding. If you’ve had pelvic radiation, it may damage the surrounding tissues, but that is a very rare side effect of radiation therapy. […] Inflammatory bowel disease can also cause proctitis, as can sexually transmitted infections (STIs). […] Commonly associated with the human papilloma virus (HPV), a sexually transmitted infection, anal condyloma causes lesions around the perineum, which is the tissue between the genitals and anus. […] Often, when a patient sees blood or feels pain in the anus, cancer is their first fear.

• #20 Common Causes of Anal Pain: Colon and Rectal Surgeons of Greater Hartford: Colon and Rectal Surgeons

  https://www.crsgh.com/blog/common-causes-of-anal-pain

  When you have anal pain, it could actually originate anywhere within the perianal area, which includes your anus, anal canal, and rectum. Your perianal area contains numerous nerve endings, which can easily become irritated and inflamed. The tissues in that area can also tear or ulcerate, which may cause bleeding. […] Anal pain could also be a symptom of an STD, including HPV infection. […] Digestive diseases such as Crohns disease and ulcerative colitis can cause pain throughout your digestive tract, including your anus. These diseases can be controlled, but not cured. […] Pelvic floor muscles that cant fully relax can make bowel movements painful. You might also have levator ani syndrome, in which the muscles around your anus spasm. Pelvic floor muscles can be retrained with physical therapy. […] Anal pain that persists for more than a couple of days could be a sign of a serious condition, including anal cancer. Benign pain, too, might need specialized treatment, including repairing traumatized tissues or removing diseased veins.

• #21 Rectal (anal) pain: Causes, treatment, and more

  https://www.medicalnewstoday.com/articles/326085

  A colonoscopy is a medical procedure that involves inserting a flexible tube called an endoscope into the anus and through the rectum to the colon. […] The skin around the rectum is very sensitive. Friction from sexual activity involving the anus or inserting objects into the rectum can cause injury, irritation, swelling, or bleeding. […] Other medical conditions that can cause rectal pain include inflammatory bowel disease (IBD), which includes Crohns disease and ulcerative colitis.

• #22 The Clinical Effect and Mechanism… preview & related info | Mendeley

  https://www.mendeley.com/catalogue/11b2922c-f6cc-3024-bb85-9b712f1ceb60/

  Anal pain and urinary retention are the two most outstanding complications of the procedure for prolapse and hemorrhoids (PPH) surgery. […] The role and mechanism of Prostant in patients and mice with urinary retention and anal pain were evaluated. […] Prostant effectively improved the urination status, lower abdomen symptoms, time to urinate and score of VAS, and the reduction of TNF- and IL-6. […] Mechanically, Prostant reversed the urinary retention-elevated the serum level of hs-CRP and TNF-, reduction of IL-2, imbalance of Treg/Th17, and level of JAK2 and phosphorylated STAT3. […] Prostant ameliorated the pain as shown by the reduction of writhing response, and the elevation of threshold of pain and degree of swelling. […] Prostant can treat patients and mice with anal pain and urinary retention by modulating the balance of Th17/Treg to regulate the secretion and production of inflammatory factors.

• #23

  https://link.springer.com/article/10.1007/s10151-011-0683-7

  Anal fissure is one of the most common and painful proctologic diseases. […] In the last decades, the understanding of its pathophysiology has led to a progressive reduction of invasive and potentially invalidating treatments in favor of conservative treatment based on anal sphincter muscle relaxation. […] Anal fissure is very painful, because it affects the multilayer squamous epithelium of the anoderm, which is richly innervated with pain fibers. […] For many years an association with internal anal sphincter (IAS) hypertonia has been evident, although in elderly patients and in postpartum patients cases of anal fissure have been reported that are associated with a normal or hypotonic IAS. […] The basal tone of the IAS is affected by various substances, including nitric oxide (NO).

• #24

  https://link.springer.com/article/10.1007/s10151-011-0683-7

  In patients with anal fissures, the synthesis of NO in the IAS is reduced in comparison with the controls. […] This pathogenetic mechanism can explain the achievement of a high rate of healing with medical therapies able to improve blood flow and/or to reduce hypertonia. […] The goal of medical treatment for chronic anal fissure is to achieve a temporary reduction of pressure of the anal canal, to facilitate the healing of the fissure (reversible sphincterotomy), thereby reducing muscle tone. […] Since the discovery of the role of NO as an inhibitor of IAS tone, the use of nitrates has been shown to reduce anal hypertonia and in many clinical contexts it has become the first-line therapy for chronic anal fissures. […] The introduction of topical nitrates has had an important impact on the reduction of the number of surgical procedures, especially in several European countries.

• #25 Nitroglycerin rectal: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing – WebMD

  https://www.webmd.com/drugs/2/drug-159329/rectiv-rectal/details

  Rectal nitroglycerin is commonly used to relieve pain in your anal region caused by a tear in the skin of your anus (anal fissure). […] Rectal nitroglycerin works by relaxing the sphincter muscles in the anus.

• #26 SciELO Brazil – Exploration of the mechanism underlying the therapeutic effect of electroacupuncture at chengshan acupoint on post-hemorrhoidectomy anal pain: Insights from the mAChRs/IP3-Ca²⁺-CaM signaling pathway Exploration of t

  https://www.scielo.br/j/clin/a/BhPhTDbQ5jbK8tLZsSvdV8d/?lang=en

  Objective In the context of postoperative anal pain, understanding the intricate mechanisms and effective interventions is paramount. This study investigates the role of Muscarinic Acetylcholine Receptors (mAChRs) and the IP3-Ca2+-CaM signaling pathway in a rat model of postoperative anal pain, exploring the potential analgesic effects of electroacupuncture. […] The authors found elevated mAChRs expression in the postoperative pain model. Antagonizing mAChRs reduced pain sensitivity and attenuated the IP3-Ca2+-CaM pathway. Remarkably, electroacupuncture treatment further mitigated pain, potentially by suppressing this signaling cascade. […] These findings reveal a novel connection between mAChRs and the IP3-Ca2+-CaM pathway in postoperative anal pain and suggest electroacupuncture as a promising avenue for pain relief through these mechanisms, offering insights into innovative strategies for postoperative pain management.

• #27 SciELO Brazil – Exploration of the mechanism underlying the therapeutic effect of electroacupuncture at chengshan acupoint on post-hemorrhoidectomy anal pain: Insights from the mAChRs/IP3-Ca²⁺-CaM signaling pathway Exploration of t

  https://www.scielo.br/j/clin/a/BhPhTDbQ5jbK8tLZsSvdV8d/?lang=en

  The mAChRs/IP3-Ca2+-CaM signaling pathway is involved in pain relief. Muscarinic Acetylcholine Receptors (mAChRs) are a type of acetylcholine receptor that form G protein-coupled receptor complexes in the cell membranes of certain neurons and other cells. […] This signaling pathway has been shown to play a role in pain relief, although the exact mechanisms are not yet fully understood. […] The present study endeavors to illuminate these mechanisms by meticulously exploring the intricate interplay between electroacupuncture, cholinergic signaling, and postoperative anal pain modulation. […] The present study aimed to elucidate the mechanisms underlying the analgesic effects of electroacupuncture at the Chengshan acupoint in post-hemorrhoidectomy anal pain. […] The significant upregulation of mAChRs, particularly the M2 and M3 subtypes, within the post-anal incision pain rat model, points toward their potential involvement in pain sensitivity.

• #28 Anal Pain: What It Is, Causes & Treatment

  https://my.clevelandclinic.org/health/symptoms/anal-pain

  A healthcare provider diagnosing your anal pain might ask you to describe the pain or ask if you have other symptoms along with it. This can offer clues to the possible causes of your anal pain. […] Anal pain that feels sharp or cutting might suggest an open wound, like an ulcer or fissure. Some people describe the muscle spasms in levator ani syndrome as a stabbing pain. A thrombosed hemorrhoid can also cause intense, localized pain. […] If you notice anal pain, particularly after pooping, it may be because pooping irritates your condition. An anal fissure is a common cause of pain after pooping because pooping stretches the fissure (tear). Pooping can also irritate hemorrhoids and cause them to bleed or to prolapse poke out of your anus. […] In many cases, you can treat anal pain at home. It often goes away within a few days. In other cases, it doesn’t get better or gets worse. It’s never a bad idea to check in with a healthcare provider about anal pain, especially if it’s severe, long-lasting or comes with other concerning symptoms, like rectal bleeding.

• #29 Anal Fissure: Practice Essentials, Anatomy, Pathophysiology and Etiology

  https://emedicine.medscape.com/article/196297-overview

  The posterior anal commissure is the most poorly perfused part of the anal canal. In patients with hypertrophied internal anal sphincters, this delicate blood supply is further compromised, thus rendering the posterior midline of the anal canal relatively ischemic. […] Pain accompanies each bowel movement as this raw area is stretched and the injured mucosa is abraded by the stool. The internal sphincter also begins to spasm when a bowel movement is passed. This spasm has two effects: First, it is painful in itself, and second, it further reduces the blood flow to the posterior midline and the anal fissure, contributing to the poor healing rate.

• #30 Anal Fissure Causes, Hemorrhoid, Pain, Treatment & How to Heal

  https://www.medicinenet.com/anal_fissure/article.htm

  Anal fissures occur in the specialized tissue that lines the anus and anal canal, called anoderm. […] Studies of the anal canal in patients with anal fissures consistently show that the muscles surrounding the anal canal are contracting too strongly (they are in spasm), thereby generating a pressure in the canal that is abnormally high. […] When an anal fissure is present, the internal anal sphincter is in spasm. […] It is thought that the high resting pressure and the „overshoot” contraction of the internal anal sphincter following a bowel movement pull the edges of the fissure apart and prevent the fissure from healing. […] The supply of blood to the anus and anal canal also may play a role in the poor healing of anal fissures. […] Anatomic and microscopic studies of the anal canal on cadavers found that in 85% of individuals, the posterior part of the anal canal (where most fissures occur) has less blood flowing to it than the other parts of the anal canal.

• #31 The clinical characteristics of patients with chronic idiopathic anal pain

  https://www.degruyter.com/document/doi/10.1515/med-2017-0015/html?lang=en

  The pathophysiology for chronic anal pain is complicated and might be accompanied with some hidden diseases. For example, in our study we found that most patients with chronic anal pain had FARP or disorders such as CP-CPPS, IC-PBS. […] The anus is located at the end of the digestive tract and in close proximity to the urinary tract and reproductive organs. The anus is also surrounded by peripheral nerve fibers and in a close relationship to the endocrine system. As a result, disorders in any of these related or adjacent systems may lead to chronic anal pain. […] Our study found that depression is common among patients with chronic anal pain. Long-term pain can inevitably cause psychological disturbance. […] In general, pain treatment for FARP patients is far challenging than the non-FARP patients because FARP has no obvious underlying anorectal or endopelvic organ disease symptom but it is a syndrome of idiopathic multi-factorial vague disorder resulting from a complex interaction among neurological, musculoskeletal and endocrine systems.

• #32 The clinical characteristics of patients with chronic idiopathic anal pain

  https://www.degruyterbrill.com/document/doi/10.1515/med-2017-0015/html?lang=en&srsltid=AfmBOorJksT9Q5RaJ_k6yxjVAhoVzwdsKRK9l4yrBsjhi1KcUhxlEORW

  The pathophysiology for chronic anal pain is complicated and might be accompanied with some hidden diseases. For example, in our study we found that most patients with chronic anal pain had FARP or disorders such as CP-CPPS, IC-PBS. […] The anus is located at the end of the digestive tract and in close proximity to the urinary tract and reproductive organs. The anus is also surrounded by peripheral nerve fibers and in a close relationship to the endocrine system. As a result, disorders in any of these related or adjacent systems may lead to chronic anal pain. […] Our study found that depression is common among patients with chronic anal pain. Long-term pain can inevitably cause psychological disturbance. Depression is more severe in patients with FARP as some researchers reported that depression occurs in about 30% of FARP patients.

• #33 Common Causes of Anal Pain: Colon and Rectal Surgeons of Greater Hartford: Colon and Rectal Surgeons

  https://www.crsgh.com/blog/common-causes-of-anal-pain

  When you have anal pain, it could actually originate anywhere within the perianal area, which includes your anus, anal canal, and rectum. Your perianal area contains numerous nerve endings, which can easily become irritated and inflamed. The tissues in that area can also tear or ulcerate, which may cause bleeding. […] Anal pain could also be a symptom of an STD, including HPV infection. […] Digestive diseases such as Crohns disease and ulcerative colitis can cause pain throughout your digestive tract, including your anus. These diseases can be controlled, but not cured. […] Pelvic floor muscles that cant fully relax can make bowel movements painful. You might also have levator ani syndrome, in which the muscles around your anus spasm. Pelvic floor muscles can be retrained with physical therapy. […] Anal pain that persists for more than a couple of days could be a sign of a serious condition, including anal cancer. Benign pain, too, might need specialized treatment, including repairing traumatized tissues or removing diseased veins.

• #34 Anal and Pelvic Pain

  https://www.surgeon.lk/conditions/perianal/analpain

  Pelvic pain and anal pain are often the result of an underlying condition that can be mild and temporary or be the signal of more serious disease. […] Proctalgia is a specific kind of pelvic pain. Just as spasms of neck muscles cause headaches, spasms of the pelvic muscles causes proctalgia. […] Proctalgia is pain due to a spasm of the pelvic floor muscles, the muscles of the anal sphincter, or the muscles of the rectum. This causes severe stabbing pain like a knife sticking into the rectum. […] A person with chronic proctalgia will experience pain that lasts more than twenty minutes. […] Proctalgia can be related to stress. It is common for doctors to refer to the mind-body connection when a person is dealing with considerable stress in their daily lives. The continued emotional stress causes the body to react, and the internal organs of the digestive system are acute receptors of stress.

• #35 Common causes of anal or rectal pain, and how to treat them | Digestive | Men’s Health | Prevention | Women’s Health | UT Southwestern Medical Center

  https://utswmed.org/medblog/anal-rectal-pain-causes/

  Hemorrhoids are veins in the rectum that are usually internal but can stick out through the rectum. When there is too much pressure on the veins, usually caused by straining during bowel movements or sitting for long periods of time, the hemorrhoids can become enlarged or swollen. […] Anal fissures are one of the most common causes of anal pain we see in our clinic they are commonly self-misdiagnosed as hemorrhoids. These are cuts in the anal tissue that can occur after large, hard stools or profuse diarrhea episodes and can reopen without proper treatment. […] Pain can be caused by spasms of the pelvic floor muscles, anal sphincter, or rectum. These spasms should be evaluated by a pelvic floor expert. […] People with PFDs are at increased risk of fissures and hemorrhoids due to constipation issues that can arise from spasms and cramping.

• #36 Anal & Rectal Pain Causes | Pelvic PT Solutions

  https://www.theoriginway.com/blog/what-causes-anal-rectal-pain-and-how-pelvic-floor-pt-can-help

  Anytime you have persistent or recurring rectal pain, its important to let your healthcare provider know so they can assess your symptoms. […] 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. […] 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 its coming from your rectum or anus (this is known as referred pain). […] If youre 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.

• #37 Anal Fissure: Practice Essentials, Anatomy, Pathophysiology and Etiology

  https://emedicine.medscape.com/article/196297-overview

  An anal fissure is a painful linear tear or crack in the distal anal canal, which, in the short term, usually involves only the epithelium and, in the long term, involves the full thickness of the anal mucosa. […] The exact etiology of anal fissures is unknown, but the initiating factor is thought to be trauma from the passage of a particularly hard or painful bowel movement. Low-fiber diets (eg, those lacking in raw fruits and vegetables) are associated with the development of anal fissures. […] Initial minor tears in the anal mucosa due to a hard bowel movement probably occur often. In most people, these heal rapidly without long-term sequelae. In patients with underlying abnormalities of the internal sphincter, however, these injuries progress to acute and chronic anal fissures. […] The most commonly observed abnormalities are hypertonicity and hypertrophy of the internal anal sphincter, leading to elevated anal canal and sphincter resting pressures.

• #38 Hemorrhoids: Background, Anatomy, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/775407-overview

  Hemorrhoids are swollen blood vessels in the lower rectum. They are among the most common causes of anal pathology, and subsequently are blamed for virtually any anorectal complaint by patients and medical professionals alike. […] Because of their rich vascular supply, highly sensitive location, and tendency to engorge and prolapse, hemorrhoidal venous cushions are common causes of anal pathology. […] Symptoms can range from mildly bothersome, such as pruritus, to quite concerning, such as rectal bleeding. […] Hemorrhoids generally cause symptoms when they become enlarged, inflamed, thrombosed, or prolapsed. […] Abnormal swelling of the anal cushions causes dilatation and engorgement of the arteriovenous plexuses. This leads to stretching of the suspensory muscles and eventual prolapse of rectal tissue through the anal canal.

• #39 Rectal (anal) pain: Causes, treatment, and more

  https://www.medicalnewstoday.com/articles/326085

  Rectal pain can result from injury, inflammation, or infections that affect the rectum or anus. […] Prostatitis occurs when the bacteria from the urinary tract or rectum reach the prostate. The condition may cause pain when urinating, along with rectal pain or pressure. […] Levator syndrome (LS) is a condition that causes episodic pain in the rectum or bony structures at the base of the spine. […] Proctalgia fugax (PF) is sudden and intense pain in the rectum that can last for several minutes at a time. […] Rectal prolapse can cause pressure and pain in the rectum or anus. […] Endometriosis is a condition in which tissue similar to the uterus lining grows in atypical places, such as the bowels. […] An anal fissure is a small tear in the lining of the anal canal, which is the end of the large intestine between the rectum and anus.

• #40 Rectal Pain: 9 Causes, Symptoms, Relief, and Treatment

  https://www.emedicinehealth.com/rectal_pain/article_em.htm

  The pain of levator ani syndrome is a constant or frequently occurring dull pain that is felt higher up inside the rectal passage. The sensation is made worse by sitting and improves with walking or standing. […] Colorectal pain may be a sign of colorectal cancer. […] Rectal pain, pressure or throbbing pain may occur with other primary problems like prostate problems, infections or other diseases. […] The best way to prevent rectal pain is to eat a high-fiber diet and drink plenty of water. This will produce soft stools that are easy to pass and result in fewer traumas to the anal passage.

• #41 The clinical characteristics of patients with chronic idiopathic anal pain

  https://www.degruyter.com/document/doi/10.1515/med-2017-0015/html?lang=en

  The pathophysiology for chronic anal pain is complicated and might be accompanied with some hidden diseases. For example, in our study we found that most patients with chronic anal pain had FARP or disorders such as CP-CPPS, IC-PBS. […] The anus is located at the end of the digestive tract and in close proximity to the urinary tract and reproductive organs. The anus is also surrounded by peripheral nerve fibers and in a close relationship to the endocrine system. As a result, disorders in any of these related or adjacent systems may lead to chronic anal pain. […] Our study found that depression is common among patients with chronic anal pain. Long-term pain can inevitably cause psychological disturbance. […] In general, pain treatment for FARP patients is far challenging than the non-FARP patients because FARP has no obvious underlying anorectal or endopelvic organ disease symptom but it is a syndrome of idiopathic multi-factorial vague disorder resulting from a complex interaction among neurological, musculoskeletal and endocrine systems.

• #42 The clinical characteristics of patients with chronic idiopathic anal pain

  https://www.degruyterbrill.com/document/doi/10.1515/med-2017-0015/html?lang=en&srsltid=AfmBOorJksT9Q5RaJ_k6yxjVAhoVzwdsKRK9l4yrBsjhi1KcUhxlEORW

  The pathophysiology for chronic anal pain is complicated and might be accompanied with some hidden diseases. For example, in our study we found that most patients with chronic anal pain had FARP or disorders such as CP-CPPS, IC-PBS. […] The anus is located at the end of the digestive tract and in close proximity to the urinary tract and reproductive organs. The anus is also surrounded by peripheral nerve fibers and in a close relationship to the endocrine system. As a result, disorders in any of these related or adjacent systems may lead to chronic anal pain. […] Our study found that depression is common among patients with chronic anal pain. Long-term pain can inevitably cause psychological disturbance. Depression is more severe in patients with FARP as some researchers reported that depression occurs in about 30% of FARP patients.

• #43 Proctalgia fugax and anal pain: Causes, diagnosis, and home remedies

  https://www.medicalnewstoday.com/articles/317254

  Proctalgia fugax refers to the sudden onset of severe pain in the rectal area, which can last from seconds to minutes. The pain is sporadic, can be without warning, and occurs due to muscle spasms in the anal canal. […] The exact cause of proctalgia fugax is unclear, but the pain is due to muscles in the anal canal and pelvic floor tightening suddenly. […] This muscle tightening is called spasming. Spasms often occur in the smooth muscles of the anal canal and the anal sphincter. […] Muscle tension and twitching are natural responses to stressful situations. […] These responses may cause a persons anal muscles to tense or cramp during periods of anxiety or emotional stress, leading to proctalgia symptoms. […] To diagnose proctalgia fugax, a doctor will primarily assess the severity and duration of a persons symptoms. Proctalgia fugax causes sharp, stabbing pain for 30 minutes or less.

• #44 Anal and Pelvic Pain

  https://www.surgeon.lk/conditions/perianal/analpain

  Pelvic pain and anal pain are often the result of an underlying condition that can be mild and temporary or be the signal of more serious disease. […] Proctalgia is a specific kind of pelvic pain. Just as spasms of neck muscles cause headaches, spasms of the pelvic muscles causes proctalgia. […] Proctalgia is pain due to a spasm of the pelvic floor muscles, the muscles of the anal sphincter, or the muscles of the rectum. This causes severe stabbing pain like a knife sticking into the rectum. […] A person with chronic proctalgia will experience pain that lasts more than twenty minutes. […] Proctalgia can be related to stress. It is common for doctors to refer to the mind-body connection when a person is dealing with considerable stress in their daily lives. The continued emotional stress causes the body to react, and the internal organs of the digestive system are acute receptors of stress.

• #45 The clinical characteristics of patients with chronic idiopathic anal pain

  https://www.degruyterbrill.com/document/doi/10.1515/med-2017-0015/html?lang=en&srsltid=AfmBOorJksT9Q5RaJ_k6yxjVAhoVzwdsKRK9l4yrBsjhi1KcUhxlEORW

  The pathophysiology for chronic anal pain is complicated and might be accompanied with some hidden diseases. For example, in our study we found that most patients with chronic anal pain had FARP or disorders such as CP-CPPS, IC-PBS. […] The anus is located at the end of the digestive tract and in close proximity to the urinary tract and reproductive organs. The anus is also surrounded by peripheral nerve fibers and in a close relationship to the endocrine system. As a result, disorders in any of these related or adjacent systems may lead to chronic anal pain. […] Our study found that depression is common among patients with chronic anal pain. Long-term pain can inevitably cause psychological disturbance. Depression is more severe in patients with FARP as some researchers reported that depression occurs in about 30% of FARP patients.

• #46 Anal Fissure: Practice Essentials, Anatomy, Pathophysiology and Etiology

  https://emedicine.medscape.com/article/196297-overview

  An anal fissure is a painful linear tear or crack in the distal anal canal, which, in the short term, usually involves only the epithelium and, in the long term, involves the full thickness of the anal mucosa. […] The exact etiology of anal fissures is unknown, but the initiating factor is thought to be trauma from the passage of a particularly hard or painful bowel movement. Low-fiber diets (eg, those lacking in raw fruits and vegetables) are associated with the development of anal fissures. […] Initial minor tears in the anal mucosa due to a hard bowel movement probably occur often. In most people, these heal rapidly without long-term sequelae. In patients with underlying abnormalities of the internal sphincter, however, these injuries progress to acute and chronic anal fissures. […] The most commonly observed abnormalities are hypertonicity and hypertrophy of the internal anal sphincter, leading to elevated anal canal and sphincter resting pressures.

• #47 Anal fissure – Symptoms and causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/anal-fissure/symptoms-causes/syc-20351424

  Anal fissures typically cause pain and bleeding with bowel movements. […] Common causes of anal fissures include constipation and straining during bowel movements. […] Straining during bowel movements and passing hard stools increase the risk of tearing. […] An anal fissure may extend into the ring of muscle that holds the anus closed. This muscle is called the internal anal sphincter. If this happens, it makes it more difficult for the anal fissure to heal. An unhealed fissure may trigger a cycle of discomfort that may require medicines or surgery to ease the pain and to repair or remove the fissure.

• #48 Anal Fissure: Practice Essentials, Anatomy, Pathophysiology and Etiology

  https://emedicine.medscape.com/article/196297-overview

  An anal fissure is a painful linear tear or crack in the distal anal canal, which, in the short term, usually involves only the epithelium and, in the long term, involves the full thickness of the anal mucosa. […] The exact etiology of anal fissures is unknown, but the initiating factor is thought to be trauma from the passage of a particularly hard or painful bowel movement. Low-fiber diets (eg, those lacking in raw fruits and vegetables) are associated with the development of anal fissures. […] Initial minor tears in the anal mucosa due to a hard bowel movement probably occur often. In most people, these heal rapidly without long-term sequelae. In patients with underlying abnormalities of the internal sphincter, however, these injuries progress to acute and chronic anal fissures. […] The most commonly observed abnormalities are hypertonicity and hypertrophy of the internal anal sphincter, leading to elevated anal canal and sphincter resting pressures.

• #49 Anal Fissure: Practice Essentials, Anatomy, Pathophysiology and Etiology

  https://emedicine.medscape.com/article/196297-overview

  An anal fissure is a painful linear tear or crack in the distal anal canal, which, in the short term, usually involves only the epithelium and, in the long term, involves the full thickness of the anal mucosa. […] The exact etiology of anal fissures is unknown, but the initiating factor is thought to be trauma from the passage of a particularly hard or painful bowel movement. Low-fiber diets (eg, those lacking in raw fruits and vegetables) are associated with the development of anal fissures. […] Initial minor tears in the anal mucosa due to a hard bowel movement probably occur often. In most people, these heal rapidly without long-term sequelae. In patients with underlying abnormalities of the internal sphincter, however, these injuries progress to acute and chronic anal fissures. […] The most commonly observed abnormalities are hypertonicity and hypertrophy of the internal anal sphincter, leading to elevated anal canal and sphincter resting pressures.

• #50 Anal Fissure: Practice Essentials, Anatomy, Pathophysiology and Etiology

  https://emedicine.medscape.com/article/196297-overview

  The posterior anal commissure is the most poorly perfused part of the anal canal. In patients with hypertrophied internal anal sphincters, this delicate blood supply is further compromised, thus rendering the posterior midline of the anal canal relatively ischemic. […] Pain accompanies each bowel movement as this raw area is stretched and the injured mucosa is abraded by the stool. The internal sphincter also begins to spasm when a bowel movement is passed. This spasm has two effects: First, it is painful in itself, and second, it further reduces the blood flow to the posterior midline and the anal fissure, contributing to the poor healing rate.

• #51

  https://link.springer.com/article/10.1007/s10151-011-0683-7

  Anal fissure is one of the most common and painful proctologic diseases. […] In the last decades, the understanding of its pathophysiology has led to a progressive reduction of invasive and potentially invalidating treatments in favor of conservative treatment based on anal sphincter muscle relaxation. […] Anal fissure is very painful, because it affects the multilayer squamous epithelium of the anoderm, which is richly innervated with pain fibers. […] For many years an association with internal anal sphincter (IAS) hypertonia has been evident, although in elderly patients and in postpartum patients cases of anal fissure have been reported that are associated with a normal or hypotonic IAS. […] The basal tone of the IAS is affected by various substances, including nitric oxide (NO).

• #52

  https://link.springer.com/article/10.1007/s10151-011-0683-7

  In patients with anal fissures, the synthesis of NO in the IAS is reduced in comparison with the controls. […] This pathogenetic mechanism can explain the achievement of a high rate of healing with medical therapies able to improve blood flow and/or to reduce hypertonia. […] The goal of medical treatment for chronic anal fissure is to achieve a temporary reduction of pressure of the anal canal, to facilitate the healing of the fissure (reversible sphincterotomy), thereby reducing muscle tone. […] Since the discovery of the role of NO as an inhibitor of IAS tone, the use of nitrates has been shown to reduce anal hypertonia and in many clinical contexts it has become the first-line therapy for chronic anal fissures. […] The introduction of topical nitrates has had an important impact on the reduction of the number of surgical procedures, especially in several European countries.

• #53 Hemorrhoids: Background, Anatomy, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/775407-overview

  Hemorrhoids are swollen blood vessels in the lower rectum. They are among the most common causes of anal pathology, and subsequently are blamed for virtually any anorectal complaint by patients and medical professionals alike. […] Because of their rich vascular supply, highly sensitive location, and tendency to engorge and prolapse, hemorrhoidal venous cushions are common causes of anal pathology. […] Symptoms can range from mildly bothersome, such as pruritus, to quite concerning, such as rectal bleeding. […] Hemorrhoids generally cause symptoms when they become enlarged, inflamed, thrombosed, or prolapsed. […] Abnormal swelling of the anal cushions causes dilatation and engorgement of the arteriovenous plexuses. This leads to stretching of the suspensory muscles and eventual prolapse of rectal tissue through the anal canal.

• #54 Hemorrhoids: Background, Anatomy, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/775407-overview

  Hemorrhoids are swollen blood vessels in the lower rectum. They are among the most common causes of anal pathology, and subsequently are blamed for virtually any anorectal complaint by patients and medical professionals alike. […] Because of their rich vascular supply, highly sensitive location, and tendency to engorge and prolapse, hemorrhoidal venous cushions are common causes of anal pathology. […] Symptoms can range from mildly bothersome, such as pruritus, to quite concerning, such as rectal bleeding. […] Hemorrhoids generally cause symptoms when they become enlarged, inflamed, thrombosed, or prolapsed. […] Abnormal swelling of the anal cushions causes dilatation and engorgement of the arteriovenous plexuses. This leads to stretching of the suspensory muscles and eventual prolapse of rectal tissue through the anal canal.

• #55 Hemorrhoids: Background, Anatomy, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/775407-overview

  The engorged anal mucosa is easily traumatized, leading to rectal bleeding that is typically bright red due to high blood oxygen content within the arteriovenous anastomoses. […] Internal hemorrhoids cannot cause cutaneous pain, because they are above the dentate line and are not innervated by cutaneous nerves. However, they can bleed, prolapse, and, as a result of the deposition of an irritant onto the sensitive perianal skin, cause perianal itching and irritation. […] Internal hemorrhoids can produce perianal pain by prolapsing and causing spasm of the sphincter complex around the hemorrhoids. […] This spasm results in discomfort while the prolapsed hemorrhoids are exposed. […] Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. […] The pain is related to the sphincter complex spasm.

• #56 Hemorrhoids: Background, Anatomy, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/775407-overview

  The engorged anal mucosa is easily traumatized, leading to rectal bleeding that is typically bright red due to high blood oxygen content within the arteriovenous anastomoses. […] Internal hemorrhoids cannot cause cutaneous pain, because they are above the dentate line and are not innervated by cutaneous nerves. However, they can bleed, prolapse, and, as a result of the deposition of an irritant onto the sensitive perianal skin, cause perianal itching and irritation. […] Internal hemorrhoids can produce perianal pain by prolapsing and causing spasm of the sphincter complex around the hemorrhoids. […] This spasm results in discomfort while the prolapsed hemorrhoids are exposed. […] Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. […] The pain is related to the sphincter complex spasm.

• #57 Hemorrhoids: Background, Anatomy, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/775407-overview

  The engorged anal mucosa is easily traumatized, leading to rectal bleeding that is typically bright red due to high blood oxygen content within the arteriovenous anastomoses. […] Internal hemorrhoids cannot cause cutaneous pain, because they are above the dentate line and are not innervated by cutaneous nerves. However, they can bleed, prolapse, and, as a result of the deposition of an irritant onto the sensitive perianal skin, cause perianal itching and irritation. […] Internal hemorrhoids can produce perianal pain by prolapsing and causing spasm of the sphincter complex around the hemorrhoids. […] This spasm results in discomfort while the prolapsed hemorrhoids are exposed. […] Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. […] The pain is related to the sphincter complex spasm.

• #58 Hemorrhoids: Background, Anatomy, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/775407-overview

  Strangulation with necrosis may cause more deep discomfort. […] When these catastrophic events occur, the sphincter spasm often causes concomitant external thrombosis. […] External thrombosis causes acute cutaneous pain. […] This constellation of symptoms is referred to as acute hemorrhoidal crisis and usually requires emergent treatment. […] Internal hemorrhoids most commonly cause painless bleeding with bowel movements. […] The covering epithelium is damaged by the hard bowel movement, and the underlying veins bleed. […] Internal hemorrhoids can deposit mucus onto the perianal tissue with prolapse. […] This mucus with microscopic stool contents can cause a localized dermatitis, which is called pruritus ani. […] Generally, hemorrhoids are merely the vehicle by which the offending elements reach the perianal tissue. Hemorrhoids are not the primary offenders.

• #59 Chronic anal pain: A review of causes, diagnosis, and treatment | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/89/6/336

  Chronic anal pain is difficult to diagnose and treat, especially with no obvious anorectal cause apparent on clinical examination. This review identifies 3 main diagnostic categories for chronic anal pain: local causes, functional anorectal pain, and neuropathic pain syndromes. Conditions covered within these categories include proctalgia fugax, levator ani syndrome, pudendal neuralgia, and coccygodynia. The signs, symptoms, relevant diagnostic tests, and main treatments for each condition are reviewed. […] Functional anorectal pain syndromes can be subdivided into 3 diagnoses with management individualized for each, albeit with a limited evidence base. […] Neuropathic pain syndromes are rare but can be positively diagnosed to allow specific management. […] Levator ani syndrome also called pelvic myalgia, pelvic floor myofascial pain, and pelvic floor muscle spasm is chronic anal pain resulting from tension or spasms in the levator muscles leading to compression of nerve endings and pain via peripheral sensitization.

• #60 Anorectal and perineal pain: new pathophysiological hypothesis – PubMed

  https://pubmed.ncbi.nlm.nih.gov/15309642/

  Anorectal and perineal pain has been described in association with a variety of organic conditions but can also occur under circumstances in which organic disorders are absent and pathophysiology is uncertain. […] The three most common functional disorders causing anorectal and perineal pain are levator ani syndrome, coccygodynia and proctalgia fugax; Alcock’s canal syndrome is also responsible for pain in these areas. […] We review current concepts about these disorders and the approach to diagnosis and management, and offer a provocative interpretation of the role of psychological factors.

• #61 Chronic anal pain: A review of causes, diagnosis, and treatment | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/89/6/336

  Chronic anal pain is difficult to diagnose and treat, especially with no obvious anorectal cause apparent on clinical examination. This review identifies 3 main diagnostic categories for chronic anal pain: local causes, functional anorectal pain, and neuropathic pain syndromes. Conditions covered within these categories include proctalgia fugax, levator ani syndrome, pudendal neuralgia, and coccygodynia. The signs, symptoms, relevant diagnostic tests, and main treatments for each condition are reviewed. […] Functional anorectal pain syndromes can be subdivided into 3 diagnoses with management individualized for each, albeit with a limited evidence base. […] Neuropathic pain syndromes are rare but can be positively diagnosed to allow specific management. […] Levator ani syndrome also called pelvic myalgia, pelvic floor myofascial pain, and pelvic floor muscle spasm is chronic anal pain resulting from tension or spasms in the levator muscles leading to compression of nerve endings and pain via peripheral sensitization.

• #62 Proctalgia Fugax: What It Is, Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/proctalgia-fugax

  Proctalgia fugax is severe anal pain that comes on suddenly, lasts briefly and often disappears as unexpectedly as it began. The anal pain isnt a one-time thing. Instead, it recurs (comes back) in episodes that may happen over several weeks or months. Proctalgia fugax doesnt involve tissue damage, but the pain can be so intense that it prevents you from going to work or school. […] The pain associated with proctalgia fugax involves the nerves and muscles associated with these organs. […] Some studies show that proctalgia fugax may arise from muscle spasms in your anal sphincter muscles or other pelvic floor muscles can cause anal pain. […] Damage to your pudendal nerve, also called pudendal neuralgia, may lead to proctalgia fugax. Your pudendal nerve carries electrical signals that allow you to experience sensations in your pelvic muscles, including muscles in your anus.

• #63 Proctalgia fugax and anal pain: Causes, diagnosis, and home remedies

  https://www.medicalnewstoday.com/articles/317254

  Proctalgia fugax refers to the sudden onset of severe pain in the rectal area, which can last from seconds to minutes. The pain is sporadic, can be without warning, and occurs due to muscle spasms in the anal canal. […] The exact cause of proctalgia fugax is unclear, but the pain is due to muscles in the anal canal and pelvic floor tightening suddenly. […] This muscle tightening is called spasming. Spasms often occur in the smooth muscles of the anal canal and the anal sphincter. […] Muscle tension and twitching are natural responses to stressful situations. […] These responses may cause a persons anal muscles to tense or cramp during periods of anxiety or emotional stress, leading to proctalgia symptoms. […] To diagnose proctalgia fugax, a doctor will primarily assess the severity and duration of a persons symptoms. Proctalgia fugax causes sharp, stabbing pain for 30 minutes or less.

• #64 Proctalgia Fugax and Anal Pain | Doctor

  https://patient.info/doctor/proctalgia-fugax-and-anal-pain

  Functional anorectal pain occurs in the absence of any clinical abnormality.1 It’s a relatively common symptom.2 Patients will often delay consulting a healthcare practitioner about this problem, due to embarrassment and fear of a sinister diagnosis, tolerating disturbing symptoms for long periods. […] The functional anorectal pain syndromes, defined by the Rome IV criteria, are based on symptom duration and digital rectal examination findings. The term 'chronic proctalgia’ was removed in the Rome IV criteria. […] PF is thought to occur due to spasm of the anal sphincter. LA is thought to be due to spasm of the pelvic floor muscles. The aetiology of UFAP is unknown. There is considerable overlap between the three conditions.4 […] The levator ani and anal sphincter muscles are anatomically contiguous in PF and LA so may co-exist, or be different manifestations of the same underlying dysfunction.5

• #65 Proctalgia Fugax and Anal Pain | Doctor

  https://patient.info/doctor/proctalgia-fugax-and-anal-pain

  Functional anorectal pain occurs in the absence of any clinical abnormality.1 It’s a relatively common symptom.2 Patients will often delay consulting a healthcare practitioner about this problem, due to embarrassment and fear of a sinister diagnosis, tolerating disturbing symptoms for long periods. […] The functional anorectal pain syndromes, defined by the Rome IV criteria, are based on symptom duration and digital rectal examination findings. The term 'chronic proctalgia’ was removed in the Rome IV criteria. […] PF is thought to occur due to spasm of the anal sphincter. LA is thought to be due to spasm of the pelvic floor muscles. The aetiology of UFAP is unknown. There is considerable overlap between the three conditions.4 […] The levator ani and anal sphincter muscles are anatomically contiguous in PF and LA so may co-exist, or be different manifestations of the same underlying dysfunction.5

• #66 Chronic anal pain: A review of causes, diagnosis, and treatment | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/89/6/336

  Coccygodynia is pain arising in or around the coccyx depending on its position. The pain is considered to arise from instability of the coccyx with or without pelvic floor spasm. […] Pudendal neuralgia occurs when the pudendal nerve is compressed by the obturator fascia as it forms the Alcock canal. […] Phantom rectum syndrome is a possible diagnosis when an organic source for pain such as perineal hernia or pelvic sepsis is excluded after proctectomy. […] Paroxysmal extreme pain disorder is a genetic disorder caused by a mutation in the SCN9A gene. The patient usually has a family history and onset in the neonatal period or during infancy.

• #67 Proctalgia Fugax: What It Is, Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/proctalgia-fugax

  Proctalgia fugax is severe anal pain that comes on suddenly, lasts briefly and often disappears as unexpectedly as it began. The anal pain isnt a one-time thing. Instead, it recurs (comes back) in episodes that may happen over several weeks or months. Proctalgia fugax doesnt involve tissue damage, but the pain can be so intense that it prevents you from going to work or school. […] The pain associated with proctalgia fugax involves the nerves and muscles associated with these organs. […] Some studies show that proctalgia fugax may arise from muscle spasms in your anal sphincter muscles or other pelvic floor muscles can cause anal pain. […] Damage to your pudendal nerve, also called pudendal neuralgia, may lead to proctalgia fugax. Your pudendal nerve carries electrical signals that allow you to experience sensations in your pelvic muscles, including muscles in your anus.

• #68 Proctalgia fugax – Wikipedia

  https://en.wikipedia.org/wiki/Proctalgia_fugax

  Proctalgia fugax, a variant of levator ani syndrome, is a severe, episodic pain in the regions of the rectum and anus. It can be caused by cramping of the levator ani muscle, particularly in the pubococcygeal part. […] Because of the high incidence of internal anal sphincter thickening with the disorder, it is thought to be a disorder of that muscle or that it is a neuralgia of pudendal nerves. […] In one study of 68 people with proctalgia fugax, 55 had tenderness along the course of the pudendal nerve. Pudendal nerve block relieved symptoms completely in 65% of the participants and reduced symptoms in 25%. This suggests that a major cause of proctalgia fugax may be pudendal neuralgia.

• #69 Anal pain

  https://www.mayoclinic.org/symptoms/anal-pain/basics/causes/sym-20050918

  Causes of anal pain include: […] Pudendal neuralgia, a nerve condition that causes extreme pain in the anal and pelvic area. […] Proctitis (inflammation of the lining of the rectum). […] Ulcerative colitis a disease that causes ulcers and swelling called inflammation in the lining of the large intestine. […] Anal fissure (a small tear in the lining of the anal canal). […] Anal fistula (an abnormal channel between the anus or rectum usually to the skin near the anus). […] Hemorrhoids (swollen and inflamed veins in your anus or rectum). […] Crohn’s disease which causes tissues in the digestive tract to become inflamed. […] Proctalgia fugax (fleeting pain due to rectal muscle spasm). […] Anal or rectal stricture (narrowing that may occur from scarring, severe inflammation or cancer). […] Trauma.

• #70 Rectal (anal) pain: Causes, treatment, and more

  https://www.medicalnewstoday.com/articles/326085

  A colonoscopy is a medical procedure that involves inserting a flexible tube called an endoscope into the anus and through the rectum to the colon. […] The skin around the rectum is very sensitive. Friction from sexual activity involving the anus or inserting objects into the rectum can cause injury, irritation, swelling, or bleeding. […] Other medical conditions that can cause rectal pain include inflammatory bowel disease (IBD), which includes Crohns disease and ulcerative colitis.

• #71 Common causes of anal or rectal pain, and how to treat them | Digestive | Men’s Health | Prevention | Women’s Health | UT Southwestern Medical Center

  https://utswmed.org/medblog/anal-rectal-pain-causes/

  This condition can present as rectal pain or rectal bleeding. If you’ve had pelvic radiation, it may damage the surrounding tissues, but that is a very rare side effect of radiation therapy. […] Inflammatory bowel disease can also cause proctitis, as can sexually transmitted infections (STIs). […] Commonly associated with the human papilloma virus (HPV), a sexually transmitted infection, anal condyloma causes lesions around the perineum, which is the tissue between the genitals and anus. […] Often, when a patient sees blood or feels pain in the anus, cancer is their first fear.

• #72 Rectal (anal) pain: Causes, treatment, and more

  https://www.medicalnewstoday.com/articles/326085

  Rectal pain can result from injury, inflammation, or infections that affect the rectum or anus. […] Prostatitis occurs when the bacteria from the urinary tract or rectum reach the prostate. The condition may cause pain when urinating, along with rectal pain or pressure. […] Levator syndrome (LS) is a condition that causes episodic pain in the rectum or bony structures at the base of the spine. […] Proctalgia fugax (PF) is sudden and intense pain in the rectum that can last for several minutes at a time. […] Rectal prolapse can cause pressure and pain in the rectum or anus. […] Endometriosis is a condition in which tissue similar to the uterus lining grows in atypical places, such as the bowels. […] An anal fissure is a small tear in the lining of the anal canal, which is the end of the large intestine between the rectum and anus.

• #73 Anal Pain: What It Is, Causes & Treatment

  https://my.clevelandclinic.org/health/symptoms/anal-pain

  Anal pain is a common condition with many possible causes. Most aren’t serious, but some may require treatment. It’s important to acknowledge anal pain and notice if it gets worse or doesn’t get better. […] Some of the most common causes of anal pain include: Hemorrhoids, swollen blood vessels inside your anus or rectum. Infections, including sexually transmitted infections (STIs) and fungal infections. Perianal abscess caused by an infected anal gland. Anal fissures, small tears in your anal lining. Trauma, from straining to pass hard poops or from anal penetration. Pudendal neuralgia, a condition that affects your pudendal nerve. It’s responsible for sensation in your anal and genital areas. […] Some of the less common causes of anal pain include: Anal fistula, a tunnel that develops when an anal abscess erodes through your skin. Inflammatory bowel disease (IBD) in your rectum, like ulcerative colitis or Crohn’s disease. Rectal ulcers, due to IBD or solitary rectal ulcer syndrome. Levator ani syndrome or proctalgia fugax, conditions that cause anal muscle spasms. Cancer in your anus or in your rectum. Anal pruritus, a skin condition that can cause intense itching.

• #74

  https://fascrs.org/patients/diseases-and-conditions/a-z/anal-pain

  Anal pain can occur before, during, or after a bowel movement. It can range from a mild ache that can get worse over time to pain that is bad enough to restrict daily activities. Anal pain has many causes, most of which are common and treatable. […] An anal fissure (also called fissure-in-ano) is a small rip or tear in the lining of the anal canal. Fissures are common, but are often confused with other anal conditions, such as hemorrhoids. […] The goal of surgery is to help the anal sphincter muscle relax, which reduces pain and spasms, allowing the fissure to heal. […] An abscess is an infected cavity filled with pus near the anus or rectum. […] While most cases of anal pain are not cancer, tumors can cause bleeding, a mass, and changes in bowel habits, as well as pain that gets worse over time.

• #75 Anal Pain: What It Is, Causes & Treatment

  https://my.clevelandclinic.org/health/symptoms/anal-pain

  A healthcare provider will ask questions about your symptoms and examine your anus, if necessary, to diagnose the cause of your anal pain. The treatment will depend on the cause. In many cases, they’ll advise the same home treatments listed above. But some more complicated conditions might require: Antibiotics, antivirals or antifungals to treat an infection. Prescription pain medications (analgesics). Targeted medications to treat IBD-related rectal inflammation. Surgery to repair a fistula, remove a thrombosed hemorrhoid or release muscle tension. […] You can always consult a healthcare provider about anal pain if you aren’t sure what’s causing it or how to treat it. If you’ve already tried to treat it at home and it hasn’t worked, contact a healthcare provider before it gets worse. See a provider right away if you experience any of the following alarming symptoms: Pain that’s severe enough to interfere with your daily activities or wake you at night. Pain that isn’t relieved by over-the-counter medications or that gets worse. Pain accompanied by heavy or continuous bleeding. Pain that prevents you from pooping, or constipation that’s not relieved by laxatives.

• #76

  https://link.springer.com/article/10.1007/s10151-011-0683-7

  In patients with anal fissures, the synthesis of NO in the IAS is reduced in comparison with the controls. […] This pathogenetic mechanism can explain the achievement of a high rate of healing with medical therapies able to improve blood flow and/or to reduce hypertonia. […] The goal of medical treatment for chronic anal fissure is to achieve a temporary reduction of pressure of the anal canal, to facilitate the healing of the fissure (reversible sphincterotomy), thereby reducing muscle tone. […] Since the discovery of the role of NO as an inhibitor of IAS tone, the use of nitrates has been shown to reduce anal hypertonia and in many clinical contexts it has become the first-line therapy for chronic anal fissures. […] The introduction of topical nitrates has had an important impact on the reduction of the number of surgical procedures, especially in several European countries.

• #77

  https://fascrs.org/patients/diseases-and-conditions/a-z/anal-fissure-expanded-information

  Anal fissures are usually caused by trauma to the inner lining of the anus. […] The injury to the tissue creates severe anal pain, resulting in anal sphincter spasm and a subsequent increase in anal sphincter muscle pressure. […] The increase in anal sphincter muscle pressure results in a decrease in blood flow to the site of the injury, thus impairing healing of the wound. […] Ensuing bowel movements result in more pain, more anal spasm, diminished blood flow to the area, and the cycle is propagated. […] Treatment strategies are aimed at interrupting this cycle to promote healing of the fissure. […] The goal of these surgical options is to promote relaxation of the anal sphincter, thereby decreasing anal pain and spasm, allowing the fissure to heal.

• #78

  https://link.springer.com/article/10.1007/s10151-011-0683-7

  In patients with anal fissures, the synthesis of NO in the IAS is reduced in comparison with the controls. […] This pathogenetic mechanism can explain the achievement of a high rate of healing with medical therapies able to improve blood flow and/or to reduce hypertonia. […] The goal of medical treatment for chronic anal fissure is to achieve a temporary reduction of pressure of the anal canal, to facilitate the healing of the fissure (reversible sphincterotomy), thereby reducing muscle tone. […] Since the discovery of the role of NO as an inhibitor of IAS tone, the use of nitrates has been shown to reduce anal hypertonia and in many clinical contexts it has become the first-line therapy for chronic anal fissures. […] The introduction of topical nitrates has had an important impact on the reduction of the number of surgical procedures, especially in several European countries.

• #79 Anal fissure – Australian Prescriber

  https://australianprescriber.tg.org.au/articles/anal-fissure.html

  Topical glyceryl trinitrate is believed to work through its metabolites. It breaks the cycle of spasm by relaxing the internal anal sphincter and reducing resting anal pressure. Topical calcium channel blockers also relax the internal anal sphincter by blocking the influx of calcium into smooth muscle cells. […] The reported healing rates of anal fissure following botulinum toxin injection are 60-80% (superior to placebo). Although recurrence can occur in up to 42% of patients, repeated injection has similar healing rates. […] The gold standard surgical operation for anal fissure is lateral internal sphincterotomy. This procedure commonly involves division of the internal anal sphincter from its distal end to either the proximal end of the fissure or the dentate line (whichever comes first). Lateral internal sphincterotomy has an excellent healing rate of approximately 95%. […] A high index of suspicion is warranted for fissures in lateral or multiple locations and those not healing despite conservative therapies.

• #80 Proctalgia Fugax and Anal Pain | Doctor

  https://patient.info/doctor/proctalgia-fugax-and-anal-pain

  Most other treatments (such as oral diltiazem, topical glyceryl nitrate and nerve blocks) act by relaxing the anal sphincter spasm but are not supported by randomised controlled trials.2 […] Patient education and reassurance are an important part of management. Biofeedback has proved effective in randomised trials, but if not available, electrical stimulation is a suitable alternative. Other treatments that have shown some benefit include digital massage, muscle relaxants and sitz baths.4 […] Patients with UFAP tend not to respond to biofeedback. Biofeedback-responsive patients can often be identified by a simple balloon evacuation test using a Foley catheter. Depression and anxiety are both frequently reported in non-responsive proctalgia patients, and addressing these conditions may prove beneficial.9 One study of botulinum toxin injections produced good results in patients with chronic functional anal pain, a high proportion of whom had UFAP.16

• #81 Proctalgia Fugax and Anal Pain | Doctor

  https://patient.info/doctor/proctalgia-fugax-and-anal-pain

  Most other treatments (such as oral diltiazem, topical glyceryl nitrate and nerve blocks) act by relaxing the anal sphincter spasm but are not supported by randomised controlled trials.2 […] Patient education and reassurance are an important part of management. Biofeedback has proved effective in randomised trials, but if not available, electrical stimulation is a suitable alternative. Other treatments that have shown some benefit include digital massage, muscle relaxants and sitz baths.4 […] Patients with UFAP tend not to respond to biofeedback. Biofeedback-responsive patients can often be identified by a simple balloon evacuation test using a Foley catheter. Depression and anxiety are both frequently reported in non-responsive proctalgia patients, and addressing these conditions may prove beneficial.9 One study of botulinum toxin injections produced good results in patients with chronic functional anal pain, a high proportion of whom had UFAP.16

• #82 Nitroglycerin rectal: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing – WebMD

  https://www.webmd.com/drugs/2/drug-159329/rectiv-rectal/details

  Rectal nitroglycerin is commonly used to relieve pain in your anal region caused by a tear in the skin of your anus (anal fissure). […] Rectal nitroglycerin works by relaxing the sphincter muscles in the anus.

• #83 Anal fissure – Australian Prescriber

  https://australianprescriber.tg.org.au/articles/anal-fissure.html

  Topical glyceryl trinitrate is believed to work through its metabolites. It breaks the cycle of spasm by relaxing the internal anal sphincter and reducing resting anal pressure. Topical calcium channel blockers also relax the internal anal sphincter by blocking the influx of calcium into smooth muscle cells. […] The reported healing rates of anal fissure following botulinum toxin injection are 60-80% (superior to placebo). Although recurrence can occur in up to 42% of patients, repeated injection has similar healing rates. […] The gold standard surgical operation for anal fissure is lateral internal sphincterotomy. This procedure commonly involves division of the internal anal sphincter from its distal end to either the proximal end of the fissure or the dentate line (whichever comes first). Lateral internal sphincterotomy has an excellent healing rate of approximately 95%. […] A high index of suspicion is warranted for fissures in lateral or multiple locations and those not healing despite conservative therapies.

• #84 Proctalgia Fugax and Anal Pain | Doctor

  https://patient.info/doctor/proctalgia-fugax-and-anal-pain

  Most other treatments (such as oral diltiazem, topical glyceryl nitrate and nerve blocks) act by relaxing the anal sphincter spasm but are not supported by randomised controlled trials.2 […] Patient education and reassurance are an important part of management. Biofeedback has proved effective in randomised trials, but if not available, electrical stimulation is a suitable alternative. Other treatments that have shown some benefit include digital massage, muscle relaxants and sitz baths.4 […] Patients with UFAP tend not to respond to biofeedback. Biofeedback-responsive patients can often be identified by a simple balloon evacuation test using a Foley catheter. Depression and anxiety are both frequently reported in non-responsive proctalgia patients, and addressing these conditions may prove beneficial.9 One study of botulinum toxin injections produced good results in patients with chronic functional anal pain, a high proportion of whom had UFAP.16

• #85 The Clinical Effect and Mechanism… preview & related info | Mendeley

  https://www.mendeley.com/catalogue/11b2922c-f6cc-3024-bb85-9b712f1ceb60/

  Anal pain and urinary retention are the two most outstanding complications of the procedure for prolapse and hemorrhoids (PPH) surgery. […] The role and mechanism of Prostant in patients and mice with urinary retention and anal pain were evaluated. […] Prostant effectively improved the urination status, lower abdomen symptoms, time to urinate and score of VAS, and the reduction of TNF- and IL-6. […] Mechanically, Prostant reversed the urinary retention-elevated the serum level of hs-CRP and TNF-, reduction of IL-2, imbalance of Treg/Th17, and level of JAK2 and phosphorylated STAT3. […] Prostant ameliorated the pain as shown by the reduction of writhing response, and the elevation of threshold of pain and degree of swelling. […] Prostant can treat patients and mice with anal pain and urinary retention by modulating the balance of Th17/Treg to regulate the secretion and production of inflammatory factors.

• #86 Proctalgia Fugax (Rectal Pain): Symptoms, Treatment & Relief

  https://www.hoag.org/specialties-services/digestive-health/diseases-conditions/proctalgia-fugax-rectal-pain/

  Depending on the outcome of the physical exam, tests may be ordered to diagnose or rule out certain conditions that may cause anorectal and pelvic pain. Once these causes have been ruled out, a diagnosis of proctalgia fugax should be considered if the episodes continue. […] There’s no known cure for proctalgia fugax, so treatment focuses on relieving symptoms and helping patients avoid factors that may trigger episodes, including constipation and excess stress. […] Warm baths can help relax spastic muscles and alleviate pain. If spasms in voluntary muscles are thought to be a contributing factor, certain exercises and relaxation techniques may be prescribed to assist in pelvic muscle retraining. […] In severe cases in which attacks happen frequently (AKA chronic proctalgia fugax), treatment options like pain medications might be prescribed to help patients control muscle spasms in the pelvic area, lower rectum and anal passage. There are also a number of promising treatments that may help control symptoms of functional anorectal pain, including electrical stimulation and Botox injections.

• #87 Anal Fissure Causes, Hemorrhoid, Pain, Treatment & How to Heal

  https://www.medicinenet.com/anal_fissure/article.htm

  This relatively poor flow of blood may be a factor in preventing fissures from healing. […] Nitroglycerin has been shown to cause relaxation of the internal anal sphincter and to decrease the anal resting pressure. […] This relieves spasms of the muscle and also may increase the flow of blood, both of which promote the healing of fissures. […] The primary side effect of botulinum toxin is the weakness of the sphincters with varying degrees of incontinence (leakage of stool) that usually is transient. […] In some series of patients but not all, the frequency of healing of fissures with botulinum toxin is high. […] Following surgery, 93% to 97% of fissures heal. […] Recurrence rates after this type of surgery are low, 0% to 3%.

• #88 Anal fissure – Australian Prescriber

  https://australianprescriber.tg.org.au/articles/anal-fissure.html

  Topical glyceryl trinitrate is believed to work through its metabolites. It breaks the cycle of spasm by relaxing the internal anal sphincter and reducing resting anal pressure. Topical calcium channel blockers also relax the internal anal sphincter by blocking the influx of calcium into smooth muscle cells. […] The reported healing rates of anal fissure following botulinum toxin injection are 60-80% (superior to placebo). Although recurrence can occur in up to 42% of patients, repeated injection has similar healing rates. […] The gold standard surgical operation for anal fissure is lateral internal sphincterotomy. This procedure commonly involves division of the internal anal sphincter from its distal end to either the proximal end of the fissure or the dentate line (whichever comes first). Lateral internal sphincterotomy has an excellent healing rate of approximately 95%. […] A high index of suspicion is warranted for fissures in lateral or multiple locations and those not healing despite conservative therapies.

• #89

  https://fascrs.org/patients/diseases-and-conditions/a-z/anal-pain

  Anal pain can occur before, during, or after a bowel movement. It can range from a mild ache that can get worse over time to pain that is bad enough to restrict daily activities. Anal pain has many causes, most of which are common and treatable. […] An anal fissure (also called fissure-in-ano) is a small rip or tear in the lining of the anal canal. Fissures are common, but are often confused with other anal conditions, such as hemorrhoids. […] The goal of surgery is to help the anal sphincter muscle relax, which reduces pain and spasms, allowing the fissure to heal. […] An abscess is an infected cavity filled with pus near the anus or rectum. […] While most cases of anal pain are not cancer, tumors can cause bleeding, a mass, and changes in bowel habits, as well as pain that gets worse over time.

• #90 Rectal pain – Wikipedia

  https://en.wikipedia.org/wiki/Rectal_pain

  Rectal pain is the symptom of pain in the area of the rectum. A number of different causes have been documented. One of the most common causes of rectal pain is an anal fissure. It involves a tear in the anal canal probably due to trauma from defecation and are usually treated effectively with sitz baths, stool softeners, and analgesics. Two more highly common causes of functional anorectal pain are levator ani syndrome (LAS) and proctalgia fugax. Both of these conditions are thought to be caused by muscle spasms of the either the levator ani muscle or the anal sphincter muscle respectively, and may overlap symptomatically with a third less-common condition called coccygodynia which is the result of previous trauma to the coccyx bone. Stress, prolonged sitting, and constipation all seem to be associated with LAS. The majority of those reporting chronic episodes of such pain are women. Some researchers group these conditions under the medical category of „tension myalgia of the pelvic floor”. Less than a third of those experiencing these conditions seek medical treatment for them. Treatment can involve the use of antispasmodic medications as well as the down-training so that spasms occur less frequently or not at all. An anorectal abscess is an infection that forms a pocket of pus within the tissues around the anus. It is treated surgically by incision and drainage. Bacterial, viral, and protozoal infections may occur in the area surround the rectum. These may be the result of a sexually transmitted infection.

• #91 My Anal Fissures Are Unbearable: What’s the Solution?: Betsy F. Clemens, M.D.: Board Certified Physician

  https://www.mwhtc-stl.com/blog/my-anal-fissures-are-unbearable-whats-the-solution

  Second, the anal tissue tear exposes the anal sphincter muscle. When you poop, the anal sphincter muscle spasms, intensifying the pain. The muscle spasms also pull on the tear, hindering the healing process. […] If your anal fissure fails to heal within eight weeks, you may need more invasive treatments to reduce muscle spasms so your tear can close. Botox injections or a surgical procedure that cuts the muscle (internal sphincterotomy) are the primary treatments for chronic anal fissures.

• #92 Anal pain – rectal pain, fissures, symptoms and treatments | healthdirect

  https://www.healthdirect.gov.au/anal-pain

  Depending on what your doctor thinks may be causing your anal pain, they may do: a digital examination of your rectum (back passage) where they gently put a gloved finger into your back passage, an anorectal swab to test for STIs. […] Your treatment will depend on what is causing your anal pain. […] You may need surgery for some causes of anal pain. This may be recommended with: an anal abscess, an anal fissure that has not healed with other treatments, an anal fistula, rectal prolapse when some part of your bowel is outside of your anus, thrombosed haemorrhoids (when a clot forms in the haemorrhoid) this is called a haemorrhoidectomy. […] Any complications from anal pain will depend on their cause and treatment.

• #93 Chronic anal pain: A review of causes, diagnosis, and treatment | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/89/6/336

  Chronic anal pain is difficult to diagnose and treat, especially with no obvious anorectal cause apparent on clinical examination. This review identifies 3 main diagnostic categories for chronic anal pain: local causes, functional anorectal pain, and neuropathic pain syndromes. Conditions covered within these categories include proctalgia fugax, levator ani syndrome, pudendal neuralgia, and coccygodynia. The signs, symptoms, relevant diagnostic tests, and main treatments for each condition are reviewed. […] Functional anorectal pain syndromes can be subdivided into 3 diagnoses with management individualized for each, albeit with a limited evidence base. […] Neuropathic pain syndromes are rare but can be positively diagnosed to allow specific management. […] Levator ani syndrome also called pelvic myalgia, pelvic floor myofascial pain, and pelvic floor muscle spasm is chronic anal pain resulting from tension or spasms in the levator muscles leading to compression of nerve endings and pain via peripheral sensitization.

• #94 The clinical characteristics of patients with chronic idiopathic anal pain

  https://www.degruyter.com/document/doi/10.1515/med-2017-0015/html?lang=en

  In conclusion, chronic anal pain is a clinical manifestation stemming from diverse pathological and physiological changes. Although the examination in the urinary and reproductive system and other surrounding organs is needed to reach a definitive diagnosis, clear understanding of the underlying pathophysiology and the patients psychological condition may help improve pain treatment.

• #95 Anal Fissure: Practice Essentials, Anatomy, Pathophysiology and Etiology

  https://emedicine.medscape.com/article/196297-overview

  The posterior anal commissure is the most poorly perfused part of the anal canal. In patients with hypertrophied internal anal sphincters, this delicate blood supply is further compromised, thus rendering the posterior midline of the anal canal relatively ischemic. […] Pain accompanies each bowel movement as this raw area is stretched and the injured mucosa is abraded by the stool. The internal sphincter also begins to spasm when a bowel movement is passed. This spasm has two effects: First, it is painful in itself, and second, it further reduces the blood flow to the posterior midline and the anal fissure, contributing to the poor healing rate.

• #96 Hemorrhoids: Background, Anatomy, Etiology and Pathophysiology

  https://emedicine.medscape.com/article/775407-overview

  Hemorrhoids are swollen blood vessels in the lower rectum. They are among the most common causes of anal pathology, and subsequently are blamed for virtually any anorectal complaint by patients and medical professionals alike. […] Because of their rich vascular supply, highly sensitive location, and tendency to engorge and prolapse, hemorrhoidal venous cushions are common causes of anal pathology. […] Symptoms can range from mildly bothersome, such as pruritus, to quite concerning, such as rectal bleeding. […] Hemorrhoids generally cause symptoms when they become enlarged, inflamed, thrombosed, or prolapsed. […] Abnormal swelling of the anal cushions causes dilatation and engorgement of the arteriovenous plexuses. This leads to stretching of the suspensory muscles and eventual prolapse of rectal tissue through the anal canal.

• #97 Proctalgia Fugax: What It Is, Symptoms, Causes & Treatment

  https://my.clevelandclinic.org/health/diseases/proctalgia-fugax

  Proctalgia fugax is severe anal pain that comes on suddenly, lasts briefly and often disappears as unexpectedly as it began. The anal pain isnt a one-time thing. Instead, it recurs (comes back) in episodes that may happen over several weeks or months. Proctalgia fugax doesnt involve tissue damage, but the pain can be so intense that it prevents you from going to work or school. […] The pain associated with proctalgia fugax involves the nerves and muscles associated with these organs. […] Some studies show that proctalgia fugax may arise from muscle spasms in your anal sphincter muscles or other pelvic floor muscles can cause anal pain. […] Damage to your pudendal nerve, also called pudendal neuralgia, may lead to proctalgia fugax. Your pudendal nerve carries electrical signals that allow you to experience sensations in your pelvic muscles, including muscles in your anus.

• #98

  https://link.springer.com/article/10.1007/s10151-011-0683-7

  In patients with anal fissures, the synthesis of NO in the IAS is reduced in comparison with the controls. […] This pathogenetic mechanism can explain the achievement of a high rate of healing with medical therapies able to improve blood flow and/or to reduce hypertonia. […] The goal of medical treatment for chronic anal fissure is to achieve a temporary reduction of pressure of the anal canal, to facilitate the healing of the fissure (reversible sphincterotomy), thereby reducing muscle tone. […] Since the discovery of the role of NO as an inhibitor of IAS tone, the use of nitrates has been shown to reduce anal hypertonia and in many clinical contexts it has become the first-line therapy for chronic anal fissures. […] The introduction of topical nitrates has had an important impact on the reduction of the number of surgical procedures, especially in several European countries.

• #99 Proctalgia Fugax and Anal Pain | Doctor

  https://patient.info/doctor/proctalgia-fugax-and-anal-pain

  Most other treatments (such as oral diltiazem, topical glyceryl nitrate and nerve blocks) act by relaxing the anal sphincter spasm but are not supported by randomised controlled trials.2 […] Patient education and reassurance are an important part of management. Biofeedback has proved effective in randomised trials, but if not available, electrical stimulation is a suitable alternative. Other treatments that have shown some benefit include digital massage, muscle relaxants and sitz baths.4 […] Patients with UFAP tend not to respond to biofeedback. Biofeedback-responsive patients can often be identified by a simple balloon evacuation test using a Foley catheter. Depression and anxiety are both frequently reported in non-responsive proctalgia patients, and addressing these conditions may prove beneficial.9 One study of botulinum toxin injections produced good results in patients with chronic functional anal pain, a high proportion of whom had UFAP.16

• #100 Anal Fissure Causes, Hemorrhoid, Pain, Treatment & How to Heal

  https://www.medicinenet.com/anal_fissure/article.htm

  This relatively poor flow of blood may be a factor in preventing fissures from healing. […] Nitroglycerin has been shown to cause relaxation of the internal anal sphincter and to decrease the anal resting pressure. […] This relieves spasms of the muscle and also may increase the flow of blood, both of which promote the healing of fissures. […] The primary side effect of botulinum toxin is the weakness of the sphincters with varying degrees of incontinence (leakage of stool) that usually is transient. […] In some series of patients but not all, the frequency of healing of fissures with botulinum toxin is high. […] Following surgery, 93% to 97% of fissures heal. […] Recurrence rates after this type of surgery are low, 0% to 3%.

• #101 The clinical characteristics of patients with chronic idiopathic anal pain

  https://www.degruyterbrill.com/document/doi/10.1515/med-2017-0015/html?lang=en&srsltid=AfmBOorJksT9Q5RaJ_k6yxjVAhoVzwdsKRK9l4yrBsjhi1KcUhxlEORW

  In general, pain treatment for FARP patients is far challenging than the non-FARP patients because FARP has no obvious underlying anorectal or endopelvic organ disease symptom but it is a syndrome of idiopathic multi-factorial vague disorder resulting from a complex interaction among neurological, musculoskeletal and endocrine systems. […] In conclusion, chronic anal pain is a clinical manifestation stemming from diverse pathological and physiological changes. Although the examination in the urinary and reproductive system and other surrounding organs is needed to reach a definitive diagnosis, clear understanding of the underlying pathophysiology and the patients psychological condition may help improve pain treatment.

• #102 Chronic Idiopathic Anal Pain. Results of a Diagnostic-Therapeutic Protocol in a Colorectal Referral Unit | Cirugía Española (English Edition)

  https://www.elsevier.es/es-revista-cirugia-espanola-english-edition–436-articulo-chronic-idiopathic-anal-pain-results-S2173507714004955

  For CIAP, since its pathophysiology is mostly unknown, management is still empirical. In fact, it is aimed at achieving pelvic floor muscle relaxation, based on its potential relation to an increase in muscle tension. […] The application of the diagnostic protocol developed in our Department enabled a reduction in the exclusion diagnosis of CIAP to 25%. Conservative measures together with biofeedback achieved an improvement of symptoms in more than 40% of CIAP cases; the application of sacral root neuromodulation should be assessed on an individual basis in patients who were resistant to other therapeutic measures.

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