Prolonged post-defecatory anal pain

Specialty: Gastrointestinal.

• Persistent anal pain after defecation
• pain from anal fissure
• prolonged anal burning

Why it occurs

• Acute or chronic anal fissure, characterized by a linear tear in the anoderm that triggers a painful spasm of the internal anal sphincter that lasts hours after defecation
• Internal or external hemorrhoidal thrombosis with associated severe inflammatory edema
• Ischiorectal abscess in the collection phase that is exacerbated by the passage of feces
• Acute proctitis of actinic or infectious origin with involvement of the proximal anal mucosa.

Initial workup

Careful anal inspection in consultation (gently separating the buttocks to visualize fissure, usually in the posterior midline, or thrombosed hemorrhoids) | Rectal examination (may be impossible to perform initially due to severe pain and spasm, postponing the examination under anesthesia if an occult abscess is suspected) | Anoscopy once the acute pain is controlled.

Standard management

• 2% diltiazem ointment or 0.2% nitroglycerin — applied topically in the anal canal every 12 hours to relax the internal anal sphincter, promoting microvascular perfusion and healing of the fissure
• Topical local anesthetics — 5% lidocaine ointment applied 15 minutes before and after defecation
• Stool softeners (polyethylene glycol 17 g per day) combined with sitz baths with warm water for 10-15 minutes three times a day.