Differential Diagnosis for Rectal Pain that Wakes a Patient Up in the Middle of the Night

• Single Most Likely Diagnosis
  • Anal fissure: This condition is characterized by a tear in the lining of the anus, which can cause severe pain, especially during and after bowel movements. The pain can be so intense that it wakes the patient up at night, making it a likely cause for nocturnal rectal pain.
• Other Likely Diagnoses
  • Hemorrhoids: Although often associated with pain during bowel movements, large or thrombosed hemorrhoids can cause significant discomfort at night, potentially waking the patient.
  • Proctalgia fugax: This condition involves sudden, severe pain in the anus that can occur at any time, including at night, waking the patient.
  • Levator ani syndrome: Characterized by chronic pain or discomfort in the rectal area, this condition can cause nocturnal waking due to pain.
• Do Not Miss Diagnoses
  • Rectal cancer: Although less common, rectal cancer can cause pain, especially if the tumor is large or has invaded surrounding structures. Missing this diagnosis could be fatal.
  • Inflammatory bowel disease (IBD): Conditions like Crohn's disease or ulcerative colitis can cause rectal pain, among other symptoms, and require prompt treatment to prevent complications.
  • Infectious proctitis: Infections of the rectum, which can be caused by bacteria, viruses, or other pathogens, need to be identified and treated to prevent serious outcomes.
• Rare Diagnoses
  • Coccygodynia: Pain in the coccyx (tailbone) area can sometimes be referred to the rectum and cause nocturnal pain, although this is less common.
  • Pudendal neuralgia: This condition involves pain along the pudendal nerve, which can cause rectal pain, but it is relatively rare and often associated with specific activities or positions.
  • Solitary rectal ulcer syndrome: This condition can cause rectal pain and bleeding, but it is less common and often associated with chronic constipation or straining during bowel movements.