Practice 10-Minute Consultation

A pain in the bottom

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f4192 (Published 01 July 2013) Cite this as: BMJ 2013;347:f4192
  1. Fareed Iqbal, research fellow, colorectal surgery1,
  2. Andrew D Beggs, clinical lecturer, colorectal surgery1,
  3. Tim Holt, clinical lecturer, primary care health sciences2,
  4. Douglas M Bowley, consultant colorectal surgeon3
  1. 1Academic Department of Surgery, University of Birmingham, Birmingham B15 2TT, UK
  2. 2Department of Primary Care Health Sciences, Oxford University, Oxford OX2 6GG
  3. 3Department of Surgery, Heart of England NHS Foundation Trust, Birmingham B9 5SS
  1. Correspondence to: F Iqbal F.Iqbal{at}bham.ac.uk
  • Accepted 1 March 2013

A 44 year old man presents to primary care with a four week history of severe, intermittent episodes of anorectal pain, each lasting for some 10 minutes without pain between episodes. Symptoms persist despite use of over the counter medications.

Anorectal pain is common, with an estimated prevalence of around 7%. It can usually be managed in general practice. However, presentation may be confounded by embarrassment and fear of serious pathology, requiring a sensitive and focused approach. In this case, the most likely diagnoses are anal fissure, haemorrhoids, or functional anorectal pain (chronic proctalgia or proctalgia fugax). Less common possibilities are listed in the box.

Functional anorectal pain occurs in the absence of any pathology; it is relatively common, affecting about 18% of patients with anorectal pain, but can be disabling. Chronic proctalgia is defined as chronic or recurrent pain or aching localised to the anus or lower rectum, with episodes lasting ≥20 minutes. The pain in proctalgia fugax lasts from seconds to minutes, without pain between episodes.

Unusual causes of anorectal pain

Anorectal sexually transmitted infections

Risk factors:

  • Men who have sex with men

  • Anoreceptive intercourse

  • Local contiguous spread from genital area (such …

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