Chronic rectal pain is pain in the rectum or anal area that lasts longer than three months. It can be a dull ache, pressure, burning or sudden stabbing pain, and it is often worse when sitting. It is more common than people think, and many delay seeking help because it is embarrassing or because they fear something serious. The first step is to make sure other causes have been properly excluded. When they have, the pain usually falls into a group of recognised conditions involving the pelvic floor muscles and nerves, and there are treatments that can help.
What is chronic rectal pain?
Chronic rectal pain is a symptom, not a single diagnosis. Under the Rome IV criteria used by gastroenterologists, when no structural cause is found, the pain is classed as functional anorectal pain. Doctors divide this into levator ani syndrome, unspecified functional anorectal pain and proctalgia fugax, based on how long episodes last and what is found on examination. In these conditions, the cause is thought to involve tension or poor relaxation of the pelvic floor muscles, sensitised nerves, or both.
Other conditions can look similar, including pudendal neuralgia, coccydynia (tailbone pain), pain after surgery or childbirth, and pain referred from the spine or pelvis. Working out which applies to you is the main task of the assessment.
Types of functional anorectal pain
- Levator ani syndrome. A dull, aching or pressure-like pain high in the rectum, lasting 30 minutes or more, often worse sitting than lying or standing, with tenderness when the pelvic floor muscle is pressed during examination.
- Unspecified functional anorectal pain. The same pattern, but without that tenderness.
- Proctalgia fugax. Sudden, cramping, gnawing or stabbing pain lasting seconds to minutes, then disappearing. It is infrequent and can be triggered by stress.
- Pudendal neuralgia. Burning or aching pain in the area supplied by the pudendal nerve, typically worse sitting and eased when standing or lying, and confirmed when a nerve block helps.
How we assess chronic rectal pain
We begin by reviewing what has already been checked. If you have not had a colorectal assessment, endoscopy or imaging where indicated, we will suggest this, so that any structural cause is not missed. Dr Poply then takes a detailed history, including the timing and triggers of the pain, links with sitting and bowel movements, previous surgery, childbirth or injury, and the effect on sleep, intimacy and mood. Where appropriate, examination is carried out with a chaperone and with your consent at every step. Diagnostic nerve blocks may help distinguish a nerve-related source, such as the pudendal nerve, from muscle-related pain.
Treatment options
Explanation and reassurance
Understanding what functional anorectal pain is, and that it is not a sign of cancer, can itself reduce fear and the muscle tension that maintains pain. This is not a “nothing wrong” message. The pain is real, and its mechanisms are increasingly understood.
Pelvic floor physiotherapy and biofeedback
This is the treatment with the strongest evidence. Biofeedback teaches the pelvic floor muscles to relax during defaecation and at rest. In reviews of proctalgia syndromes, biofeedback to improve defaecation dynamics is the only therapy with proven effectiveness in a randomised setting for levator ani syndrome. We can refer you to a specialist pelvic physiotherapist.
Simple measures and medicines
Warm baths, avoiding prolonged sitting, and stool softeners where constipation adds to pain can help. Muscle relaxants and medicines for nerve-type pain are sometimes tried. NICE advises against several medicines for chronic primary pain, so we approach these carefully and stop those that are not helping.
Nerve blocks and injections
A ganglion impar block places local anaesthetic, sometimes with steroid, near a cluster of nerves in front of the coccyx that carries pain signals from the pelvic organs and perineum. A pudendal nerve block can test for and treat pudendal neuralgia. Botulinum toxin has also been used to relax overactive pelvic floor muscles, although the evidence is limited. Dr Poply performs ganglion impar blocks and other pelvic nerve blocks as part of her practice.
Neuromodulation
Sacral neuromodulation, dorsal root ganglion stimulation and spinal cord stimulation are used in some forms of pelvic pain. For chronic rectal pain specifically, the evidence is limited. Published reports come largely from small series, and reviews describe mixed results for sacral neuromodulation in proctalgia. We therefore consider Neuromodulation only for carefully selected people whose pain has not responded to simpler, better-supported treatments, after multidisciplinary discussion, and with a trial period before any implant. Dr Poply offers sacral nerve stimulation for pelvic pain and dorsal root ganglion stimulation for pelvic and perianal pain.
Psychological support
Chronic pelvic pain is stressful and can affect relationships and sleep. Psychological therapies such as CBT or acceptance and commitment therapy do not imply the pain is “in your head”. They give tools that reduce the pain’s grip and are recommended in NICE guidance for chronic primary pain.
Privacy and comfort
We understand that this is a difficult topic. Consultations are private and unhurried. You are welcome to bring someone with you, and you can ask to pause or stop any examination at any time. Nothing is done without your explicit consent.
About your specialist
Dr Kavita Poply is a Consultant in Pain Medicine and Neuromodulation at St Bartholomew’s Hospital, London, and a Reader at Queen Mary University of London. Her clinical interests include inguinal and perianal pain, pelvic and abdominal pain, and pudendal and other pelvic nerve conditions. Her nerve block procedures include ganglion impar blocks, and she provides neurostimulation for selected pelvic pain.
Frequently asked questions
Q.1 What causes chronic rectal pain?
Ans. When infections, fissures, fistulas, haemorrhoids, inflammatory bowel disease and tumours have been excluded, chronic rectal pain is usually functional. That means it comes from muscles, nerves or how the body processes pain, rather than visible damage. Conditions include levator ani syndrome, proctalgia fugax and pudendal neuralgia. A careful assessment distinguishes between them.
Q.2 What is the difference between levator ani syndrome and proctalgia fugax?
Ans. Levator ani syndrome causes a dull, aching or pressure-like pain that lasts 30 minutes or longer and recurs, often worse when sitting. Proctalgia fugax is sudden, brief, severe pain lasting less than 30 minutes, often only seconds to minutes, and it is infrequent. Both are diagnosed after other causes have been ruled out.
Q.3 Is chronic rectal pain a sign of cancer?
Ans. Functional rectal pain is not a sign of cancer, and cancer typically presents with other features such as bleeding, a change in bowel habit or weight loss. If you have any of those, see your GP promptly. That is why a proper assessment to exclude structural causes comes first, so you can be reassured with confidence.
Q.4 What is the best treatment for levator ani syndrome?
Ans. Pelvic floor physiotherapy with biofeedback has the best evidence. Simple measures such as warm baths and avoiding prolonged sitting can help, and some people benefit from muscle relaxants or nerve blocks. Treatment is usually a combination and takes time to work, and psychological support can help you cope while it does.
Q.5 Can nerve blocks or neuromodulation help chronic rectal pain?
Ans. Nerve blocks such as ganglion impar or pudendal blocks can help diagnose and sometimes relieve pain. Neuromodulation is used in selected people with pelvic pain, but evidence for chronic rectal pain specifically is limited, so we consider it only after simpler treatments and a multidisciplinary discussion, with a trial before any implant.