Anorectal pain is an incredibly common condition. Thanks to our low-fiber Western diet and often inadequate hydration, constipation is a frequent occurrence. People also often spend long periods on the toilet. We used to read books, but now many play games or text on their smartphone. Constipation and prolonged sitting on the toilet can lead to several different problems. While discussing these symptoms can be awkard or uncomfortable, please talk to your doctor if your symptoms don't go away on their own.
So what is anorectal pain?
Although "butt pain" may be a common complaint, I want to be clear with my explanations. In reality, “butt” more accurately refers to the gluteal region, which is also known colloquially as derriere, buttock, backside, or fanny. It may be simplest to describe the butt as the area that rests on the surface of a chair when you sit. Anorectal refers to a more specific location, the anus and rectum, where stool passes through when you have a bowel movement. Please see the anatomically correct depiction below.
What are the common causes of anorectal pain?
Fissures
Hemorrhoids
Pruritis Ani
Abscesses
Less common- pelvic floor dysfunction, cancer
Anatomy of the anus and rectum
Two sphincter complexes encircle the rectal vault. The internal sphincter provides 85% of the resting tone. It is under involuntary control- this is how your body controls when you have a bowel movement. The external sphincter provides 15% of resting tone- it is under voluntary control, which means this is how you consciously control holding in a bowel movement.
The internal hemorrhoids are veins that line the inside of the rectum, while the external hemorrhoid plexus is on the anal verge. These means that hemorrhoids are a NORMAL part of anatomy! They fill with blood to aid in incontinence, helping you control when you have a bowel movement. Anything that increases pressure in the abdomen, including prolonged straining, coughing, pregnancy, and enlarged prostate requiring straining to urinate, can lead to abnormally large venous plexuses, which are what most people know as hemorrhoids. See “Hemorrhoids” below for more details.
Glands line the inside of the rectum and help lubricate stool. When the glands become obstructed, they can lead to abscesses.
What are the common symptoms of anorectal disease?
Pain
Bleeding- either blood dripping in the toilet, blood on the toilet paper with wiping, and blood mixed with or on the stool's surface.
Mucus drainage (constant moisture), which can cause challenges with perianal hygiene
Pruritis (itching)
Palpable mass
Constipation/ diarrhea, incomplete voiding
What causes anorectal disease?
Prolonged straining or prolonged time sitting on the toilet, often due to constipation (hemorrhoids)
Constipation and passing a hard stool can lead to tears in the skin (fissure)
Underlying gastrointestinal disease (inflammatory bowel disease, etc.)
How do I prevent anorectal disease?
The goal is to improve bowel habits and minimize constipation.
High fiber diet. Most Americans have a low-fiber diet, consuming way less than the recommended 20-35 grams of fiber per day. Fiber can come from dietary intake (the foods you eat) as well as supplements. Take the time to read labels. The foods we commonly think of as “high-fiber,” including lettuce, are not as fiber-rich as we think. A word of warning If you quickly add a significant amount of fiber to your diet, this can lead to gastrointestinal distress (gas, diarrhea, cramping, etc.). Add fiber slowly until you reach your goal!
Stay hydrated! Fiber without adequate hydration will create hard stools (rabbit pellets), making constipation worse. The recommendation is a minimize of 64 ounces of water per day. Plain water is best, but flavoring with Crystal Light, lemon, or lime can make it more palatable.
Listen to your body regarding bowel movements. Hold it until socially acceptable, but don’t hold for longer than necessary. But just as important, don’t force a bowel movement if you don’t feel the urge. Some people may be trained to try to have a bowel movement before leaving for work- if this works for you, that’s fine. But don’t let the clock dictate when you have to use the bathroom.
Minimize the amount of time sitting on a toilet. Prolonged sitting increases pressure, which predisposes to pathology.
If you are still having challenges, consider investing in a device to facilitate improving your posture. We are accustomed to using toilets…unfortunately, sitting creates an angle that makes it difficult to have a bowel movement. Squatting, with knees elevated closer to the chest, creates a straighter path leading to more optimal conditions to have a bowel movement. Consider a squatty potty!
Specific Anorectal Pathology