Posterior pain has patient perplexed

Dear Dr. Roach: I hope you can help me. I have a pain that I would be embarrassed to share, in my small town, with the person who makes my doctor appointments, then the young girls who take my blood pressure and weight, and then, finally, with the doctor. I’m in my late 40s. In the past year, about three or four times I have been awakened in the middle of the night with pain in my anus. Other than that I’m eating better, I can’t think of any changes in my life to account for this. Should I be worried?

Anon. You have what sounds like a classic, if somewhat infrequent, case of proctalgia fugax, a condition of periodic rectal pain I have heard about far more frequently in letters than I ever have seen in my clinical practice.

This probably is because many people, like you, are reluctant or embarrassed to speak to their doctor about it (only about 20 per cent of people with this common condition have reported it to their physician).

However, you should do so, not because proctalgia fugax is dangerous (it isn’t), but because there are uncommon causes of rectal pain that are more worrisome.

An anal fissure, a small tear in the lining of the anus, is probably the most common cause, but hemorrhoids and ulcers are painful too, and can be excluded with a physical examination. The prostate and coccyx (tailbone) may become inflamed and painful, and this can feel like anal pain.

In women, pelvic inflammatory disease should be ruled out. You will be due for your screening colonoscopy at age 50, but your doctor will consider doing a sigmoidoscopy or colonoscopy to make sure there is no inflammatory bowel disease. Blood tests to look for infection or inflammation should be normal with proctalgia fugax and can help ensure that there is no more worrisome cause.

Your physician is used to hearing about every element of body function imaginable — and some you might not be able to imagine.

Don’t be embarrassed. You can tell your doctor’s assistants that you prefer to discuss your issue with your doctor directly. While I understand that you are more likely to run into your doctor in a small town, doctors have an obligation to keep your personal information private.

Proctalgia fugax often is treated effectively with firm pressure, such as sitting on a baseball or tennis ball. More severe cases benefit from medication, such as topical cream or oral medications. Those are prescribed only by your doctor. Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu.