What sort of pain is it?
- A knife-like pain when you have your bowels open, and which may last for 10–15 minutes afterwards, is probably caused by an anal fissure. Some people describe it as like ‘passing glass’. In addition to the pain, you may notice some bright red blood on the toilet paper.
- A similar knife-like pain can be caused by herpes simplex virus.
- A nagging, aching discomfort made worse by defecation could be due to piles.
- A throbbing pain, worsening over a few days, and bad enough to disturb your sleep, is likely to be caused by an abscess.
- An occasional, severe, cramp-like pain deep in the anal canal, lasting about half an hour, is probably a condition called proctalgia fugax.
- A continuous aching pain in the anus needs to be sorted out by your doctor. It is most often caused by a back problem (when a part of the spine presses on a nerve).
An anal fissure is a split in the anal skin, just inside the anus, usually towards the back. The pain of an anal fissure feels like being cut with glass when you have your bowels open and afterwards. It is worse when you have had a hard bowel motion. You may notice some bright red blood on the lavatory paper at the same time. You may be able to feel a small lump alongside the crack; this is a ‘skin tag’.
- Avoid constipation – this is very important. Keep your faeces soft by eating lots of bran cereals, fruit and vegetables.
- Smear some painkilling gel around the area just before you have your bowels open. You can buy a suitable painkilling gel from a pharmacy; they are sometimes labelled ‘for piles’ or ‘for haemorrhoids’. It will prevent the anus going into a spasm, which can make the problem worse. Do not use the gel at any other time, or for more than 1 week, because you can easily develop an allergy to its ingredients. If you notice soreness and itching, in addition to the sharp pain, it is quite likely that the gel is responsible.
- Warm baths twice daily can help, if you have the time. Put a handful of ordinary kitchen salt into the bath.
How your doctor can help. You should see your doctor if the problem is not improving after 3 weeks. If you feel anxious about this, look at the section on seeing your doctor about an anal problem. For some treatments, your doctor will need to send you to the ‘rectal clinic’ at your local hospital. Some of the treatments your doctor may use are listed below.
- Glyceryl trinitrate ointment, applied several times a day, heals about 50% of people (The Surgical Clinics of North America 2010;90:33-44). However, about 1in 4 people using this treatment gets a headache as a side effect.
- A gel containing the drug diltiazem, applied twice daily for 6–8 weeks, seems to be as effective as glyceryl trinitrate.
If glyceryl trinitrate or diltiazem do not work for you:
- Injections of botulinum toxin (Botox) into the muscle of the anus are a possibility. Botulinum toxin prevents spasm of the muscle, because it blocks transmission of nerve impulses to the muscle. Healing rates are about 69–90%.
- The most common treatment (before diltiazem gel and glyceryl trinitrate ointment came on the scene) used to be a small operation under a general anaesthetic. The operation is designed to overcome the spasm of the anal muscle by stretching the anus. The pain relief is dramatic and instantaneous. In the past, this operation could leave you less able to control wind, but this is less likely with a newer type of operation called lateral internal anal sphincterotomy (British Journal of Surgery 2005;92:403–8).
Unfortunately, the fissure comes back within 3–4 months in about one-third of people treated with glyceryl trinitrate or diltiazem, and in about 40% of people after treatment with botulinum toxin (Gastroenterology 2002;123:112–7). Surgery seems to be the best long-term cure and is effective in about 90% of cases.
Herpes virus infection
An abscess close to the anus produces a throbbing pain that worsens over a few days, and is usually bad enough to disturb your sleep. You may be able to feel a tender swelling in the skin beside the anus, or the abscess may be hidden inside. This is unlikely to go away on its own; it needs to be lanced by a doctor.
- Try putting pressure on the perineum (the area between the back passage and the vagina or base of the penis) by sitting on the edge of your bath or on a tennis ball.
- Sit in hot water or, alternatively, apply some ice.
- Two paracetamol (acetaminophen) tablets and a hot drink may give some relief.
Written by: Dr Margaret Stearn
Edited by: Dr Margaret Stearn
Last updated: Wednesday, April 4th 2012
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