What are the causes and treatments for sharp rectal and vaginal pain?

Sharp Rectal and Vaginal Pain: Diagnostic and Treatment Approach

Begin with a focused physical examination including digital rectal examination and pelvic examination to identify structural causes, particularly anorectal abscess, anal fissure, thrombosed hemorrhoids, or pelvic inflammatory disease, as these require urgent intervention to prevent serious morbidity. 1

Immediate Assessment Priorities

Critical Red Flags Requiring Urgent Intervention

• Anorectal abscess presents with perianal pain, swelling, fever, and potentially discharge; this is the most common emergency requiring prompt surgical drainage to prevent extension, systemic infection, and fistula formation 1
• Strangulated rectal prolapse with signs of shock or gangrene requires immediate surgical treatment 1
• Pelvic inflammatory disease (PID) should be suspected in sexually active women with uterine/adnexal tenderness or cervical motion tenderness, requiring empiric broad-spectrum antibiotics to prevent tubo-ovarian abscess and long-term reproductive complications 1

Physical Examination Findings

• Perianal and ischiorectal abscesses typically show visible swelling, cellulitis, and exquisite tenderness with few systemic symptoms 1
• Deeper abscesses (supralevator, high ischiorectal) may present with pain referred to the perineum, low back, or buttocks with significant systemic symptoms but minimal local findings 1
• Anal fissure causes sharp pain during and after defecation, typically visible on inspection in the posterior midline 2
• Thrombosed external hemorrhoids present as a tender, tense, bluish perianal mass requiring surgical excision if within 48-72 hours of symptom onset 2

Diagnostic Imaging Algorithm

Initial Imaging Based on Clinical Presentation

For suspected gynecologic causes with vaginal pain: Combined transabdominal and transvaginal ultrasound is the initial imaging study of choice, providing anatomic overview and high-resolution detail of the uterus, fallopian tubes, ovaries, and adnexal masses 1, 3

For suspected anorectal pathology: Clinical examination and digital rectal examination are usually sufficient for superficial abscesses; imaging is reserved for specific scenarios 1

When to Obtain Advanced Imaging

• CT pelvis with IV contrast is indicated for atypical presentations, suspected deep/occult supralevator abscesses, complex anal fistula, or when clinical examination is inconclusive 1
• MRI pelvis is appropriate for further characterization of sonographic findings in gynecologic causes or for evaluating complex perianal fistulae 1
• Plain radiography has no role in evaluating chronic pelvic pain 3

Differential Diagnosis by Pain Location

Deep Pelvic/Rectal Pain

• Pelvic congestion syndrome: Caused by engorged and refluxing pelvic veins (≥8 mm diameter) with retrograde ovarian vein flow; ultrasound with Doppler is the initial diagnostic study 4, 3
• Chronic inflammatory disease or hydrosalpinx: Requires ultrasound evaluation 1, 3
• Intraperitoneal adhesions or cervical stenosis: May cause deep pelvic pain 1, 3

Vaginal/Perineal Pain

• Vaginal atrophy, vaginismus, vaginal or vulvar cysts, vulvodynia, or pelvic myofascial pain: These conditions typically present with superficial pain localized to the vagina, vulva, or perineum 1, 3
• Imaging is primarily indicated only with abnormal physical examination findings 1

Functional Anorectal Pain

• Levator ani syndrome: Characterized by tender puborectal muscle on digital rectal examination with pain lasting >30 minutes 5, 6
• Proctalgia fugax: Sharp paroxysmal pain lasting <30 minutes 5, 6
• Consider only after excluding structural disorders through examination and appropriate imaging 7, 5

Treatment Approach

Anorectal Abscess Management

Immediate surgical incision and drainage is definitive treatment for all anorectal abscesses to prevent serious complications 1

• Empiric broad-spectrum antibiotics covering Gram-positive, Gram-negative, and anaerobic bacteria should be administered if systemic signs of infection are present, in immunocompromised patients, or with significant cellulitis 1
• Do not delay surgical drainage to attempt conservative management in hemodynamically unstable patients 1

Anal Fissure Treatment

• Medical approach first: Sitz baths, stool softeners, and analgesics are adequate for most acute fissures 2
• Topical vasodilators (nitroglycerin ointment) or botulinum toxin to decrease internal anal sphincter tone for chronic fissures 2, 5
• Lateral sphincterotomy is the surgical procedure of choice for chronic fissures unresponsive to medical therapy 2

Pelvic Inflammatory Disease

Empiric treatment should be initiated immediately in sexually active women with minimum criteria (uterine/adnexal tenderness or cervical motion tenderness) and no other identifiable cause 1

• Broad-spectrum antimicrobial coverage must include N. gonorrhoeae and C. trachomatis 1
• Additional supporting criteria: Oral temperature >101°F, mucopurulent cervical discharge, WBCs on saline microscopy, elevated inflammatory markers, or laboratory documentation of cervical infection 1

Pelvic Congestion Syndrome

• Ovarian vein embolization plus internal iliac vein embolization has been shown to be safe and effective 4
• Symptoms may subside after menopause due to decreased estrogen stimulation 4

Common Pitfalls to Avoid

• Do not miss occult deep abscesses: Symptoms are frequently absent or diminished in older patients, diabetics, immunosuppressed patients, and those with necrotizing soft-tissue infection; maintain high suspicion and aggressive approach 1
• Do not attribute all pelvic pain to gynecologic causes: Interstitial cystitis/bladder pain syndrome can masquerade as and coexist with other causes of pelvic pain, particularly endometriosis 8
• Do not delay treatment for PID: Maintain a low threshold for diagnosis given the difficulty of clinical diagnosis and potential for reproductive damage even with mild or atypical presentations 1
• Exclude Crohn's disease: A detailed medical history is mandatory to exclude undiagnosed underlying Crohn's disease in every patient with anorectal abscess, especially if recurrent 1
• Rule out malignancy: Maintain high index of suspicion and obtain biopsy of suspicious anorectal lesions, as anal carcinomas commonly present with rectal bleeding and pain 2